CIHM 
Microfiche 
Series 
(l\/lonographs) 


ICIMH 

Collection  de 
microfiches 
(monographies) 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Technical  and  Bibliographic  Notes  /  Notes  techniques  et  bibliographiques 


The  Institute  has  attempted  to  obtain  the  best  original 
copy  available  for  filming.  Features  of  this  copy  which 
may  be  bibliographically  unique,  which  may  alter  any  of 
the  images  in  the  reproduction,  or  which  may 
significantly  change  th.'  usual  method  of  filming  are 
checked  below. 


D 
D 
D 


n 

D 
D 
D 


D 


D 


Coloured  covers  / 
Couverture  de  couleur 

Covers  damaged  / 
Couverture  endommag^e 

Covers  restored  and/or  laminated  / 
Couverture  restaur^  et/ou  pellicula 

Cover  title  missing  /  Le  titre  de  couverture  manque 

Coloured  maps  /  Cartes  g^ographiques  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)  / 
Encre  de  couleur  (i.e.  autre  que  bleue  cu  noire) 

Coloured  plates  and/or  illustrations  / 
Planches  et/ou  illustrations  c^n  couleur 

Bound  with  other  material  / 
Relid  avec  d'autres  documents 

Only  edition  available  / 
Seule  Edition  disponible 

Tight  binding  may  cause  shadows  or  distortion  along 
inteiior  margin  /  La  reliure  serr^e  peut  causer  de 
I'ombre  ou  de  la  distorsion  le  long  de  la  marge 
int^rieure. 

Blank  leaves  added  during  restorations  may  appear 
within  the  text.  Whenever  possible,  these  have  been 
omitted  from  filming  /  Use  peut  que  certaines  pages 
blanches  ajout^es  lors  d'une  restauration 
apparaissent  dans  le  texte,  mais,  lorsque  cela  ^tait 
possible,  ces  pages  n'ont  pas  6X6  film^es. 

Additional  comments  / 
Commentaires  suppl^mentaires: 


L'Institut  a  microfilm^  le  meilleur  exemplaire  qu'il  tui  a 
6X6  possible  de  se  procurer.  Les  details  de  cet  exem- 
plaire qui  sont  peut-dtre  unkjues  du  point  de  vue  bibli- 
ographique,  qui  peuvent  modifier  une  image  reproduite, 
ou  qui  peuvent  exiger  une  modifk»tion  dans  la  m^tho- 
de  normale  de  filmage  sont  indiqute  ci-dessous. 

I     I  Coloured  pages  /  Pages  de  couleur 

I I  Pages  damaged  /  Pages  endommag^es 


D 


Pages  restored  and/or  laminated  / 
Pages  restaur^s  et/ou  pelliculdes 


r~^  Pages  discoloured,  stained  or  foxed  / 
bLi  Pages  dteolordes,  tachet^es  ou  piqu^es 

I        Pages  detached  /  Pages  d^tach^es 

\>y    Showthrough/ Transparence 

I      I   Quality  of  print  varies  / 


D 
D 


D 


Quality  in^gale  de  I'impression 

Includes  supplementary  material  / 
Comprend  du  materiel  suppl^mentaire 

Pages  wholly  or  partially  obscured  by  errata  slips, 
tissues,  etc.,  have  been  refilmed  to  ensure  the  best 
possible  image  /  Les  pages  totalement  ou 
partiellement  obscurcies  par  un  feuillet  d'errata,  une 
pelure,  etc.,  ont  6t6  filmies  k  nouveau  de  fafon  k 
obtenir  la  meilleure  image  possible. 

Opposing  pages  with  varying  colouration  or 
discolourations  are  filmed  twice  to  ensure  the  best 
possible  image  /  Les  pages  s'opposant  ayant  des 
colorations  variables  ou  des  decolorations  sont 
filmtes  deux  fois  afin  d'ojtenir  la  meilleure  image 
possible. 


This  Htm  Is  filmtd  at  th«  raduction  rntio  chtcktd  balow  / 

C*  docunwnt  nt  filni4  au  taux  da  r/;duction  indlqiM  ci-dastout. 


lOX 

14x 

18x 

22x 

26x 

30x 

1 

J 

12x 

16x 

20x 

24x 

28x 

32x 

Th«  copy  filmed  h«r«  has  b««n  r«produc«d  thanks 
to  tho  goncrotity  of: 

HcCin  University 
Health  Sciences  Library 
Nontreal 

Tha  imagaa  appearing  hora  ara  tha  bast  quality 
possible  considering  the  condition  and  legibility 
of  tho  original  copy  and  in  keeping  with  the 
filming  contract  specificetione. 


Original  copies  in  printed  paper  covers  are  filmed 
beginning  with  the  front  cover  and  ending  on 
the  last  page  with  a  printed  or  illustrated  impres- 
sion, or  the  back  cover  when  appropriate.  All 
other  originei  copiea  are  filmed  beginning  on  the 
first  page  with  a  printed  or  illuatrated  impres- 
sion, and  ending  on  the  laat  page  with  a  printed 
or  illustreted  impression. 


The  lest  recorded  freme  on  eech  microfiche 
shall  contain  the  symbol  ^^-  (meaning  "CON- 
TINUED"), or  the  symbol  V  (meaning  "END"), 
whichever  applies. 

Maps,  pistes,  charts,  etc..  mey  be  filmed  at 
different  reduction  ratios.  Tho^a  too  large  to  be 
entirely  included  in  one  exposure  ere  filmed 
beginning  in  the  upper  left  hend  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  as 
required.  The  following  diegrams  illustrate  the 
method: 


1 

2 

3 

1  2 

4  5 


L'sxcmplair*  film4  fut  rcproduit  grlc*  A  la 
g4n4rosit*  d«: 

NcCni  University 
Hulth  Sciences  Library 
Montreal 

Lm  imagat  suivantas  ont  ttt  raproduitas  avec  la 
plua  grand  soin,  compta  tanu  da  la  condition  at 
da  la  nattat*  da  raxamplaira  film*,  at  en 
conformity  avac  laa  conditiona  du  contrat  da 
fiimaga. 

Laa  examplairaa  originaux  dont  la  couvartura  en 
papiar  aat  Imprimia  tont  film4a  an  commandant 
par  la  premier  plat  at  an  tarminant  toit  par  la 
darni4ra  paga  qui  comporta  una  empreinte 
d'impraasion  ou  d'illustration.  soit  par  la  second 
plat,  salon  la  eaa.  Tous  las  autras  exemplaires 
originaux  sont  filmte  an  commandant  par  la 
premiere  paga  qui  comporta  una  empreinte 
d'imprassion  ou  d'illustration  at  en  terminant  par 
la  darniira  paga  qui  comporta  una  telle 
amprainta. 

Un  daa  symbolas  suivants  apparaltra  sur  la 
darniira  image  da  cheque  microfiche,  selon  le 
cas:  la  symboia  — ^>  signifie  "A  SUIVRE".  le 
symbola  ▼  signifie  "FIN". 

Les  cartas,  planches,  tableaux,  etc.,  peuvent  itre 
filmAs  i  das  taux  da  reduction  diffirents. 
Lorsqua  la  documant  est  trop  grand  pour  itra 
reproduit  en  un  seul  clichi.  il  est  IWmi  A  partir 
da  I'angla  supirieur  gauche,  da  gauche  A  droite, 
et  da  haut  en  bas.  an  pranant  la  nombre 
d'imagaa  nicessaira.  Las  diagrammes  suivants 
illustrant  la  m^thoda. 


2 

3 

5 

6 

MIOtOCOrY   tBOlUTION  TfST  OMIT 

(ANSI  and  ISO  TEST  CHART  No.  2) 


■  2^ 

|Z5 

tli 

|W 

■  2.2 

Hi 

|3^ 

Uh 

III 

li£     1 

12.0 

1.8 


1.6 


_J  >1PFLIED  irv/MGE    Inc 

S^  16S3  Tost   Ma.n   Str*«t 

rrf  RochMter.   Htm   Yoft.         U609       USA 

^g  (716)  482  -  0300  -  Pfion* 

^B  (716)  2S0-59B9  -Fa. 


THE   PRINCIPLES  OF  PATHOLOGY 

Volume  I 

GENERAL  PATHOLOGY 

By  J.  George  Adami,  M.A.,  M.D.,  LL.IX,  F.R.H. 


Volume  II 

SYSTEMIC  PATHOLOGY 

By  J.  George  Adami,  M.A.,  M.D.,  LL.D.,  F.R.S. 

AND 

Albert  G.  Nicholls,  M.A.,  M.D.,  D.Sc,  F.R.S.  (Can.) 


,    9 


THE 


PRINCIPLES  OF  PATHOLOGY 


BY 

J.  GEOl'OE  ADA  MI,  M.A.,  M.D.,  LL.D.,  F.R.S. 

PROnsasoR  or  patbo.  -•'      .N  mcgTEL  iivivcbsitt,  and  patholoowt  to  the  rotal  victoria  llOaPlTAL, 

MONTRrAL;    HTK    FELLOW    OF    JMn»    COLLEGE,    CAMBRIOUE,    ENGLAND 

AND 

ALBERT  (i.  NICHOLLS,  M.A.,  M.D.,  D.Sc,  F.R.S.  (Can.) 

ArWISTANT    PROFE.WOR    OF    KATHOLOOr    AND    LECTURER   IN    CUNICAL    MEDICINE    IX    MC  OIU.    CNIVER8ITT; 

OUT-PATIENT    PHYSICIAN    TO    THE    MONTREAL    GENERAL    HOSPITAL;    ASSISTANT 

PHYSICIAN    AND   PATHOLOGIST  TO  THE    WESTERN    HOSPITAL 


VOLUME  II 

SYSTEMIC   PATHOLOdY 


WITH     310     ENGRAVINGS    "AND     15     PLATES 


LEA  &  FEBIGER 
PHILADKL'    MA  AND  NEW  YORK 

1909 

McGILL  UNIVEKSiTY, 
MONTREAL,  Canada 


EntereJ  according  to  Act  of  Congress,  in  the  year  1909,  by 

LEA  &  FEBIGER, 
in  the  Office  of  the  Librarian  of  Congress.     All  rights  reserve*!. 


TO 


WILLIAM  H.  WELCH 

TO     WHOM     MEDICAL     HESEARCH     IS    NORTH    AMERICA    OWES    ITS    DEEPEST    DEBT 

AXD   TO 

THEIR  PREDECESSOR 

AVILLIAM  OSLER 


WHO  INITIATED  THE  TEACHING  OF  Pa     TOLOOT  AT  McOILL  UNIVERSITY- 


THIS  VOLUME 


19   AFFECTIONATELY  DEDICATED   BY 


ITS  Al'THORS 


PREFACE. 


Little  in  the  way  of  prefac-e  is  here  needed  by  thote  who  have  made 
themselves  familiar  with  the  first  volume  of  this  work.  In  that  we 
dealt  with  the  causes  of  disease  and  the  morbid  and  reactive  processes; 
now  we  pass  forward  to  discuss  the  results  of  disease  as  it  affects  the 
different  systems  and,  through  them,  the  body  as  a  whole. 

We  will  not  pretend  that  our  first  volume  was  other  than  bulky;  to 
many  readers  it  may  have  seemed  that  the  treatment  of  the  various 
sections  was  unneces-sarily  full.  These  same  readers  may  be  inclined 
to  consider  that,  working  upon  the  same  scale,  the  subject  matter  of 
special  pathology  demands  at  least  twice  the  space  now  afforded,  or, 
put  otherwise,  that  our  treatment  of  systemic  pathology  is  as  condensed 
as  that  of  general  pathology  was  diffuse.  A  little  consideration  will,  we 
trust,  show  that  our  method,  if  unusual,  is,  nevertheless,  ra  -onal.  Pro- 
vided  that  the  student  bus  ac^juired  a  good  grasp  of  the  principles  of 
general  pathology,  he  has  but  to  apply  those  principles  in  order  to  become 
possesse<l  of  a  sound  l>asis  of  special  pathology.  If,  to  cite  exampl<es, 
he  be  well  acquainted  with  the  modifications  of  the  inPnnmatory 
process  as  it  affects  parenchymatous  and  connective  tissut  .  epithflia' 
and  serous  membranes,  respectively;  with  the  different  foi  is  of  tumors 
originating  from  the  different  orders  of  cells;  witli  the  particular  orders 
of  degeneration  likely  to  affect  cells  of  one  type  or  another;  then  his 
familiarity  with  the  liisiology  of  the  different  organs  gives  him  tlie  key 
to  special  patiiological  histology.  Taking  this  knowledge  for  grafted, 
it  becomes  unnecessary  to  describe  in  detail  the  different  conditions  of 
inflammation,  tumor  growth,  and  degeneration  that  affect  the  different 
organs.  Where  these  conditions  are  typical  in  their  manifestations 
their  existence  alone  need  lie  cited.  It  is  only  when  tlicir  manifestations 
present  peculiarities  that  extended  description  is  demanded;  as  also  are 
the  details  of  the  gross  morbid  anatomy,  or  naked  eye  appearances,  of 
the  various  organs  under  various  conditions  of  disease. 

We  have  proceeded,  therefore,  upon  the  assumption  of  a  knowledge  of 
the  main  data  ol  general  pathology  as  afforded  in  our  first  volume,  and 


IHi 


^..,  PREFACE 

this  seconil  volume  would  have  had  relatively  small  dimensions  had  we 
not  in  the  first  pla«-e.  in<lud«l  the  pathology  of  the  blood  and  orgaw  of 
circulation  (usually  ami  erroneously  included  under  general  pathology), 
and,  in  the  s«»nd  place,  endeavored  to  make  our  treatment  mor« 
complete  by  dealing  with  the  disturbances  of  function,  as  well  as  those 
of  stnictuif.     We  woul.l  i^iterate  that  pathological  anatomy  (and  hjs- 
tologv)  is  but  one  division  of  our  subject,  and  that  from  the  pathologist 
of  t<xlav  then?  is  cjually  demamled  an  acijua^ntance  with  the  effects  ol 
diseasc*uponthe/«Hrf,on  of  organs.     Upon  this  we  would  lay  particular 
stress.  Imause  it  is  this  department  or  aspect  of  pathology  which  for  the 
clinician  and  practitioner,  if  not  the  more  important,  is  assuredly  that 
capable  of  the  more  immwliate  application.     It  is.  indee<l.  interesting  to 
n..te  the  extent  to  which,  nowr.days.  the  advanced  teaching  m  medicine 
is  based  upon  what  we  would  term  fun'-tional  pathology,  nay.  has  l^K-ome 
teaching  in  this  and  little  more;  to  ol«H-rve,  for  example,  the  prominence 
given  in  the  modern  Sy..tems  of  Medicine  to  the  preliminary  chapters 
upon  the  "phv.siological  pathology"  of  the  different  organs.     As  a  con- 
..ecting  link,   therefore,  between  theory  and  practice  this  functional 
pathology  is  of  prime  importance. 

Realizing  the  attention  that  this  branch  of  pathology  receives  from 
our  colleagues,  we  have  not  attempteil  an  exhaustive  treatment; 
instead,  remembering  that  the  inclusion  is  more  or  less  of  a  novelty, 
we  have  taken  into  consideration  the  functional  pathology  of  the  more 
important  svstems  only,  and,  doing  this,  have  but  dealt  with  certain 
aspects-with  thase  which,  in  the  light  of  recent  research,  appeared  to 
call  for  special  remark. 

In  short,  neither  the  previous  volume  nor  this  is  to  be  regardwl  as 
exhaustive.  We,  the  authors,  realize  most  acutely  the  deficiencies  and 
the  defects  of  iH.th.  The  most  we  can  plead  is  that  we  have  attempted 
to  lay  clown  bnnidly  the  main  outlines  ..f  general  and  systemic  pathology 
in  what,  we  hold,  is  a  logical  se«iuence. 

It  would  l.e  a  false  modesty  that  led  us  to  l.e  silent  regarding  the 
kindly  welcome  aeconled  to  the  first  volume,  despite  its  imperfections, 
and  our  appreciation  of  the  same;  the  very  wannth  of  that  welcome  has 
prt,ved  to  us  that  we  were  not  wholly  wn,ng  in  the  belief  that  the  time 
was  ripe  for  a  work  of  its  nature;  it  in  no  sense  les.sens  our  admiration 
for  the  courage  displayed  by  Messrs.  I^a  &  Febiger  in  publishing  what 
was.  in  so  many  respec-ts,  an  innovation.  The  present  volume  is  less  of 
a  departure.  We  would  express  the  hope  that  the  dual  authorship  has 
been  of  advantage  in  rcHhicing  the  imperfections,  and  that,  by  so  much 


PREF  \CK 


t\ 


as  it  has  rwluc«l  the  iiulividuality  of  the  teachinf;,  it  has  iiicTeasef'  ilit» 
value  of  the  work  as  a  text-l>ook. 

Thcxse  imperfections  of  the  pi-evious  volume,  unavoidable  under  tb 
conditions  surrounding  its  publication,  we  have  l)een  able  t<»  reme«ly 
to  a  large  degree  in  this.  With  infrequent  exceptions  the  illustrations 
are  o»ir  own,  "  have  l)een  taken  from  the  collections  of  our  colleagues 
from  the  Met  a]  Museum  al  McGill,  the  Montreal  (General,  and  the 
Uoyal  Victc  Hospitals.  W^  are  particula-'  ■  indebted  to  Dr.  Colin 
Hussel,  Dr.  A.  E.  Vipond,  Dr.  F.  J.  SI  ,  -•«  ami  Dr.  Maude  K. 
Ahlmtt.  When  not  from  these  sources,  .» *■  '  »ve  made  the  selections 
from  the  colle<-tion  of  cuts  in  the  ptissesMoi;  of  our  publishers.  We 
would  most  cordially  express  our  appreciation  to  them  for  this  as  for  so 
many  other  ser\-ices  in  c-onnection  with  the  production  of  this  volume. 
To  Messrs.  WcmmI  &  Company  and  the  W.  B.  Saunders  Company 
we  are  in<leltteil  for  the  permission  to  utilize  illustrations  which  have 
appeared  in  works  or  articles  by  one  or  other  of  us  published  by  them. 


J.  G.  A. 
A.  G.  N. 


Montreal,  1009 


CONTENTS. 

HJTBODUCTORY    . 

17 

SECTION  I. 

THE  CARDIOVASCULAR  SYSTEM. 

CHAPTER  I. 

THE   BLOOD-gOANTITATIVE   ALTERATIOKS-ANKMIA-HyPEREMIA    ....  19 

CH.\PTER  II. 

THE  BLOOD— THE  EFFECTS  OF  CLOSURE  OF  VESSELH 33 

CHAPTER  III. 

THE  BLOOD — HEMORRHAGE 

76 
CHAPTER  n'. 

THE  BLOOD— QUALITATIVE  CHA.NOES 

8;i 

CHAFIER  V. 

THt  LYMPHATIC  SYSTEM — tEDEM\ 

103 

CHAPTER  VI. 

THE  CARDIOVASCl'LAH  SYSTEM 

115 
CHAPTER  VII. 

THE  HEART  •   PATHOLOGICAL  ANATOMY  AND  HISTOIOCV 

loo 
CHAPTER  VIII, 

THE  VESSELS-VASCULAR  FUNCTION  AND  rre  DISTURBANCES I7, 

CHAPTER  IX. 

190 

CHAPTER  X. 

THE  nrOOD-PORMINO  ORGANS 

208 


XII 


CONTEXTS 


SECTION    II. 

THE  RRSI'IUATOIIY  JSVSTEM 

CHAPTER  XI. 

THE  BEHPIRATOHY  FINCTION  ANIl  ITM  mSTl'MBANCKH 

(  H.XITER  XII. 

THE  RESPIHATOnV  PA»»A(iK» 264 


.     237 


THE  HIN08 


THE  PLEl'R.K 


CHAPTER  XUI. 


CHAFfER  XIV. 


CHAPfER  XV. 


THE  MEDIASTI.NfM 


283 


324 


333 


SECTION     III. 

THK  .\L1MENTAIIY  SYSTEM. 
CHAPTER  XVI. 

THE  DIOKSTIVK  nxCliOXS  AM)  THEIU  DI»TI'HHAX(  KW   . 

CHAITER  XVI!. 

THE  MOfTH  AND  ITS  ACCKSHOIIIKS 

CHAITRR  XVIII. 

THE  WiSOPHAfilS 


.      .     .')39 


381 


.397 


CHAPTER  XIX. 

THE  STOMACH 404 

CHAFIER  XX. 

THE  INTE.STINES 422 

CHAPTER  XXI 

THE  MVEK 455 


CHAPIER  XXII. 


THE  niLIARY  PASSAGES 


.       489 


COXTESTS  jjjjj 

CHAinER  XXIII. 

THE  PAXCREAS    . 

483 

CHAPTER  XXIV. 

THK  PEHITO.VEIM      . 

504 

SECTION  IV. 

THE  XERVOUS  SYSTEM. 

CHAPTEK  XXV. 

THE  MH.rrr..HE  ..K  THE  NE«Vors  svsxEM  .N„  .-.s  ,.EAH,N,;  rPOX  „,SEA«E  .       515 

CHAPTER  XXVI. 

THE  HKAI.V    . 

523 

CHAKIER  XXVII. 

THE  SPINAL  COHI)      . 

569 

CHAKIER  XXVIII. 

THE  PERIPHEKAf.  NKHVE.s 

000 

CHAITER  XXIX. 

THE  EYE 

007 

CHAPTER  XXX. 

THE  EAR 

655 

SfX'TION  V. 

THE  DUCTLESS  GLANDS. 

CHAFIER  XXXI. 

I  ME  Kl  .VCno.NS  or  THE  .IC  TLESS  GLANDS  AND  THE.R  n,STt„,.ANcF-        ...       675 

CHAI-IER  XXXII. 

THE  THVHOII)  AND  THY.\Us  (iHNDs 

687 

CHAPIER  XXXIII. 

THE    .SIPRARENAL     UI.AND,     PITI  [TMiY      Pivr.i        .v. 

70() 


xiv  COlfTENTS 

SECTION  VI. 

THE  URINARY  SYSTEM. 

CHAPTER  XXXIV. 

THE  RENAL  FUNCrTIONtt  AND  THEIH  DISTURBANCES 715 

CHAPTER  XXXV 

THE  KIDNEYS  AND  URETERS 728 

CUAi^ER  XXXVI. 

THE  BLADDER  AND  URETHRA 774 

SECTION  VII. 

THE  REPRODUCTIVE  SYSTEM. 
CHAITEK  XXXVII. 

THE  MALE  SEXUAL  OROANH 787 

CHAFIEU  XXXVIII. 

THE  FE.MALI    SEXUAL  OROANH 810 

CHAITEK  XXXI.X. 

THE  PUERPKRAL  UTERUS  AND  THE  PRODUCTS  OF  CONCEPTION S69 

CHAFl'EU  XL. 

THE  MAMMARY  OLAND 882 


SECTION  VIII. 
THE  TEGUMENTARY  SYSTEM 


CHAPTER  XLI 

THE  SKIN  AND  ASSOCIATED  STRUCTURES  .... 


907 


CONTENTS 

SECTION  IX. 

THE  MUS(:ULAR  SYSTEM. 
CHAPTER  XLIL 


TH5  SKELETAL  MUSCLES 


VI 


979 


SECTION  X. 

THE  OSSEOUS  SYSTEM. 
CHAPTER  XLni. 

THE  P0NK8,  JOINTS,  AND  CAHTILAGES 


1003 


SYSTEMIC    PATHOLOGY 


INTRODUCTORY. 

In  the  first  volume  of  this  work,  after  having,  if  we  mav  so  express  it 

excavated  w.th  the  endeavor  to  lay  bare  so  far  as  poss'ibk 'heTun- 

dations  of  Cellular  Pathology,  we  proceeded  to  discuss\St  is  commoX 

known  as  General  Pathology,  inquiring  fin,t  into  the  causes  TdTs^^'e 

I  and  next  mto  the  geneml  morbid  and  reactive  processes.    D^hiTs 

fT.TrH  "J'".  1  ''""^y^J  '^'  *""^  *°  »'-'  °'  the  tissues  S  K 
form  and  ende,!  bv  considering  the  progres.,ive  and  regressive  chanj^s 
«^.ch  may  affect  those  tissues.  Thenc?  we  pass  naturally  to  a  S 
..  the  yet  arger  aggregates,  namely,  of  the  org*ans  and  different  system^ 
of  the  IxKly.  and  engage  in  the  study  of  whaT we  would  terSysSc 
Pathology.  Moreover,  just  as  in  the  fin^t  volume  we  departed  fmm 
custom  and,  instead  of  making  our  treatment  mainly  WstoEf  l^^ 
ourselves  to  a  ™,.   derable  extent  upon  the  phyjology,  eSnZv 

Kl  -r^tr  -something  more  than  the  time-honored  S 

Pathology,  l.v  which  has  come  to  be  underetood  the  study  of  aCw 
Anatomy  and  Histology,  and  of  that  alone.  ' 

We  would  once  again  emphasize  that  our  subject  has  undereone 
nmtenal  development,  and  that  to^ay  something  more  than  Z^s 
uemande.].  Inev.tablv,  the  study  of  Special  Path5log.v  forms  "he  bulk 
of  our  work,  but  nievitably  also  the  study  of  the  anatom^al  chan^^ 
jurnng  m  the  various  o,^ans  has  led  to  inquiries  into  t"e  st^S^^^ 
.f  these  changes  and  the  influence  they  exert  'upon  the  functiof of  th^e 
organs,  and.  what  ,s  more,  upon  the  oigan^rn  as  a  whole  Some 
knowledge  of  Functional  Pathology,  or.  ^  some  would  express  T 
hy«olog.caI  Pathology  (although  this  designation  involvesT^nt™: 
kX/w  '7\  '•:  ""*• '^"'■^ite,  and.  inde^,  forms  a  most  in.^rta™t 
n  imZ"-^'  '"'^'^  "^  the  pathologist  and  the  clinician.  To  iEate 
kIi™  "^"T™^"'^  ^^"^  but  mention  the  popularity  of  irof^r 
Krehls   ^ell-known  work,  and  the  many  editi^"  it  h^s  undTn^ 

svl^  -ir  "'°"«^i  "  ^'"^  '°  P^-f"^  «"'■  '"-^t'nent  of  the  in.liSuai 
systems  w,th  «  consideration  of  the  bearings  of  morbid  chances  In  the 
component  parts  of  that  system  upon  functfon.  The  vast  aZod^ta 
tha  have  accumulated  in  connection  with  the  MorW?  An^^my  and 
Histologj-  of  the  different  oi^ns  make  any  adequate  modem  teSb^k 


INTRODUCTORY 

of  Special  Pathology  nec^nly  a  U^  volume-  Hence-^^.^S 
thesefurther  chapters  it  hw  been  'n'*»P^'*'*.her  than  a  detailed 
iX-'we'ca-n'o^SI^'-  thM^ona!  chapter  will 

ramifications  which  spread  throughout  f«  TJ^'J^^^^^^^  ^^^Ual  are 
vascular  and  the  ^^'^r^^j'^^^TL\denngth.«  intimate 
structurally  more  "''''''^J^  ^T^tydy^t  y^oMhe  appmpriate 
relationship  with  every  region  o'  «*«  »^y'  "g^t  here  certlin  prac 
to  consider  these  two  umversal  f J'f  "t  *"^„y  ^^^ons  the  ne^us 
tical  difficulties  present  ^^f  1°^^;  _*^^L  Sons^re  so  important, 
system  t"j**«*- P^Cse  of  IrAfoSer  systems,  that  it  might 
so  sharply  defined  '«""  Z*^*.  °'  *"    aj-missed  before  distussing  the 

well  be'treated  first  --^'Tj^^^^'tZ^  ™>'«  '"*'™*^*y  r* 
other  systems  which  '"°«^»l°°£.h?nnd  that  because  the  study  of  its 
necte«l.    But  this  course  is  "'a'^visable,  and  tnat  d^  ^^^^^ 

pathology,  if  the  most  P^^J^  tts^X  4^*  H^^^  does  not 
that  study  is  so  specialized  ^^a* '*  ^^^^J'",  ^%^Jc  pathology.  It 
naturally  lead  up  to  *^,  "Jj'^^X  Js  JyS 
is.  therefore,  most  practical  and  ^^V^*  «lJ™bod  at  large,  the  blood 
of  the  vascular  system  and  t*-^!' ""^^  T^  froSis  almS  inevitably 
and  lymph  and  the  J^^^^^^^^^^^r^^  Zd  this  is  addition- 
we  pass  on  to  consider  the  *>7*^^^^^^^  has  been  customary  to 

ally  advisable  when  it  ""^f  >^^ /,X„cls  affecting  the  distribution  of 
take  up  the  more  importan  d'^^^'Ya  ^fetiom  Arombosis.  embolism, 
the  blood  and  iU  ~-i;f,^"3j  ^^nMhf  1^^  Sn  General' Pathology, 
hemorrhage,  oedema,  etc.)  as  part  ot  tne  to  n,ige  between 

respiratory  sy^*^'"  "«»  *^T?"/^^  f  uW  is  rupplied  with  nutrient 


SECTION   I. 
THE  CARDIOVASCLLAR  SYSTEM. 


CHAPTER    I. 

THE   BLOOI^  QUANTITATIVE   ALTERATIONS-AXEMIA-HYPEHEMIA. 

In  distussing  the  lirtulation,  we  have  to  consider  (1)  the  cirrulatine 
medium,  the  bl,KKl.  an<  with  it  the  lymph,  for  this,  as  ifganls  its  fluid 
.onstituent  at  least,  is  drawn  from  the  fjood,  an«l  like  that,  circulates 
even  If  slowly  and  imperfectly,  and  (2)  the  circulatory  apparatus,  the 
heart,  bloodvessels,  and  lymphatic  system.  It  is  difficult  often  to  serrate 
these,  disturbances  m  the  distribution  of  the  blood,  for  example  beinjr 
now  dependent  upon  primary  disturbances  in  the  bloodvesselsfand  now 
the  averse  being  the  case.  Remembering  this,  and  being  prepared  to 
hnd  that  a  certain  amount  of  overUpping  is  inevitable,  it  is,  on  thVwhole 
c-onducive  to  greater  clearness  if  firs!  the  circulating  medium  be  taken 
into  consideration,  and  later  the  circulatory  apparatus 

That  the  blood  is  the  life  is  an  old  saying;  t£at  it  ministers  to  the  life 
of  the  constituent  cells  forming  man's  body,  and  is  essential  for  the  con- 
tinuance of  the  same,  more  nearly  states  the  facts  of  the  case  as  we  under- 
stand them  at  the  present  time.  If  this  be  so,  if  through  diffusion 
osmosis,  and  active  or  selective  assimilation  or  excretion  the  cells  gain 
their  nourishment  from  It,  and  directly  or  indirectly  discharge  into  it 
the  products  of  their  activity,  then  obviously  the  well-being  of  the  organ- 
ism as  a  whole,  as  of  each  constituent  part,  is  liable  to  be  affected  bv 

luaht^  of  the  blocMl,  either  present  in  the  body  as  ^  whole,  or  supplied 
to  a^particular  region  or  organ.     Whence  it  follows  that  we  have  t^^con- 

I.  Quantitative  alterations  in : 

1 .  The  amount  of  blood  as  a  whole, 
r-i    ^"  ^^^.  *™°""*  supplied  to  particular  regions. 
C'psey  allied  to  these,  the  further  alterations  in  the  amount  and 
distribution  of  the  blood  caused  by:  "mount  ana 

3.  Products  of  disorganization  (thmmbi  and  thrombosis) 

4.  Presence  of  abnormal  constituents  and  their  effects  (emlwli 
and  embolism). 

5.  Escape  of  blood  out  of  the  vessels— hemorrhage. 


r 


ao 


THE  aUMW 


il.  QuHlittttivf  uhfratioii.<i  in: 

1.  'Vhe  fluid  ineiwtmum  of  tin-  hlmnl. 
2   The  c-orpusfulur  fleiiM-nts. 
W'v  Imv.'  writtfii  nli.)v.-  us  tlM>UKl«  «lw'  I»I"«>«1  i-hiim-  iiito  itninediate 
.,,nmrt  with  the  wiistituent  <rUs  of  the  IhmIv.     Suvo  in  the  <•»■«•  of  the 
nulotheliul  lininK  c.f  the  veHsels.  the  .ell.  of  the  splenie  sinuses  ami 
tlwse  of   thr  heUMilvniph  kIhu.I.s.  un<i  «rrtain  trlls  of  c-ertain   tissues, 
r  ,1     Ih.-  Kupfer  His  of  the  liver  iMm-iuhyinu.  this  is  not  the  ease. 
It  is  not  the  1)Ukh1  us  sueh  that  .linttiy  atfonls  nourishment  to  the 
vast  niuioritv  of  the  eells  of  the  orKiinism.  nor  do  these  rells,  as  a  rule, 
disiharje  their  pnHJu.ts  dinntly  into  th-  UUhhI  stream.    It  is  the  lymoh 
dtrive.1  from  the  I.UmmI  that  is  the  ...ssential  imdium  of  interchanp'  for 
most  of  the  .  lis  of  the  Uxlv.     Here  therefore  we  have  to  consider: 
III    Tin-  Iviiiph.  »K>th  ns'n»5«nls  .iiinntitative  and  quahtative  changes. 


QDAMTITATITI  AI.TSBATI0M1. 

1   In  the  Total  Qoantity  of  Oirculatiiig  Blood.— We  are  apt  to 

um-pt  t.io  frtelv  that  the  total  anwunt  of  hliKxl  in  the  Ixnly  is  about 
one-thirtetnth  of  the  IkhIv  weijfht.    This  estimate  we  owe  to  BischoJT 
mon-  than  a  half  «nturv  u>?o.     His  tnetluKi  c.msiste.1  in  taking  two 
.-omlemncl   .riininuls.   weighing   them   In-fore  decapitation    collecting 
the  l.loo«l.  washing,  so  fur  n,s  ,M).s.sihle.  all  the  remuming  blo<Kl  out  of 
the  vessels,  wushing  their  clmppe^l-up  organs,  uiid  Hnally  dwlucting  the 
weight  of  the  wushcd  nsi.luum  fn>m  the  originul  weight.     Ihe  methwl 
wus    to  sav  the  least,  somcwlmt  crude  an<l  lacking  in  uccuracy.     A.s 
slu.wn   bv'Hal«lane   un.l   lA)rrain   Smith,'  his  results  were  excessive. 
'I'hev  found   that   the  umciint  varies  l)etween  one-thirtieth  an«l  one- 
sixtwnth  of  the  IkkIv  weight,  the  average  given  Ix-ing  roughly  one- 
twentieth  (j]  ^).  or  4.78  grams  per  100  grams  of  »»«^y7^'«nt:     ^^^ 
iiicthml  employed  bv  those  observers  was  ingenious,  and  based  upon 
previous  observations  by  VVelcker  and  (Irehunt  and  Quinquaud.      The 
liemoglobin  of  the  corpuscles  takes  up  curlwn   mont  -de   (carbonic 
oxide)  with  very  much  greater  avidity  than  it  takes  up  oxy^^n  (accord- 
ing  to  Nasmvth  and  Graham*  the  affinity  is  140  times  as  gr-at)  and  by 
.•olorimet-ic  metho<ls  the  proportion  taken  up  by  a  given  blood  can  be 
accurately  determine.!.    ITius,  if.  for  example,  an  individual  be  made  t.) 
inhale  .luring  a  short  period  a  knoufi  amount  of  the  gas,  well  below  th.- 
am.)iint  necessary  to  saturate  the  blood,  and  then  a  few  drops  of  the  hloo.1 
U-  removed,  and  the  percentage  of  CO  present  in  this  sample  be  deter- 
mine.! then  it  is  a  simple  matter  to  determine  how  much  has  been  alxsor»>e. 
per  cubic  centimeter  and  what  ratio  this  bears  to  the  total  amount  ot 

•■  Ztilschr.  f.  «i.s.  Zool.,  7  :  iX.V>  :  331.  and  9  :  18S7  :  Ki. 

'  .lour,  of  Physiol.,  25:  1900:  331. 

»  .lour,  de  I'Anat.  et  de  ia  Phymol.,*1882:  StM. 

«  Jour,  of  Physiol,  35:'1906;32. 


THB  TOTAL  QUAXTITY  OF  CIRCVLATINO  BKJOD  21 

Sv  S.k'^' "i-  <?"?*  t-    """"'  ♦*"  «»''*'".r.s  .l.nK.n..tr».«l  that 
m  fairiy  healthy  in.l.v..h,«U  then-  may  In-  vUm-  up,n  twi,v  as  m.i.h  bl,K,.l 

.nembern  of  .l.fferent  Hpetu.,  of  aninwl...  Bo||i„Krr'  amvl.1  «,  si  nilar 
ronclu.sK,n.s  Ue  Urn,  oun.l  ,n«rk«l  varia.ion.s  in  the  «,nount  of  bl^l 
pn.p„rtK>„al  to  the  IkkIv  weight  when-  there  was  „„  i„.|icati.,n  of  dt 
ease.  IVse  ob«ervatK  .s  are  fully  Um.e  <,„t  l,y  th,.  n,rr..nt  observa- 
.on.  of  any  p«  hologtst  who  performs  a  lon^  s^-ries  of  antop.sie.s.  ( yttvn 
...  ederlv  people  a.s  agam  in  thase  who  ha.l  suffeml  fmm  nrt.Krts.sve 
w«.tmg,h.sei«.   the  tissue,  and  ve.s..|.s  are  «l.ara.teri.sti,.dlv^x^,."  .s 

contrary  ooze  abundant  bl„™l  at  every  cut ;  this  la.st  i.s  p«rti<uf«rh'  notiee- 
abk  It  has  seemed  to  us,  m  eases  of  obstnutive  heart  cWs«.       ' 

mua  It  rau-st  be  kept  in  mind  that  departures  fn>m  the  normal,  not 
only- m  the  .spec-ific  gravity  of  a  sample  of  I7.mhI  taken  fmm  the  Z^^rZ 
i..be  of  the  ear,  but  also  m  the  n.unlH>r  of  ervthnnvtes  per  c.mm  .ki  n  t 
by  anv  meaas  necessarily  mean  only  .,Uttlit«tive.  but  Jl*  mly  indcS 
.,uant.tat.ve  changes.  A  heightene.1  s'p^-iHe  gravity,  or  ^nZ^^T  , 
the  numl,er  of  „,rpu.s,.|.^s.  may  meanVreduetion'  n  the  fluid  7the 
blo.Hl-R  TtHluetion  m  the  anx.unt  .inulating-an.l  not  «.<  inc^as«| 
p-tKlucfon  of  .^rpusc-les;  a  lo«  ...1  s,KH.ific  gSivitv.  or  .L^^ai  hTe 

eZl2.^    'he  l,l^«|  ,j     „„    „,„,  „^j  ^^  ;^^.^^^,  d,.stn,eti«n  of  the 
epthrocytes.     In  short,  the  mer,-  study  of  a  bl.HKl  film  and  enumeration 

amoun  of  the  emulating  blocnl.  or  (as  is  too  often  held)  variations  in  the 
pitKluetion  or  destn.etion  of  the  ervthitn-ytes.  Hitherto  w^lm  V  uln 
reasoning  on  totally  inadequate  .fata.  Thus.  „s  I "  n.h  Sm  h  has 
pointed  out,  not  a  few  conditions  which  hitherto  have  1^."  '  li^  amon^ 
.he  anemias  or  c;onditi«n.s  of  lack  of  bloo.l  are  trulv  states  of  hLrZl^ 
of  hlution  and  inereas,.  in  actual  amount  of  LLmhI.  Wc  admU  7^^' 
hat  theorganisu.  p,,,.s...s.ses.  as  shown  by  Sherrington,  Llov.f  Jo  es^;^ 
(obbett.  a  singularly  .leli.ate  m.vlmnism   to  «,ui.t -nu-f  a  ismld  n 

Mipplj  to  all  the  tissues-tt  mechanism  so  delicate  that  within  a  vcrv  few 

n..id  from  the  lymph  spaces  and  tissue  .t-lls  in  onler  to  restore  th. 
irtfth'^r"'''*^"?."'^'"''"-     «"''hisadinission,Wsmt"pJ,t 

W  ellerK  It^    T'r"""'^  '"••"'  ^■">'  '"♦f^-"'  «"-"»ts  of  llE 
iour  elderly  maiden  lady  living  sparelv,  and  exercisin.r  her  muscles  with 

a^Til    ''T-  '"  *'"^  P"'"^'  "^  '"«n''.KKl.-i,i  whom  Z^nlti^ 

•Indi  r T/';^  pr^r\p"'«^  «p«<--  And  if  this  ih.  ;? ,' 

.-onditiou.  of  relative  health,  the  variations  in  quantity  of  blo.«l  in  states 
linch.  med.  W.ich.,  1886 :  Xos.  .",  and  H. 


it 


jl  THB  BWOD 

of  diarw  muM  br  rvro  morr  in-rk«i.  We  .it  hound,  then-forr  to 
KTOsnise  the  existence  of  comlitions.  of  oligemi*.  or  diimnuUon  in  the 
amount  of  »-inul»ting  blond,  ami  of  plethora,  or  iiKrea«ed  amount. 

OUf«mU  (iMteaift.  AB*«I»).-Where,  a»  may  hapijen  in  seci>ndary 
anemia-H  and  in  pernicious  anemia,  during  life  the  in.hvidual  lias  been  |j» 
hloofJless  that  it  has  been  difficult  to  secure  a  drop  of  bbod  from  the 
finaer,  and  where  at  autopsy  the  amount  of  blood  m  the  heart  and 
ves^b  is  noticeably  small  m  addition  to  being  thin  and  of  pale  color, 
there  ran  Iw  no  doubt  that  a  condition  of  oligemia  has  \iten  Dr.s-nt. 
Similar  re«luction  in  quantity  may  follow  extreme  or  ^V'^^lf^''- 
rhaae,  or  great  loss  of  the  fluid  pwt  of  the  blood,  as  from  cholera  or 
pe^cious  vomiting.    We  are  here  speaking  of  quantitative  changes 
but  it  must  be  remembered  that  these  conditions  may  produce  pmfound 
qualitative  changes  also.    Thus,  within  a  very  few  minutes  after  a  «.n. 
Jderable  hemorrhage  there  U  a  great  drain  of  fluid  fn,m  the  >""" '"to 
the  blooilvessels      hereby  the  quantity  of  blood  is  brought  toward  the 
normal.    If  the  '  -morrhage  be  repeated,  the  tissues  may  no  longer  be 
able  U.  afford  iim)..-  fluid;  what  blood  there  is  left  in  the  vessels  may  be 
lioth  thin  and  small  in  nmount;  the  corpuscle  count  will  be  greatly 
lowered.     In  cholera,  on  the  other  hand,  there  is  no  loss  of  corpuscles; 
what  blood  there  is  left  is  thicK  and  so  concentrated  as  to  be  almost 

'*Pl«thora.-For  long  years  the  teaching  of  Cohnheim»  has  influenced 
pathologists  to  disbelieve  in  the  existence  of  plethora     Cohnheim  showed 
[hat  if  Mline  s..lutions  wen>  injected  into  the  vessels  they  underwent  a 
rapid  excretion  by  the  kidneys  and  removal  from  the  blood  into  the  lymph 
spaces  of  the  Iwdy;  the  failure  to  pioduce  plethora  by  this  metho. 
l«l  him  to  realize  the  remarkable  regulative  power  of  the  vessels  and 
tissues  whereby  the  organism  in  health  preserves  a  constant  blood 
ratio     He  neglected  to  tiike  into  account  that,  as  with  all  other  mechan- 
isms of  the  organism,  this  also  might  be  thrown  out  of  order  in  disease^ 
The  ohst-rvations  of  I-orrain  Smith'  by  his  carlx^n  monoxide  method 
have  (..mpletely  overthmwn  this  older  teaching     It  would  seem,  as 
a  jKiieral  nile,  that  ample  nutrition,  coupleil  with  active  .levelopmen 
of  the  muscular  system,  is  associated  with  increase  ii.  the  amount  of 
bloo<l  above  the  normal.    Take  two  individuals  of  the  .same  age  ami 
height,  the  .)ne  a  city  clerk,  the  other  a  university  athlete,  ami  the  large 
heart  and  full  pulse  of  the  latttr  can  only  mean  a  large  amount  of  circu- 
lating Llood.    The  rate  of  heart  beat  may  not  be  laster  in  the  muscular 
Tnanrin.leed  it  may  be  .slower,  but  one  has  only  to  examine  the  hear, 
of  such  a  case  to  determine  the  large  size  of  the  cavities,  which,  with  th.' 

•  The  term  anemia  has  m.fortunately  come  to  moan  not  what  it  ghould  gigiiilv. 
•want  of  blood,"  but  diminution  in  the  hemoglobin  content,  or  in  the  number  of  n  .1 
corpuscles.  It  ten.U  t«  !?reater  precision  to  refer  to  this  condiuon  as  oligemia,  -r 
small  quantity  of  blood  (<>>j)'K,  few). 

'  Lectures  on  General  Path-logy,  cap.  7.  ,.    .    ^    .        at^\.  . 

'  For  an  epitome  of  Lorrain  Smith's  work  see  his  Appendix  to  Graham  Steel,  s 
Diseases  of  the  Heart,  Manchester,  University  Press,  1906: 361 


PLETHORA 


23 


•Momlfd  gmiter  aiie  of  the  aorta,  ran  only  imiirate  a  laiwr  volume  of 
Wood  to  be  propelled.  Therr  is  mit-h  a  rondition  as  simple  plethora, 
I.  e.,  actual  inrreaae  in  the  amount  of  normal  blood. 

But  as  with  oligemia,  so  here:  ronditions  of  f  bnormal  plethora  aie 
more  recognisable,  c-onditioni  in  which  there  is  -rease  in  the  fluid  of 
the  blood  in  excc-w  of  actual  increase  in  the  actual  number  of  corpuscles. 
n>ere  can  be  no  question  regarding  the  existence  of  watery  or  hydremic 
pk-thom.  huch  occurs,  as  already  noted,  in  many  cases  of  obstructive  heart 
ard  liver  disease.  There,  from  the  incTeased  venosity  of  the  blood,  it  may 
be  mistaken  i  r  true  plethora,  although  study  of  the  blood  serum  in  these 
ca.s..s  has,  in  general,  shown  that  it  is  of  lessened  specific  gravity,  i  e 
that  the  .scrum  is  diluted,  and,  as  Grawite  has  pointed  out,  a  coincident 
eariy  sign  of  failure  of  compensation  is  reduction  in  the  number  of 
eiythPDcytes  per  cmm.  I^rrain  Smith's  observations'  show  that  in 
these  cases  the  volume  of  blood  becomes  increased  two  and  three  times 
above  the  normal;  thev  show  that  at  first,  to  antagonize  its  dilution  and 
the  slowing  of  the  pulmonary  cireulation,  the  reduction  in  the  number 
of  red  corpuscles  is  not  proportional  to  the  hydremia,  and  further, 
that  the  color  index  of  the  corpuscles  is  increased  with  indications  of 
a  compensatory  hcmatopoiesis.  Many  more  studies  are  neede.1  before 
we  are  fully  co  .versant  with  the  changes  in  the  blood  accompanvinff 
heart  disease.  "     " 

What  is  the  cauisc  of  this  form  of  cardiac  plethora  it  is  difficult  to  say, 
whether  it  is  v  ue  to  the  associated  impaired  circuUUon  through  the 
kidneys,  and  disturbance  of  their  function,  or  to  heightened  venous  and 
capillary  pressure,  dilatation  and  widening  of  the  stream  bed  necessi- 
tating a  larger  ainoi-^it  of  fluid  in  order  to  keep  the  bkxxl  in  movement. 
A  similar  hydremic  plethora  has  been  noted  in  connection  with  obstruc- 
tive lung  disease.  C  rly  allied  is  the  plethora  accompanying  the 
Munich  beer  heart,  a:.iy  studied  by  Bollinger.  The  hypertrophy  and 
dilatation  of  the  heart  that  follows  the  conscientious  dai'lv  consumption 
of  many  liters  of  light  l)eer  would  indicate  that  with  ab^rption  of  this 
t»eer  there  is  a  daily  wn.siderable  increase  in  the  amount  of  the  cireiilat- 
ing  blood. 

Yet  another  form  of  hydremic  plethora  is  associated  with  parenchy- 
.natous  nephritis.  It  used  to  be  thought  that  the  accompanvingVlbumin- 
una  and  dram  of  serum  albumin  from  the  blood  was  the  cause  of  its  more 
watery  condition.  That,  however,  would  not  account  for  the  observed 
increase  in  amount  in  many  of  the  cases,  and  for  the  absence  of  the 
plethora  in  other  types  of  nephritis.  French  observers  have  of  late  indi- 
cated a  more  probable  cause,  both  of  the  hydremia  and  of  the  plethora. 
J  hey  have  called  attention  to  the  deficient  disehai^  of  sodium  chloride 
irom  the  kidneys,  and  it  is  now  gaining  increasing  acceptance  that  the 
accumulation  of  the  chlorides  in  the  blood  and  tissues  attracts  an  in- 
•■reused  amount  of  water  leading  to  both  hydremia  and  (edema.     Re- 

'  Trana.  Path.  Soc.  London,  53  :  1900: 136. 


24 


THE  BLOOO 


■■i' 


strictioii  of  chloridi's  has  iKtii  foiiiid  to  Ix*  followeii  by  matt-rial  improve- 
ment.' 

2.  Local  Alterations  in  the  Quantity  of  Blood  Supplied  to  a 
Part.— It  is  om'  of  thf  wmmonplaces  of  physiological  kiiowledgf 
that  the  i)loo«l  supply  of  a  part  vanes  aetording  to  circumstances;  that 
increased  activity  of  an  organ  is  accompanied  by  increase*!  passage  of 
blood  to  the  same;  that  such  increase  is  largely  controlled  by  the  central 
nervous  system  through  the  vasodilator  and  vasoconstrictor  nerves, 
although  at  the  same  time  conditions  within  an  organ,  and  again,  the 
composition  of  the  blood— the  presence,  for  example,  of  acids  or  alkalies— 
directly  affect  the  walls  of  the  smaller  arteries  and  capillaries,  causing 
dilatation  or  contraction  of  the  same,  and,  in  consequence,  variation  in 
the  blood  supply  to  the  organ. 

Where  there  is  excess  of  blood  in  a  part  we  speak  of  vl'H-al)  hyp«remia, 
where  deficiency,  of  (local)  knemia. 

In  the  al)ove'rapid  statement  we  have  by  n(»  means  exhausted  the  list 
of  conditions  leading  to  a  physiological  alteration  of  the  bl(K)d  supply 
of  a  part.  The  tone,  or  state  of  partial  contraction  of  the  vessels,  has 
to  be  kept  in  mind ;  the  fact  that  the  amount  of  bloo<l  is  much  below 
the  capacity  of  the  vessels  that  carry  it;  that  hyperemia  and  <liiatation 
of  the  vessels  of  one  region  demand  a  compensatory  relative  anemia  of 
the  rest  of  the  body,  or  of  some  region  of  the  .same;  that  there  is  evidence 
of  a  special  nervous  control  when-by,  under  normal  conditions,  the  supply 
of  blood  to  that  region  which  in  the  erect  position  should  l>e  the  first 
region  to  suffer  fmm  diversion  of  blood  to  other  parts,  namely,  the 
cranium  and  brain,  becomes  the  last  to  b<>  .seriously  affected.  X  kn«»wl- 
edge  of  the  data  upon  which  these  conclusions  are  founded  must  he  taken 
for  granted. 

Local  Hyperemia. — Three  conditions,  it  will  1)0  seen,  determine  the 
presence  of  an  excessive  amount  of  blood  in  an  organ  or  part,  namely: 
(1)  the  passage  of  an  increased  amount  of  blood  into  it,  the  outflow 
remaining  the  same;  (2)  diminished  outflow,  the  inflow  Ix-ing  unalten'd; 
(.3)  no  change  in  the  caliber  of  the  entering  vessels  or  in  the  arterial 
bhwd  pressure,  and  no  resistance  or  obstruction  to  the  outflow  tlm)Ugh 
the  veins,  but  a  widening  of  the  capillary  channels  in  the  organ.  The 
first  of  these  we  term  active  or  arterial  hyperemia,  the  second  passive 
hyperemia  or  venous  congestion;  the  existence  of  the  thinl  is  largely 
neglected;  we  may  refer  to  it  as  capillary  hyperemia,  and  di.scuss  it  first. 
Okpillary  Hyperemia. — ^The  clearest  'physiological  and,  we  are  inclined 
to  think,  pathological  examples  of  this  condition  are  affonled  by  an 
organ  wliich,  it  is  true,  does  not  so  much  possess  capillaries  as  bUxMl 
sinu.ses.  .\s  shown  by  Roy  in  his  well-known  oncometric  observations 
upon  this  organ,  the  normal  spleen  exhibits  a  slow  pulsation  of  its 
own,  gradually  expanding  independently  of  any  change  in  the  general 


'  Vaguez  et  Digne,  Ktudcs  sur  la  Uetention  et  I'Kliniination  des  Chlorures,  Tari-s, 
liMm;  Ambard,  Les  Uetentions  ("lilorures,  Paris,  MK).').  This  matter,  however,  must 
lie  n?garded  as  still  sub  jiuiirc. 


AcriVH  IIYPEHEMfA 


25 


1)Io«k1  pressure,  and  Hun  >jra<luully  (oniractiiiK.  'i'^is  pulsaJioii  is 
attributed  to  the  expansion  and  ctHitrartion  of  the  phiin  muscle  fil»er.s 
contained  in  the  capsule.  Wifii  each  a<t  of  <ontra< tion  the  capillaries 
and  blood  spatrs  of  the  orj;an  are  c.)nipn-.ss«'d  and  lilond  is  driven  out 
of  them;  with  each  exjwnsion  tiies«-  ix-come  filled  aRairi.  To  some 
extent  this    must   Im>   true   of   all   viscera    possessing    nnisular  walls- 

expansion  of  that  muscle,  or  loss  of  tone  of  the  sa must  passivelv 

pennit  a  hyperemia  of  the  capillary  anas  within  the  muscle  layer.  It 
may  well  he  that  the  enlarged  hyperemie  con.lition  of  the  spl.-t-n  in  Uphold 
and  other  infections  is  not  so  much  an  example  of  arterial  or" active 
hyjx-remia  as  of  the  capillary  hyperemia  due  to  jmresis  and  givinc 
wav  of  the  musc-ular  elements  of  the  capsule,  although  with  this  another 
prolmble  factor  is  the  actual  obstruction  to  onflow  of  th.>  blood  encoun- 
ten-cl  m  the  sinuses  themselves,  through  the  arrest  and  a.cunuilation  there 
of  the  red  corpuscles.  But  even  in  this  latter  case  it  will  Ik-  seen  that  the 
hyperemia  is  of  neither  arterial  nor  venous  origin.  It  will  l)e  nralled 
that  a  similar  capillary  obstniction  has  Ik-cii  noted,  answerable  for  the 
obstruction  to  the  pa.ssage  forward  of  the  blood  an«l  for  the  hvperemia 
seen  m  acute  mflammation  (vol.  i,  p.  .SH-)),  which  thus,  sine  iii  its  first 
stages,  can  scarce  be  regarded  as  trulv  of  the  active  type.  What  mav 
Ih"  regarded  as  almost  physiological  examples  of  this  order  are  seen  in 
the  effects  of  cuppmg  and  hyperemia  induced  bv  suction. 

Active  Hyperemia.— This  may  be-  either  dlrert,  <lue  to  changes 
te  hng  (hrect  y  ujion  the  arteries  pa.s.sing  to  a  part,  and  leading  to  their 
<hlatation,  whereby  a  wider  bed  is  afforded,  and  more  blood  enters  the 
j)art,  or  collateral,  due  to  contraction  of  other  arteries,  wherebv,  other 
thmgs  l)eing  equal,  the  blood  pressure  is  raised  and  more  blood  is  ix)ured 
into  the  arteries  under  consideration,  and  so  into  the  nglon  supplied  bv 
them.  Little  need  In-  said  regarding  the  latter  condition;  we  rarelV 
<-ncounter  well-marked  pathological  examples  save  in  the  development 
of  collateral  circulation  in  a  limb  or  other  region.  The  din-ct  form 
IS  relatively  frequent,  and  may  l)e  due  either  to  (1)  stimulation  of  the 
vascKlilators,  (2)  paralysis,  or  inhibition  of  the  va.soconstrictors,  or  (3) 
.Im-ct  local  action  of  physical  or  chemical  agents  (warmth,  temporarv 
ligature,  atropine,  croton  oil,  etc.)  upon  the  walls  of  the  arterioles,  leading 
to  a  giving  way  or  expansion  of  the  inu.sciilatiire.  Diminution  of  ex- 
ternal pr.>ssur.-  acting  u|K)n  an  arterv  has  a  .similar  effect ' 

Ihe  appearances  of  the  affecte<l  part  in  true,  active  hvperemia  are 
characteristic;  it  is  enlarged  and  swollen,  the  color  is  of  a  bright,  arterial 
ml;  superhcial  parts,  from  the  more-  abundant  and  freelv  circulating 
bl<K.d,  are  warmer  than  the  surrounding  regions,  an.l  in  no't  a  few  cases 
It  has  l)een  noted  that  the  blood  passing  from  the  veins  of  the  part  is 
arterial  m  character.     In  extreme  cases  there-  may  be  a  sc-nsition  of 

'  It  may  l,e  urge.i  that  the  example  affor.le.l  l,y  us  to  illustrate  capillarv  hvperemia 

my  he  explained  m  this  way,  and  that  ho  thi«  c.mlition   n.av  1,..  placed  a.m.MK 

H-  active  hyperemias.     There  seems,  however,  to  be  a  distinct  .liHVrence  l«.tw,vn 

dening  the  capillary  bed  by  reduction  of  pressure  or  active  ,.vp,.„.si„„  „r  ,hr  orpin 

ilsnif,  and  removal  of  pressure  from  the  afferent  x  «,cl 


26 


THE  BUH)D 


hi 


throbbing  in  the  affectetl  part,  together  with  visible  pulsation  of  the 
smaller  arteries,  or  even  of  the  capillaries,  as,  for  example,  at  the  base  of 
the  nail.  The  re<l(lening  may  Ik'  distinguished  from  that  due  to  hemor- 
rhage by  (in  general)  its  brighter  color,  and  more  particularly  by  its 
temporarj'  disappearance  when  pressure  is  applied. 

Examples  of  these  different  forms  of  active  hyperemia  may  here  l)e 
rapidly  passed  in  re\iew. 

Neuroparalytic  hyperemia  due  to  removal  of  va.soconstrictor  influ- 
ences. The  type  example  of  this  form  was  atfonle«i  by  CI.  Bernard  in 
his  well-known  experiment  of  dividing  the  cervical  sympathetic  nerve 
in  the  rabbit.  In  man  it  has  been  note<l  that  .similar  section  of  the 
cervical  sympathetic,  or  destruction  of  the  same  by  tumors,  etc.,  leads  to 
hyperemia  of  the  side  of  the  facv,  and  dilatation  of  the  retinal  vessels, 
with  heightened  temperature.  A  like  unilateral  reddening  seen  in 
some  forms  of  migraine  or  licmicrania  has  been  attributetl  to  inhibitory 
disturbance  of  the  same  nerve.  It  has,  however,  to  be  noted  that  not  all 
the  paralytic  hyperemias  obscr\'ed  in  the  lower  animals  as  the  result  of 
nerve  section  are  to  be  encountered  in  man. 

Neurotonic  hyperemia,  due  to  stimulation  of  the  vasodilators.  The 
type  example  by  which  this  is  demonstrated  is  the  intense  hyperemia  of 
the  submaxillary  gland  which  ensues  upon  stimulation  of  the  chonia 
tympani,  a  hyperemia  so  intense  that  the  bloo<l  in  the  emergent  veins 
is  of  arterial  character.  To  this  order  probably  belong  many  of  the 
fugitive  erythemas  of  particular  areas  seen  in  neural^!-  and  hysterical 
conditions,  as  again  in  food  and  drug  idiosyncrasies  (vol.  i,  p.  372). 
Here  also  probably  l)elongs  that  striking  condition,  herpes  soster,  in 
which  the  cutaneous  distribution  of  one  or  more  ner^•es  is  sharply  picked 
out  to  be  the  site  of  acute  hyperemia  followed  by  exudation  and  vesicle 
formation.  We  have  already  discussed  the  relationship  of  events  of 
this  onler  to  inflammation  (toI.  i,  p.  410).  Of  the  same  order  would 
seem  to  be  erythromeUlgia,  a  condition  in  which,  suddenly,  restricted 
areas,  often  symmetrically  situated  on  the  feet  or  hands,  present  a  burning 
pain,  with  pronounct'd  nnlness,  heat,  and  pulsation,  (^losely  allied 
are  tlie  reflex  hyperemias,  of  whicli  blusbing  aflonis  the  familiar  example, 
f'liaracteristic  instances  of  this  onler  are  seen  in  certain  ciistvs  of  referred 
hyperemia  or  inflammation,  e.  g.,  in  the  rwldening  ami  swelling  of  the 
side  of  the  face  which  may  accompany  acute  inflammation  of  a  tooth. 
The  rash  upon  the  cheeks  of  infants  when  teething  (roseola  infantilis)  is 
of  the  same  order. 

Myoparalytiv  hyperemia  (Lubarsch)  due  tti  influences  acting  directly 
on  the  arterial  wall.  Of  influences  which  directly  induce  arterial  expan- 
sion may  1k'  mentioned  warmth,  temporary  ligatun>  or  compression 
(the  activ«'  congi'stion  which  follows  the  use  «>f  Esman-h's  bandage  is 
a  well-marked  example),  the  pn'senw  of  acids  in  the  circulating  blood, 
whidi,  as  (iaskell  has  shown,  causes  dilatation  of  the  cerebral  vessels 
(whereas  alkalies  bring  about  contraction),  atropine,  etc.  In  the  experi- 
mental production  of  inflammation  it  has  been  demonstrated  that  croton 
oil  applied  to  the  rabbit's  car  acts  so  slowly  that  the  arterial  dilatation 


PASSIVE  CONGESTION,  OR  VENOUS  HYPEREMIA 


27 


can  only  be  due  to  direct  action  and  not  reflex.    In  bacterial  inflamma- 
tion the  toxins  must  act  similarly. 

Effects  of  Local  Hyperemia.— Where  this  is  fugitive  no  effects  may  lie 
detected;  where  prolonged,  the  increased  blow!  flow  is  inevitably  accom- 
panied by  increase*!  transudation  from  the  distended  capillaries,  with, 
as  a  result,  some  swelling  (a'dema)  of  the  part  and  increase<l  flow  of 
lymph  from  the  same.  Such  increased  flow  signifies  also  increase*!  nutri- 
tion. We  have  already  discussed  whether  increased  nutrition  in  itself 
leads  to  increased  growth,  concluding  that,  unless  there  be  some  coin- 
cident strain  or  demand  for  increased  work,  cells  subjected  to  increased 
nourishment  do  not  of  necessity  take  on  growth  (vol.  i,  p.  rAo).  We 
did  not  then  take  into  account  the  undoubtwl  influence  of  increa.se<l 
warmth  in  stimulating  activities  and  growth.  Such  increased  warmth 
IS  present  in  active  hypenmia  of  a  superficial  area,  and  we  wouUl 
suggest  that  this  may  help  to  explain  an  appannt  exception  to  the  nde 
that  has  been  noted,  namely,  that  after  section  of  the  cervical  sympathetic 
in  the  rabbit,  the  ear  and  the  hair  on  the  affected  side  grow  more  than 
do  those  on  the  sound  side. 

Extreme  arterial  hyperemia  in  an  orj,'an  prf)vidwl  with  a  limiting 
capsule  may,  by  compression  of  the  s|X'cific  c«>lls,  cause  definite  disturb- 
ance of  function,  as  also  in  loosely  constnictetl  organs,  by  overfilling, 
it  may  lead  to  capillary  hemorrhages. 

Puiive  Oongestion,  or  Venous  Hyperemia.— As  alnady  laid  down, 
passive  congestion  is  brought  alwut  by  obstru<tion  or  closure  of  a 
vein,  so  that  the  blood,  propelled  forwarrl  through  the  arteries,  accu- 
mulates behind  the  point  of  arrest.  There  is  this  striking  difference 
between  active  and  passive  hypenmia,  that  the  former  can  onlv  affect 
a  relatively  restrictetl  area,  the  latter  may  lie  widespread.  A  little  con- 
sideration shows  why  this  is  the  case-.  Normally  there  is  considerable 
tone  or  partial  contraction  of  the  arteries.  Removal  of  this  tone  over 
a  wide  area  n-nders  the  bed  t.K)  big  for  the  available  blood  delivered 
from  the  heart,  ar -!  within  a  very  short  time  there  is  insufficient 
fluid  entenng  the  ..series  to  k«H|)  tluni  distende<l  and  hvix-remic 
lo  preserve  an  overfilling  of  the  arteries  of  one  region,  there  must  be  an 
extensive  contraction  of  the  arteries  of  other  regions.  The  very  con- 
vergence of  the  veins,  so  that  all  from  n-latively  large  districts  come 
together  and  pour  their  blood  in*'>  a  common  trunk,  necessitates  that  any 
of)struction  in  this  j-ommon  trunk,  or  e%en  in  the  heart  itself,  results  in 
a  heaping  up  of  blood  behind  the  point  of  obstruction;  the  blood  becomes 
dammed  m  the  main  trunk  or  trunks  and  in  the  organs  from  which 
these  trunks  pass.  In  this  way  obstructive  disease  of  the  left  heart 
leads  to  passive  congestion  of  the  whole  pulmonary  an-a;  obstructive 
disease  of  the  lungs  or  of  the  right  heart  causes  cyanosis  and  congestion 
of  the  faw,  ne<k,  liver,  and  other  abdominal  orga'ns;  obstructive  disease 
of  the  hver  or  portal  vein  causes  passive  congestion  of  the  intestines, 
spleen,  etc  Paradoxically  it  may,  and  often  does,  hapiien  that  even 
compete  blockage  of  a  smaU  vein  leads  to  little  or  no  passive  congestion, 
ami  this  because  m  most  of  the  organs  of  the  bofly  the  smaller  veins 


PASSIVE  CONGESTION,  OR  VENOUS  HYPEREMIA 


27 


can  only  be  due  to  direct  action  and  not  reflex.    In  bacterial  inflamma- 
tion the  toxins  must  act  similarly. 

Effects  of  Local  J lyperemia.— Where  this  is  fugitive  no  effects  may  lie 
detected;  where  prolonged,  the  increased  blood  flow  is  inevitably  accom- 
panied by  increase*!  transudation  from  the  distended  capillaries,  with, 
as  a  resuU,  some  swelling  (adema)  of  the  part  and  increase*!  flow  of 
lymph  from  the  same.  Such  increased  flow  signifies  also  increase*!  nutri- 
tion. We  have  already  discussed  whether  increased  nutrition  in  itself 
leads  to  increase*!  growth,  concluding  that,  unless  there  be  some  c*)in- 
cident  strain  or  demand  for  increased  work,  cells  subjected  to  increased 
nourishment  do  not  of  necessity  take  on  growth  (vol.  i,  p.  .54.5).  We 
did  not  then  take  into  acc-ount  the  iindoubte*!  influence  of  increase*! 
warmth  in  stimulating  activities  and  growth.  Su*h  increased  warmth 
is  present  in  active  hyperemia  of  a  superficial  area,  and  we  woul*! 
suggest  that  this  may  help  to  explain  an  appannt  exception  to  the  nde 
that  has  be«;n  note*!,  namely,  that  aft«T  s«Ttion  of  the  cervical  sympathetic 
in  the  rabbit,  the  ear  and  the  hair  on  the  affect**!  side  grow  more  than 
do  those  on  the  soun*l  side. 

Extreme  arterial  hyperemia  in  an  orjjan  providi-*!  with  a  limiting 
capsule  may,  by  compression  of  th<-  sfx-cific  e*'lls,  cause  definite  disturb- 
ance *)f  function,  as  also  in  loosely  *-*)nstni*te*!  organs,  by  ov«Tfilling, 
it  may  lead  to  capillary  hemorrhagi-s. 

Pasiive  Congestion,  or  Venous  Hyperemia.— As  already  laid  down, 
passive  congestion  is  brought  alwut  by  obstru*tion  or  closure  of  a 
vem,  so  that  the  blood,  propelled  forwarrl  through  the  arteries,  accu- 
mulates behin*!  the  point  of  arrest.  Tlierc  is  this  striking  difference 
between  active  and  passive  hypenmia,  that  the  former  *an  onlv  affect 
a  relatively  restricte*!  area,  the  latter  may  Ik?  wiflespread.  A  little  con- 
sideration shows  why  this  is  the  cas*-.  Normally  there  is  (■onsiderable 
tone  or  partial  contraction  of  the  arteries.  Removal  of  this  tone  over 
a  wide  area  renders  the  be*!  t<M)  i)ig  for  the  available  blood  delivered 
from  the  heart,  ar -I  within  a  very  short  time  th*'re  is  insufficient 
Huid  entenng  the  . series  to  k*H|)  tluni  distend*-*!  an*!  hvjH'remic. 
I o  preserve  an  ov*'rfilling  of  the  arteries  *)f  one  region,  there  must  be  an 
extensive  contraction  of  the  arteries  of  „ther  ngions.  The  very  con- 
vergence of  the  veins,  so  that  all  from  r<-lativ<'lv  large  districts  come 
t<5gether  and  pour  their  blood  in*-^  a  common  trunk,  necessitates  that  any 
oJjstruction  in  this  «-omm*)n  trunk,  or  e%en  in  the  heart  itself,  results  in 
a  heaping  up  of  blood  behind  the  point  of  obstruction;  the  blood  becomes 
ilammed  m  the  main  trunk  or  trunks  and  in  the  organs  from  which 
these  trunks  pass.  In  this  way  obstructive  disease  of  the  left  heart 
it-ads  to  passive  *-*)ngestion  of  the  whole  pulmonary  an-a;  obstructive 
(li.sease  of  the  lungs  or  of  the  right  heart  caust-s  cvanosis  and  congestion 
of  the  face,  n»-*k,  liver,  and  other  abflominal  organs;  obstructive  disease 
of  tlie  hver  or  portal  vein  causes  passive  congestion  of  th*-  intestines, 
spleen,  etc  Paradoxically  it  may,  and  often  does,  hapt)en  that  even 
*-ompete  blockage  of  a  smaU  vein  leads  to  little  or  no  passive  congestion, 
and  tins  because  in  most  of  the  organs  of  the  body  the  smaller  veins 


28 


THE  Buton 


W': 


i     ri 


present  abiiiidaiit  anastomoses,  as  a  n-sult  of  wliieli,  if  one  vein  In'comes 
overloaded,  the  i>liKMi  whieh  should  |)as.s  alonj;  it  finds  easy  outlet  along 
<-ollutenil  channels.  It  is  when*  thes*'  anastoinost-s  do  not  exist,  (»r  are 
inadequate — in  what  is  known  as  absolute  or  n-lative  terminal  veins — that 
we  encounter  the  most  extreme  rt'sults  of  localize*!  passiv«>  congestion. 

The  raiutm  o{  arn-stwl  onflow  of  the  I»1(hhI  in  the  vein.s  an-  manifold. 
In  the  mon-  widespn-ad  cases  of  j)aissiv«'  congestion  it  is  not  essential 
that  there  should  Ik*  actual  narn)wing  of  the  vascular  channel;  men- 
weakening  of  the  heart  muscle,  as  from  fatty  <legeneration  without 
valvular  disease,  may  result  ii  lack  of  propulsive  power,  whereby  the 
l)loo<l  l)ec«mes  heaped  up  in  tde  '.enous  system.  Again,  it  has  to  Ik* 
rememlx'nvl  that  the  normal  advanj-t-  of  the  blwid  along  the  veins  is  not 
dependent  only  on  the  I'is  a  tergo  of  the  ventricular  pump  acting  through 
the  arteries  and  capillaries.  Every  muscular  contraction  presses  on 
certain  veins,  and  through  the  agency  of  the  frequent  valves  present  in 
them  drives  the  blood  forward;  every  beat  of  the  arteries  must  have 
a  like  influence  on  its  venu;  committentes.'  The  adjuvant  action  of 
the  negative  pressure  on  the  thorax  during  inspimtion  and  the  negative 
pressure  in  the  ventricles  during  diastole  (see  laiir')  nee<l  no  comment. 
We  mention  these  things  in  onler  to  » i  .hasize  tlic  fact  that  (1)  cardiac 
weakness,  (2)  hindrances  to  jK-rfcct  iiispiration  (jwralysis  of  the  dia- 
phragm, or  obstniction  to  the  pn)|H'r  action  of  the  same,  accumulation 
of  fluid,  or  new-growth  in  the  pleurp.l  cavity,  etc.),  (3)  lowered  bloo<l 
pri'ssure  and  weakened  pulsttion,  and  (4)  lack  of  muscular  activity, 
all  play  a  part  in  lessening  the  onflow  of  the  venous  blimd,  and  all  to 
a  gn-ater  or  less  degree  favor  venous  congestion. 

Such  congestion,  it  may  Ik-  added,  tends  to  show  itself  more  esjK-cially 
in  those  regions  in  which  tlv  veins  n-ceive  least  sup|)ort  or  compression 
from  the  surrounding  tiss:,es,  and  when  at  the  same  time  these  adjuvant 
factors  an'  least  brought  into  play.  Thus,  other  things  In-ing  equal, 
i'  is  in  those  taking  little  exenise  that  piles  <  hemorrhoids  an'  mon- 
particularly  apt  to  show  themselves;  in  those  standing  much  on  their 
iVft,  rather  than  in  those  indulging  in  much  walking  cxen-ise,  that  vari- 
cosj'  veins  of  the  leg  an'  to  be  encountered.  Natunilly,  however,  it  is 
when'  there  is  narn)wing,  blocking,  or  oblitenttion  of  the  venous  channels 
that  the  passive  hy|M'n'mia  below  the  jK)int  of  obstruction  is  most  marked. 
To  cite  all  the  means  whereby  these  conditions  an'  bn)\ight  alxiut  in  tlie 
heart  and  veins  would  <lemand  a  very  lengthy  list;  we  must  ctmtent 
ourselves  with  briefly  classifying  the  main  onler  of  events  into  ( I ) 
conditions  acting  fn)m  within  the  blood  channel  (development  of  parietal 
thmmbi.  Chapter  H)  of  intravascular  new-gn>wths,  n'tnignide  emlK)li 
(Chapter  II);  (2)  conditions  affecting  the  vessel  walls, leading  to  stenosis 
or  narn)wing  (endocanlitis  of  iieart  valves,  syphilitic,  and  other  forms 
of  phlebitis,  new-gn)wths  involving  the  walls,  etc.);  and  (3)  conditions 
acting  fniin  without,  compn'ssing  the  vessel  (tumors,  fluid  aceunndations, 

'  Sir  I.audcr  ISniiitdii,  Tii(ia|K>iuir.-  of  thr  ('irciilatiiui,  liKIS:  ."). 
Mlmpters  VI  and  .\I. 


PASSIVE  CONOESTIOX,  OH  VENOUS  HYPEREMIA  'HA 

iiiHammatorj-  ciiatrHv.s.  Kmnulomas,  pressuiv  of  enlarged  ormns  e  a 
of  the  pregnant  uteru,-.  etc.).  The.se  (Hinditions,  t..  n-peat.  inav  affect' the 
heart  or  larger  veni.s,  or.  again,  imlividual  vein.s  nithin  an  organ  or  tis.sm- 
RfmJi»-~Aii  organ  or  part  which  is  the  s«rt  of  pas.sive  hvp«-re,nia 
(I)  1.S  en  arg.-<l  prinmrily  in  eon.se.|nen«-  of  (he  increa.stnl  amount  of 
n.ntaiiu-.lblo«.,. secondarily  as  a  n-suit  of  increased  transudation 
from  the  distendwl  ci-pdiaries;  (2)  is  of  a  dark,  purplish  c-olor,  owing  to 
the  di.sten.sion  of  its  ves.sels  with  I.I.kmI,  which,  owing  to  long  (t,ntimianc<- 
■n  the  yeasel-s.  has  U'coine  intensely  ven..us;  (3)  is  (when  .superficial) 
cooler  than  the  surrounding  parts,  owing  to  the  .slowt^l  ciwiilation 

A  few  wonls  are  necessary  reganling  ti.e  significaiu-e  of  thes,.  .lifferent 
changes  upon  the  bl(K)d.  the  ve.s.s«.|s,  and  the  ti.s.sues. 

The  fi/oa/.-Helative  or  active  arrest  of  the  hlood  within  th.-  capillaries 
leads  to  gn-ater  giving  up  ..f  oxygen  aii.l  iiMreascnl  <hffusion  into  i^  of 
earlKin  dioxide.  It  tliu.s  Ix-comes  inten.selv  venous.  Thu.s,  lupine  found 
as  much  as  64  per  cent,  of  CO,  in  the  venous  I,1,h..I  of  «  <.a.se  of  ohstnicti  ve 
heart  disea.se.  It  ,s  this  that  explains  the  cyuioii.  (or  "blue"  state) 
of  sufferers  from  pa.ssive  congi-stion.  One  exception  has  to  l3<>  noted  • 
the  brain  and  spinal  cord,  when  <-onge.stt><l,  ,lo  not  exhibit  cvanosiv- 
at  most,  mu  tiple  bl.HKl  points  (distended  capillaries)  staml  out' against 
the  pale  background  of  the  cut  surface  of  the  white  matter  Complete 
stasis  or  arrt'st  may  In-  f,.llowe<l  by  coagulation  and  thromlnisis. 

Ihel  cixfl »  «//.Y.-(  '„ntniu<-d  pa.s.sive  congestion  is  constantlv  followe,! 
by  indications  .,f  injury  to  the  venous  and  capillarv  endothelium;  in  the 
first  place,  it  is  abnormally  stretched  and  thinn.Ml;  in  the  .st-c<  id  it 
exhibits  fatty  .legen.-ra»ion,  presumably  as  a  r.-.sult  of  ci,rl)on  dioxide 
intoxication. 

The  Tim.-\.^  u  result  there  is  incifa.s,-d  transudation,  uii.i  it 
maybe,  iiKxIifu'd  (exudation),  with  .some  heaping  of  fluid  in  the  inter- 
stitial tissue  ccdeina).  This  may  not  W  marke.l  in  individual  organs 
pn.vided  with  a  limiting  <-apsule.  but  ^vhen■  ther,-  is  general  venous 
congt-stion  of  larg  ireas,  as  from  heart  .liseas*-,  it  is  one  of  the  most 
striking  features,  with  gmit  accumulation  of  fluid  in  the  IhkIv  cavities 
(ascites,  .vdrothorax)  and  in  the  subcitaiu-ous  tissues  (anasarca). 
1  he  ..  pul  acciimulation  of  fluid  occurs  in  cases  of  sud.len  blockajre 

'.h.."n,  I'l"  'i        u  '•'"""'  '■'■'."=  '"'"''  «PPa"'>'tl.v,  in  coiLsequeiur  of 

th.  p,,,  l,l,K,d  with  Its  material  ab.sorlnHl  from  the  intestines  In-iiur 
mon-  toxic  than  .systemic  blood  in  general.  When>  the  mngi-stion  is 
c>  trenie  aiu  the  capillaries  ill-supported,  there  mav  l,e  in  addition 
'XsTuTi  "h  T'  'T"  ™F;'-v  hemorrhages  (Chapter  III),  and  as 
.  result  of  the  breaking  down  of  the  hemoglobin  the  ti.s.sue  mav  a.s.sume 
.1   brownish   c-olor     In   addition,    through   malnutrition   and' fhrouirh 

IZZ'  Tir"'"  "  •'  i  1  '■"";;  ""  ^P'  '"^  '^^^'  degeneration  ait 
atrophv.  Ihis  ,s  particularly  w<>ll  seen  in  the  liver,  where,  thn.ugh 
,|a.ssive  ,•ongc^st.on.  the  cells  of  the  c-entrt-  of  the  lobule  first  undeS 
diminution  in  .size  with  pigmentation,  and  eventually  iH-come  completed 
atrcjphied  and  disappear,  their  place  being  taken  bv  greatlv  dilatcnl 
capillaries  (Chapter  XXI}.  •    *^        •    """"^' 


ao 


THE  BLOOD 


I! 


lIuTe  is  still  some  debate  as  to  whether  passive  congestion  of  any 
onler  can  lead  to  increase*!  tissue  growth.  This  we  have  already  dis- 
cussed (vol.  i,  p.  414).  \\v  woulil  repent  that  just  as  the  Polish  Jew 
or  Chinaman  can  live  and  even  thrive  under  con<litions  in  which  the 
.\nglo-.Saxon  would  starve,  so  when  the  cong»'stion  is  of  a  nKxlerate 
gratle,  the  sin  'cr  and  haniier  whit*-  and  yellow  connective  tissues  may 
exhibit  growtl.  iind  prolifenition  at  the  .same  time  that  the  m(»re  highly 
organized  speciHc  j-ells  of  a  ti.s.sue  manifest  progressive  atrophy.  In 
addition  to  relative  fibn)sis  due  to  this  atrophy  of  the  nobler  elements,  in 
the  liver,  for  example,  w«'  have  to  recognize  deKnite  cases  of  productive 
tibrosis,  not,  we  would  emphasize,  when  the  congestion  is  extreme, 
but  when  it  has  been  of  a  mmlerate  grade  and  long  continued.  Thus 
there  is  deveiopiHl  a  tnie  cyanotic  flbroiii  or  indnration.  Where  the 
congestion  is  extreme,  where,  that  is,  there  is  complete  obliteration  of 
the  vein  or  veins  of  a  part,  with  inadequati-  means  of  developing  a 
collateral  <-irculation,  then-  tlie  stasis  of  the  blcxMl  is  inevitably  followed 
by  necrosis  or  death  of  the  whole  an-ii,  resulting  in  the  production  of 
gangrene  if  the  area  of  (listrii)ufion  Ik-  largi',  r.  ij..  tiie  f<M)t  or  leg  (vol.  i, 
p.  OOS),  or  of  hemorrhagic  infarct  if  tht>  termiial  vein  of  one  portion  only 
of  an  organ  Ik-  involvj-d. 

Local  Anemia. — lioeal  unemiu  may  Ik-  but  part  of  a  general  IiKhkI- 
lessness— as  aftt-r  a  profound  hemorrhage;  it  may  also  lie  cMateral, 
due  to  determination  or  drainage  of  blood  to  other  regions,  as  in  the 
anemia  of  tiie  l)raiii  in  syn<-opal  attacks  following  upon  dilatation  of 
the  splanchnic  vessels  (vol.  i,  p.  529).  Mon-  often,  however,  we  have 
to  take  into  acwunt  the  n-sults  of  local  disturbanws  of  the  blood  supply 
through  particular  arteries,  leading  to  deficient  circulation  in  the  areas 
served  by  those  arteri«s.  The  causes  of  such  local  anemia  are  of  the 
same  order  as  are  those  of  lo«-al  passive  hyjK'remia,  though  here  it  is 
the  artery  passing  to  a  part  that  is  afft'cted,  instead  of  the  vein  passing 
from  it,  and  the  nsiilts  are  widely  contrasted.  Disturbances  may  be 
brought  abt)ut  (1)  by  nervous  influt-nees  acting  upon  the  arteries,  (2) 
by  pressuri'  upon  it  from  without,  (.'})  by  diseas*'  affecting  its  walls,  and 
(4)  by  obstruction  or  plugging  of  the  arterial  lumen  by  fon-ign  or  abnormal 
matter. 

1.  Neurotic  Anemia.- -Witii  Lubarscli  we  can  (perhaps  somewhat 
inst'curely)  divide  tlie  cases  in  which  individual  arteries  Ix'come  con- 
tracted through  nervous  influences  into  tiie  direct  and  the  reflex.  Thus, 
fort-most  among  the  direct  lie  plac«'s  tlie  local  anemias  due  to  the  action 
of  cold.  We  admit  fn-ely  with  him  that  it  is  in  females  and  those  of 
a  high-strung  lurvous  leni|K'raincnt  that  such  local  contractions  of  the 
arteries  most  easily  and  most  frequently  show  theinselves.  But  in  the 
first  place,  we  are  inclined  to  In-lieve  that  cold,  like  heat,  acts  directly 
on  the  muscles  of  the  arteries,  an<l  in  the  .sj-eoiul,  to  doubt  whether  here, 
as  indicated  by  the  gnater  sensitiveness  to,  and  perception  of,  cold  by 
the  airectetl  individuals,  there  is  not  al.s<)  a  reflex  element  present.  The 
ease  dws  not  .s«'em  to  Im-  a  jnire  one.  More  probably  Raynaud's  disease 
or  symmetrical  local  asphyxia  comes  into  this  category.     Here  we  deal 


HEMATOGENOUS  ANEMIA  3J 

with  a  remarkable  ronditjon.  at  first  spasmodic,  later  persistent  of  ct,n. 
traction  of  certain  arteries,  usually  Symmetrical.  mEst  ^mmonly  ^ 
certain  hnger.,  and  fx-s.  altlKJURh  the  whole  hand  or  thv^^^ at  thl 
ears  may  I.  aff...tcd.  The  aff^Unl  parts  become  SJLZcJim 
dead  or  tingle  ('  p.ns  ami  necllcs";;  If  the  condition  contini™  forLm. 
hours,  they  gradually  lx,t,m.-  blue  (thmugh  lack  of  pn.puls Ln  0^^ 
bl.HKl  which  slowly  accumulates  i„  the  ..apillaries).  \\ttr  ^"„?  time 
the  condition  may  pa.^s  off  and  the  aff«te<l  a  J  resume  iUnorZ 

longer  and  longer  until  the  prolonged  anemia  leads  to  death  of  th^  w 
and  gangrene.     Recent  observations  favor  the  view  that  in  these  cJL 
we  deal,  .f  not  at  first,  c,rtainly  later,  with  definite  sclen,  ?c    hanc^Tn 
the  arteries.     It  is.  indeed,  difficult  to  grasp  the  ronditioJ.  of  n^^^lL^ 

?T.e  .vl  «f/-ne.scent  or  «,H.all«l  spontaneous  gang^^-ne. 
prim/riWn  P.lw.tT  '"""'JPI.-V  <.;  a  p.".  a„,i  l„„|  .„,„,.,  .„ 


If! 


32 


77/A  BUM)h 


(a)  UIhi.  tlin..iKli ubundunt  artirial  Him.sto.iK)i...s a  wllatml  emulation 
iM  rapidlv  .I.v..|o|»hI.  Hm.  ilisturbaiur  ina.v  Im-  hut  transient,  (b)  Wlu-rt- 
artrnal  ana.stom.|.s...s  an-  pn-st-nt.  but  the  an-a  suppliVtl  l.v  the  bUnke.! 
artery  .8  larp.  nlative  to  tlu-  size  of  the  .bilateral  vessels!  it  is  obvious 
that  at  hrst.  the  rj'Kion  thus  deprive,!  of  its  i-orinal  blo(Ni  sui>plv  obtains 
ma.  iciuate  nourishment,  ami  its  funrtionn!  a.  ivitv  is  tfravelv  depres.s,^| 
Nuh  conditions  we  find  obtaining  eharaeteristicallv  in  the  lunVs,  in  whi.li 
every  repon  has  a  double  arterial  suoply.  in  the  ^m  fmm  the  bn,nch.s 
of  th,.  pulinonary  artery,  but  in  ad.htlon  fn)m  th..  (smaller)  branches  of 
the  bit)nchial  art. Ties,  (r)  When  the  artery  is  tnilv  terminal.  We  shall 
.lis.  uss  the  n  suits  in  tlw  f-.llowinjf  chapter. 


CHAPTER    II. 

TUK  HUMW)  -IHK  KI  KKris  (,K  (  M^^lKK  (.K  VESSELS. 

It  ha.  Ut,.  ,ns...,narv  |o  ,Ji.s<u,,s  .Ik-  ..ff«t.s  of  am-st  of  .ircnlation 
tlm.uKh  a  vcv^^l  „.  c.onn«.ion  with  tlH-  .n-afment  of  hKa.ion  (in" uS 
works),  or  of  emlwlism  an.l  .hroniUwis.  Th.-  rtsuh  ha"  b^n  .^otJ 
I.Ml.-  rep....,.o„.  a„.l  a  tcn.h.nc,  to  «.^nl  th.  «..sultsa  le  U  "o"  or 
oth..r  ,«r  uular  <aus...  „,„J  „..t  „.  ,h.  natural  o.,t«.,„..  of  .he  shnph 

su  .j...t  of  .KrIuMo,.  first,  an.l  later  to  .leal  with  particular  LXs 

,m  ti.'ult'"Ts;.i'''  th"'  '''I'"'-  "'V  '?'"'^'  "^  "'*-  '*'"-'  ""'^  •hm.Kh  a 

imrti  ular  lesM-l.    h,-  p-n.-ral  cir.u!atioii  «,ritinuiiiir.  inav  Im-  Im.iiirht 
ahout  .n  thr...  „„.,„  w„vs:     ,1)  By  p^-ssun-  acting  fmm' w?h<.ut7' 
h  overKrowth  of.  or  ^n.wth  within,  the  vess,-!  walk  either  cw^nti;- 
"...I  .hffu-..  or  i,M-ah.ej  .  ^,  that  the  lumen  InKtmHs  ,no«.  aS  mo^. 

'ri'Tr^            ;'  '"*  ""!."-■  "'•'"'•""«'=  "^  '••*)  I'.v  l.l.Kka^.7rom  within 
I  he  pn-ssur,.  fmm  without  may  in-  very  variouslv  pn„lu.,.l-me^ha  w 
••al  y.  as  l.v  hKatur...  or  from  general  <t,mprvssion 'exertecrover  a^irt 
ov.-ra,mrtuular  vessel  ,..  y.,  ,,y  a  toun.i,,;,et,.  I.v  the  Kn.wth  of  a^m  r 
..r  cyst,  enlarge.!  glands.  c.i.-atnVial  hanlls.  et,-      'IV  X    0",^ 
. hmmufon  of  the  vascular  lumen  by  over^n^wth  of  the*Tsle    S 
.no.sc.|en,s,s  (en.iartentis  obliterans,.     The  ...rrespon.linK  <t  nriition 
I.I.  lH,s,len,s,s.  .Km-s  ocrur.  but  rart-ly  pnM«.|s  so  far  as  J,  .Ztemte 
'"■I""""  of  veins.     The  infiltration  of 'the  intinu.  bv  new-^n  wt^  W 
....I  .0  hke  results.     HKn-kaKe  fn.m  within  is  ,lue  to"  ei therT  of  "w" 
ses   or  „  ,„„.,,.,„.,    „f  ,he  two.  na.nely  //,r„,«W.,  the    mmvite 
It  avascular  'ViottinK"  of  the  I.I.kkI.  an.l  .,nholi..„,  ,he  ar^st^ 
-natter  foiviKi,  to  the  nonnal  bl.Hxl  at  some  point  when-  the  sLTan, 
mnhKuration  of  the  vessel  pi^-vents  further  pmgn^.ss  along  the  Lrn 
Niichforeiini  matter,   fof  ri*.„.l„,..» __..'?    .  ,.     ""«  '"«^  '""len. 


ASTERUL  O0OLU8I0N. 

a'teries    3?the SeofTh  P'*"*"''*"  "'  '''''*"^*  "^  anustomcsing 

( 4)  t  c^'extint  o    th  *       v''^  T^P"""'  *'*'' »'»'  ^«"«teml  ves.sels^ 

'I  •  heart^an"    arter^LlTr  7^^''"^  ^■'  t  ':"">'  ''^^  '''^  ™"'J't'°"  ^^ 
neart  and  artenal  blooci  pre.ssurr,   (6)  the  venous  blooci  pres-sure 


ARTERIAL  OCCLUSION 


(7)  the  rate  of  ik>w,  or  perhaps  more  arcuntely,  the  difference  between  the 
arterial  and  venous  pnvisure  of  a  nart. 

We  have  placrd  in  the  first  ...ace  what  at  first  thought  would  seem 
to  be  a  minor  factor;  further  unsideration  shows  ''  'lere  is  no  factor 
that  so  materially  mo<lifies  the  result,  llie  slow  -k  .  union  of  an  artery 
extending  over  days  before  it  is  ctimplete  permitj  the  development  of 
an  a<lequate  collateral  circulation,  so  tnat  wnen  occlusion  iNHtimes  com- 
plete  the  region  supplied  by  tht>  iilm-ketl  artery  may  exhibit  not  a  sign 
of  disturU-d  nutrition;  the  .sudden  iMx-lnsion  of  an  artery,  as  by  an  em- 
IkiIii.s,  may  lie  pnKluctive  of  grave  <li.sturbances,  even  of  necrosis  in  the 
area  of  supply,  and  this  notwithstanding  the  prt>sen(«  of  collateral  ana.s- 
tomosing  vessels.  Before  these  vessels  become  sufii<>if  ntly  dilat(>d  to 
afford  an  adequate  blood  supply,  the  imperfect  aeration  may  have  lc«l 
to  tissue  death. 

The  presepce  or  absence  of  anastomosing  arteries  is  a  very  important 
factor.  As  Cohnhcim  pointed  out,  the  arteries  of  the  body  are  of  two 
types,  the  anaatomonng  and  the  terminal,  as  indicated  in  \\  »  accompany- 
ing diagrams. 


Fill.  I 


SiliMna  of  an  anaatumuving  cirrulaliun.  If  a  branch  be  ligaturrd  or  blocked  an  at  a.  ili.' 
j»Kiiiii  supplied  by  that  branch  rec-ivw  abundant  blood  through  the  anaatomnaeii  between  it 
anil  other  arterie»,  6  and  c.  At  lno«t  Ihrre  w  an  arretted  circulation  in  the  artery  itaelf  aa  f:ir 
a»  the  nearest  points  of  branching  or  anastomosis  alHive  .  .nd  below. 

Ax.V.ST0M08IN(i  AhTKRIES— COLLATKKAL  ClKlTLATION.— It  is  obvioilS 

that  ill  those  of  the  former  order,  ligature  or  bloc!  age,  say  at  a,  will  iiinc 
very  little  effect  upon  the  circulation  of  the  area  beyond ;  bloofl  can  ><i 
ea.sily  pass  into  the  area  from  the  arteries  6  and  c.  The  case  pr<  <ents  mo 
difficulties  under  the  .simple  conditions  exhibited  in  the  diagruin.  'llii' 
conditions,  however,  are  not  always  so  simple.  A  large  and  import.mt 
artery,  such  as  one  of  the  iliacs,  may  liecome  obliterated.  The  doisil 
aorta,  even,  tlirough  imperfect  development,  as  in  tlic  i-undiliun  kisc  mi 
as  coarctation,  may  Ik-  either  cxce.s.sively  narrowe<l  or  completely  blocked 
just  above  the  region  of  entrance  of  the  ductus  Botalli.  And' notwith- 
standing the  arrest  of  blood  flo  >    through  such  important  chanii'  Is, 


ANASTOMOSINO  ARTERIEH-COLLATERAL  CIRCULATIOS       35 

inst^  of  the  part<i  lupplied  becoming  necrose.!,  we  find  that  thev 
receive  siifBrient  nutntion  to  remain  alfve,  n.y.  1m.1t. .  after  a  tiim.  the 
«rcuUtion  through  them  may  become  wholly  »ufli<.ient  for  the  demand-, 
made  upon  the  region  m  the  course  of  eveiynlay  existence.  In  these 
cases  we  .leal,  it  is  true,  with  the  same  phen..n».non,  but  with  this  differ- 
ence,  that  the  anastomosing  or  collateral  ves.*ls  an'  ..ften  vessels  which 
iiormallv  are  inconspicuous,  that  it  is  not  iiu'itly  the  branches  im- 
mediately  al«ve  ami  below  the  obliteration  that  c-any  the  necessary 
blood  that  vessels  over  a  smgukriy  wide  aifa  may  1^  involve.1.  and 
the  collateral  channels  may  be  curiously  ro.in.l  al«ut.  An  extraordinary 
and  widesprra.1  series  of  arterial  anasfoiiH.ses  an.l  cnlai^l  collatera'l 
channels  IS  to  In-  ina.le  out  in  the  cases  of  congenital  .^D«lt  tation  of  the 
aorta.     Apart   from  persistem-e   of   th..   .lu.tus   arteriosus,    what   are 

I  i.i.  i 


.hir,y.fiv.y,.„.     (After  J.  K.  M«T"l::d",:„r.:)    '  '"'""   """'"•     »"""»">■"•■««'■' 

ordinarily  unrect.guiEable  anastomoses  between  th..  interct)stal  arteries 

I     \\hat,  It  may  be  asked,  is  the  process  whereby  these  small  ai.us- 
IN)   as  to  Junction  as  mam  channels y     It  cannot  be  said  that  wo 

Kbi«"t  h^I^y^-H^S'  P"""--  ''^^'  "»•«  "^^  -pec"  y  studi:. 
Rhe  subject,  has  laid  down  certain  principles,  but  these  do  not  exnlan 
fhey  only  state  the  facts  as  we  find  Siem.^  With  TW.  we  are  foS 


AHTKRIM  (HXLVSUtS 


in  !in-  ttiHt  it  ix  iH>t  primarily  hii  ut-tivp  distfiuiiMi  uf  th«-  ivillatrnil 
vt-jiiifls  thntuKh  incTcB.tHl  prp.isun-.  It  is  tnu'  tluit  wliere  tt  larjfp  vessel 
iNt^iiiiifs  siiililtiily  or<  lii)le«l,  that  iM-ciiiMinn  iiHliitrs  iiifiva.>ie(l  pit'Hitun* 
ill  tlw  v«'.H.st>l  (anil  its  hraiiches)  iN-hiriil  tlie  region  of  obliteration, 
but  this  is  only  u  tenifioniry  stale;  within  a  very  .short  time  tlu*  bkioii 
iMttimes  reilistribiiteil  anil  tlH>  |ire.s.siin-  falls  to  tile  iHirmal.  .Vs  von 
UeckliiiKlituiscn  iiointed  out,  the  important  factor  is  the  rate  of  blixMl 
flow,  .\iiil  here  it  inii.st  In-  iiotiil  that  that  rate  is  iletermineil  primarily 
by  ri'lnlitr  pren/mrt;  I.  «■.,  by  tin-  ilifft-n-iMv  in  pnvssun-  in  the  ve.s.sels 
alNive  (he  obstniclion  iiiiil  tlHis*-  in  the  area  whose  supply  has  U-en  eiit 
off;  the  greater  the  iliffen-iui'  U-twei'ii  tlies*'  two  pn'ssiire.s,  the  more  rapiil 
the  flow  of  bliNNi  into  the  |Mrt  thn>iif(li  ve.ssels  that  are  still  open.  Thcmia 
lays  ilowii  as  his  first  principle  that  tlw  ilistension  of  the  vessj'ls  is 
ile|M-nileiil  ii|ioii  tlie  rate  of  flow  through  them.  'I'his,  liowever,  iIik's 
not  carry  us  very  iiiiich  farther.  Immeiliately  after  li)(atu'v  or  other 
obstruction,  the  |m's.sim-  in  the  artery  U'vomi  tlie  obstruction  sinks  to 
/(To.  HIimnI  then  |)oiirs  into  the  artery  from  anastonM^sing  vess«-ls;  tla- 
j{r»'ati  r  the  pressure  in  the  artery  aUive  the  olxstniction,  the  jfreater 
the  rate  of  the  flow  through  tluvse  vessels.  Hut  circulation  caniHit  In* 
nestablislieil  throiif;h  the  capillaries  of  the  area  suppliisl  by  the 
bliM'keil  artery  until  the  pressure  in  those  capillaries  lieitunes  hijfher 
than  that  in  the  veins.  Or  otherwise  the  time  must  come — anil  that 
nlulivcly  soiMi,  unless  the  an-a  of  supply  is  to  die  from  sta((nation  of 
the  lontuineil  IiIinmI  when  in  the  vessels  forming;  the  ana.stomo.ses 
tlun-  is  no  inarkeil  ilejuirtun-  fniiii  the  normal  pnssun-  iiiffer«'nce 
U'twcen  aritry  .--'I  Nci'i,  iiinl  when,  then-fore,  the  rate  of  flow  must 
tend  toward  the  ..ininal  and  tin-  liilatHlion  of  tlies*-  collateral  vessels, 
acconlin^  to  'i'lioma's  principle,  must  U-  bnuiKht  to  an  end  and  should 
^ivi-  plaii-  to  I'ontmctlon. 

\Vc  would  sufj^-st  thai  another  principle  has  to  In-  taken  into  ui-ci>iiiit, 
not  (oiisidensi  by  'riioiim  -the  principle  akin  li  tha*  of  Harris' 
"  fiiiictioiial  inertia,"  noted  in  our  first  volume  (p.  M>),  the  priiuiple 
of  "overndaptatioii,"  which  time  and  ajjain  we  obx-rve  in  vital  phe- 
nomena. We  would  thus  sujjp-st  that  when  collateral  vess»-ls  e.\|Nind, 
owiii^  to  iiicn  used  rate  oi  '  ''H)!!  flow  throu){li  them,  the  eX|>an.sion  is  in 
jtn-ater  ratio  than  the  iiicreasi-  in  rate  of  flow,  with  the  rt-sult  that  the 
capillary  pn'ssiin-  in  the  ar»-a  of  supply,  instead  of  U-iiij;  lower,  tends  to 
Ih-ioiiic  even  hi>;her  than  that  in  the  surmiiniliii);  ti.s.sues,  whereby,  in 
place  of  stu^nation  of  the  bliKMl,  an  active  circulation  is  favored,  t.  e., 
a  jjreater  "fall"  into  the  effen-nt  veins.  We  fully  accept  Thoma's 
s«-cond  incchanical  principle,  that  with  dilatation  of  a  vessel  the  addcnl 
strain  of  the  larjp-r  stream  of  bliKx!  jMissinj?  throuj»h  it  leads  to  j?n>wtli 
of  the  walls — pntvided  that  the  strain  In*  not  e.\ces.sive  (.see  vol.  i,  p.  M\ ). 
Thus  it  is  that  what  had  iNt-n  little  more  than  arterioles  may  liecome 
developed  into  relatively  larjp-,  thick-walleil  arteries. 

In  other  wonls,  a  collateral  circulation  can  In-  maintaintsl  only  in 
thos«'  cas«-s  in  which  tin-  anastomosing  vessels  are  sufficiently  largi' 
or  sutticiently  numerous  to  pn-.si-rve,  when  dilatt-il,  the  circulation  in 


ANASTn.MosiNO  VKISS  ^ 

iIm-  ari'n  Ih-voihI  t\w  oltliti-rHtioii.  Wlirn-  jIm-v  uri'  iiiiMl«-<|iiuti-,  tlH-n-  iIh-v 
|Miiir  likMMl  iiifai  tlH-  un-a,  iiixi  in  iIk-  al>.-«'n<v  of  u  .HuWkii-iit  m  a  l(rm>, 
t\w  hkNMi  tttagnatc.H  in  the  |mrt.  atul  Uy  its  HtHKimtion  the  flow  tlm>UKli 
rh*'  •■oIIhUtbI  vewteld.  in.Hti>a<l  of  i-oMtiniiinj{,  Im'k'imih's  am-sj*-)!,  biuI  iiifan-t 
foriimlion  or  ((angri'iH'  is  tlw  iH>«-«>.H,Hitry  consfqiiciKi-. 

AxAMToMoHix(!  Vkixm.  — In  th«'  i-asi"  of  th*-  v«'ins.  wi-  lmv«-,  it  is  truf,  a 
soim-what  ilifft-ivnt  comlition  of  affairs;  tlic  I)|«nmI  imssinK  «hn»ujjh  the 
collateral  ve.viels  lias  not  to  supply  later  a  eanillary  area;  it  lias  nn-rrly  to 
fimi  its  way  into  anotlwr  vein  nean-r  tin-  heart!  'I'he  ilaiiKir  tn-re  is 
not  one  of  sfajjnation  in  front,  hut  of  stagnation  in  the  cBiMllan-  area 
U-hinil. 

^'eiMHis  anastitinoses  an'  fn-«T  anil  uHire  wi<lespr«'a«l  than  an-  arterial, 
r  as  a  result,  the  extent  of  the  collateral  « iniilation  .s»'t  up  is  at  times 
\  extraonlinary.  'i'hus.  when  the  jmrtal  vein  lH'<-otnes  M-rimislv 
ohstnutj-cJ.  the  I>I<mnI  fnun  the  iM)rtal  an'u  may  find  its  wav  thmiiKh 
a  very  wiile  wries  of  tortuous  willateral  ehannels— tlmiuKh  the  (t»n)narv 
veins  of  the  stomach  into  th.'  cisophageal  veins,  thntu^h  th<.s«.  of  the 
jtastnM-piploic-  omentum  to  the  diaphragm  ami  m>  into  the  vena  azyjjos, 
thmujfh  anastomoses  U-tween  the  inferior  me.s«'nterie  and  the  hemor- 
rhoidal veins,  and  throuKh  the  retn)|M<riton«al  veins  of  Uetziiis  joining 
the  mdicles  of  the  |)ortal  veins  in  the  mesenteries  with  liranches  of  the 
inferior  vena  cava,  as  also  thnmgli  the  veins  of  the  niiind  and  suspensory 
ligaments  of  the  liver  to  the  epipistric  and  inaminar\-  veins.  When  the 
«>mnion  iliac  veins  an-  (Hrludwl,  or  the  lowei-  end  of  the  inferit)r  vena 
( uva,  we  similarly  find  the  hlcHxl  fmm  the  lower  extremities  wmvevwl 
tliniURh  the  epigastrics  and  veins  of  the  anterior  abilominal  wall'iip 
to  the  mammary-  veins,  with  the  Tormation  of  a  pn)nounce<l  upnt 
medusiB,  or  (nngeries  of  tortuous  disteiuh-il  veins  in  the  n-jfioi:  of  the 
navel.  " 

The  obliterati.in  of  a  large-  vein  coming  fmm  u  part  must  undouhti-.llv 
Ik  fol[.>we«l  by  a  marke*l  ri*  of  pn-ssim-  l.ehin.1  the  obstruction,  and 
that  nse  and  the  accompanying  dilatation  of  the  capillaries  of  the  an-a 
IS  fn-quently  act-ompanied  by  «pdema  an<l  ac-cumulation  of  fluid  in  the 
tis.sues  and  spaces.  When-  it  w-ctirs,  this  indicates  that  a.lequate  «-ol- 
latcral  circulation  is  not  imraetliately  develop»Hi.and  that  for  some  pt-ricxi 
at  least,  the  emulation  through  the  afTectc«l  part  is  impeded  'i'he  ris^ 
of  pnis-siin-  must  materially  incn-ase  the  rate  of  flow  thnjugh  the  col- 
lateral veins  Certainly  the  impn-.ssion  givc-n  is  that  the  combineil  cm.ss- 
section  of  thes.-  c-.)lliiUrn'-.  comes  in  inanv  cases  to  exc-eefl  that  of  the 
o  .literat(-d  ves.si-1,  ...,.d  t".;„  the  oi-ciusion  ^\m  mon-  than  compensation, 
un  ttie  other  hand,  the  gn-ut  tortuosity  of  thes*-  vessc-ls  and  their  long 
and  often  muiidah  •  course-  has  to  lie  taken  into  c-<m.si<leration,  as 
.tninteracting  the  free  discharge  of  blood  from  the  affecte<l  an-a.  ( )n  the 
whole,  we  .see  no  rea.son  to  imagine  that  the  sam.-  principles  are  not  at 
work  in  the  case  of  the  development  of  a  venous  collateral  circulation 
as  m  hat  of  an  arterial,  ami  we  think  that  for  then-  to  be  f n-e  .Irainage, 
he  dilatation  of  the  anastomosing  vessels  must  lie  more  than  proportional 
to  the  increased  rate  of  flow  through  them. 


38 


ARTERIAL  itCCLUSloN 


Terminal  ARTKR.»>,.-The  «,«■  is  very  diffen-nt  in  cases  of  the  latter 
b^  onrf  "fp'T '•«*}""'  *t «  wh„lly  cuts  off  the  arterial  supply  to  the  rt-gion 
th;  V  •  ■   r!J        /  "'PP'-''  '''f '  '■''"  "''^'» ''  '"^  ^*"'"  K^-  h«ck  flow  through 

^riZrv  of  ^iT  '  °"  '  V  ?''  "'*'  '*'".'"d''"'  -Pi'W  ana-stonwses  at  the 
periphery  of  the  art'a.  Not  to  enter  into  what  has  been  quite  an  active 
discuMion  we  may  say  that  the  first  of  these  methods  is  now  genera  I v 
discredited.  Such  back  flow  would  not  create  a  circulation. The^as 
microscopic  examination  of  the  peripheral  capillaries  shows  that  they 
become  greatly  d^ted  and  distended  with  blood.  Whatever  ci^-ulatSn 
or  entrance  of  blood  occurs  into  the  part  we  now  attribute  to  those 
capllanes  But  these  may  be  inadequate  to  nourish  the  part,  Sv^ 
perhaps,  at   he  ye^  edge  of  the  area  of  arterial  supply,  and  Sa  resuU 


Kici.  3 


ki,2v  Tr'"'""'  T*""^"'  ?^  '^'  '"^^  "^  "-''"^"y  g^^'^"  «'^':  those  of  the 
kidney,  bram  and  spinal  cord,  spleen,  the  branches  of  the  pulmonarv 
arteru-s.  the  coronary  arteries,  arteria  centralis  retime,  and  superior 
mej-ntenc  artery.    More  accurately,  these  are  the  arterie;  in  «,nSon 
with  which  infaret  formation  is  encountered.     Further  investigation 
^u,ws  that  these  are  not  necessarily  terminal  arteries  in  the  strict  Sn^ 
so  that  Uhnheim  himself  was  forced  to  modify  his  views,  and  speak 
of  Mc/^„«/  end  arteries.    The  branches  of  the  superior  mesenS 
notoriously  have  free  arterial  communication  with  those  above  and 
IHow,  and  yet  true  and  often  very  extensive  infarction  of  the  small 
mtestme  is  encountered     The  same  is  tnie  of  the  comnaiy  LSs 
these  are  not  devoid  of  definite,  if  small,  anastomoses,  aTth"^me' 
may  be  said  of  the  brain,  and  even  of  the  kidnev.     In  th;  lung,  as  a^T 


INFARCT  FORMATION 


^m 


ao 


in  the  liver,  while  the  pulmonary  and  hepatic  arteries  are  of  the  terminal 
type,  ''ey  do  not  afford  the  sole  blood  supply  to  individual  areas;  in  the 
one  case  branches  of  the  bronchial  artery  open  into  the  same  capillary 
network,  in  the  other  the  portal  vein  supplies  abundant  blood.  We 
come  back  then  to  this:  that  it  is  not  the  abaence  of  atuutomoaea  or  of 
other  arteries  supplying  the  same  area  that  is  essential  to  infarct  formation, 
but  the  absence  of  arterial  anastomoses  sufficiently  large  to  insure  the 
f/rrper  nutrition  of  a  part  once  the  main  nutrient  vessel  to  that  part  becomes 
xu'Mu-'-.ly  occluded. 

InLarct  Fonnation. — What  then  is  the  nature  of  infarct  formation? 
\\h<  n  such  a  main  nutrient  artery  becomes  occluded,  collateral  arterial 
•<iii>ply  is  inadequate  to  cause  a  sufficient  circulation  through  the  asso- 


Fio.  4 


White  infarct  of  the  spleen.     Section  was  made  thmuch  one  infarct  at  a  and  another  at  6,  tlie 
organ  being  thereby  laid  open.     (From  the  Patholoxical  .Museum  of  .Mctiill  l"nivenity.) 

ciated  capillary  area,  and,  owing  to  the  cutting  off  of  the  main  vis  -i 
tergo,  the  blood  pressure  in  the  area  sinks  either  to  nil  or,  when 
there  exist  small  collateral  arterial  supplies  to  the  area,  to  a  point  which 
is  below  even  the  venous  pressure  of  the  surrounding  tissue.  As  a 
consequence,  the  specific  tissue  cells  of  the  part  no  longer  gain  sufficient 
oxygen;  anabolism  is  arrested,  although  catabolism  and  disintegration  of 
these  substances  may  continue  and  result  in  the  diffusion  of  carbon  dioxide, 
and  other  end  products  into  the  lymph  and  blood.  We  may  compare  the 
process  with  the  continued  discharge  of  carbon  dioxide  by  the  frog  placed 
in  an  oxygen-free  atmosphere,  or  the  liberation  of  carbon  dioxide  from  the 
removed  kidney  through  which  is  perfused  an  oxygen-free  salt  solution. 


40 


AHTERIAL  (»(<LVSH>S 


llu  r,.M, U  wouKI  My.n  (o  Ik-u  ,K.i,s,„n„K„f  tl„.  tksur  with  tlu-  pnMlu.fs„f 

•s  own  (lu.nh.grat,«n      ^^•hiI..  ,|.i.s  is  p„Kr.<li„K,  1,1ch.I  ten  Is  t  >  ,m,  r 

mto  the  raptllancs  of  the  part  fmm  th,-  snrn.nn.HnK  .apillaries  wi.l    hi 

but  with  It  follownng  Wey^^n's  com-ei.Hon  of  the  pnKrss,  th.-r,-  w„ui< 
appear  to  Ik;  .some  mcrea.secl  tmnsudation  of  fl.nVI  fn.m  the  ,  apillaries 
and  absorption  of  the  same  by  the  tissue  ,rlls.  The  nuelei  o  thS 
ceHs  lose    he.r  chromatin.     Wheth.r  this  ,liffu.sc..s  out.  or  is  .^mverted 

hrough  the  formation  or  libemtion  of  a  thmmbil,  or  fibrin  ferment' 
.he  whole  area.  ,ells.  K n.ph.  and  blood,  „nder«,K-s  a  proce.s.s  of  eoa^fa- 


Iin. 


i 


ih/ 


Anrmi<'  iiifunt  ,>f  i-,,rti.\  i,f  ki.lnpv  i,,    ],   ..  i 

"I  M>iiitr>ti>>ii:  ,     nrtprv.     (Orth.) 

tion;  they  pa.s,s  into  a  ,„„dition  of  cmKulation  necmsis      The  whol.- 

r.rrr4;i:„:;tTh;',,';.';,;a''  K;",nia"""  r  ^"t 

vellnw  nnl.J ,,.1.  J  *     .    .".'•     *'  "■''»  "t  either  of  a  pa  e.  eravish 

•li^A^r^tt  "^  """""■  '"''"•'•  "■•  "'  ■*  ''-P  Wood-^ll^rf  or 

in  ^^?id^i^{^'^''''7■'•"'^''"^r*  '■"  ^'"^-ntered  almost  eonstantlv 
u.  the  kKlnex.  freq.„.nfly  ,n  the  brain,  heart,  and  liver.  les.s  f«.quently 


khJU  tXFAHCT 


41 


ill  the  .splwn.  rari'ly  in  the  skin  uiul  intrstiiir,  pmctknlly  iitvcr  in  (lie 
lunj^.'  Wlien-  rwt'nt,  thr  finer  histology  manifests  a  |HTi]ilifral  p^atly 
<-onj<esti'<l  zone,  in  which  the  capillaries  are  j{n'atl_v  distended  with  hjnod, 
and  within  this,  nn  almost  hyaline  mass,  in  which  the  outlines  of  the 
constituent  tissues  can  Ih>  faintly  distinguished,  the  coiistituent  wlls 
appearing  to  nm  into  each  other;  the  nuclei  are  invisible,  anfl  the 
whole  area  has  a  homogeneous,  unstaineil  appearance 

Red  Infiret.^This,  as  reganls  incidemr,  is  the  c<mverse  of  the  white; 
is  practically  always  the  form  present  in  the  lung,  is  the  commonest 
form  met  with  in  the  intestine,  is  ran-ly  pnvsj-nt  in  the  kidney,  etc.  We 
would  add  that  the  so-call«l  red  infarcts  of  the  liver,  due  to  obstruction 
of  branc  hcs  of  the  portal  vein,  cannot  1h'  considen-d  as  genuine  infarcts; 
they  exhibit,  it  is  tnie,  enonnous  congestion  of  the  capillaries,  but  the 
liver  cells  and  vessel  walls  an  not  necrotic.  There  is  still  in  them  a 
collateral  circulation  sufficient  to  prt-vent  (t'll  death. 

Where  n'e«>nt,  micro.scopic  examination  .shows  that  not  only  an'  the 
capillaries  thnnighout  the  n-d  infarct  gn'atly  distended  with  coagulated 
bl<M)«l,  but  in  addition  then-  is  abuntlant  evidence  of  hcmon  hagt-;  the  tissue 
spaces  are  filled  with  extnivasatt-il  blood  cells.  Then-  is  no  evidence  of 
actual  ruptun'  of  the  capillaries,  the  hemorrhagi-  has  In-en  iM-rdiafH'dexin. 
The  ti.ssue  cells  of  the  affecte<l  area  slir)w  necro.sis  and  ab.sence  of  staining 
of  the  same  order  as  that  seen  in  the  white  infarct.  Hen-  one  partial 
exception  must  Ik*  made:  in  most  n'd  infarcts  of  the  hing  we  have  Iteen 
able  to  recognize  still  the  nuclei  f)f  the  capillary  endothelium,  staining, 
it  is  true,  more  feebly  than  normal,  but  standing  out  with  some  j)r  nii- 
iience  in  contrast  with  the  surnnniding  non-staining  tissues.  This  is, 
we  hold,  correlated  with  the  existence  of  a  second  arterial  blfMxl  supply 
to  the  ()art  through  the  bn)nchial  arteries.  .Such  ti.s.suc  is  not  ab.s«)lutely 
iie<rotic,  and  through  it  the  cin-ulation  can  eventually  Ikh-ouic  n-stored; 
<-oiisiderations  which  explain  the  singular  rareness  of  indi<ati()ns  of  old 
cicatrize<i  infarcts  in  the  lungs.  It  is,  imleerl,  singular  how  mrc  it  is  to 
encounter  anything  that  may  be  reganled  as  the  cicatrix  of  a  previous 
infarct  in  the  lung,  and  yet  infarction  at  a  pn-vious  period  must  Iw 
comiiion,  especially  in  cases  of  long-standing  canliac  disease.  When-, 
as  in  the  lung,  there  is  this  double  circulation,  we  must  conclude  that  in 
a  (rrtain,  it  may  Im"  a  large,  proportion  of  cast's  the  vitality  of  the  tissues 
is  not  entirely  lost,  and  that  subs<'quent  resf)lution  and  n-generation  of  the 
alvt-olar  epithelium,  etc.,  is  jK).s.sible,  the  part  n'turning  to  the  utatux 
quo  ante.  We  thus  n'cognize  a  series  of  transitional  ca.s<s,  tlmmgh  the 
"n-d  infant"  of  the  liver,  with  little  or  no  ne<n>sis,  the.s«'  nd  infarcts  of 
Ihe  hmg,  with  m'cro.sis  of  .some,  but  not  of  all  the  comjHinent  tissues, 
up  to  the  infarct  proper,  with  complete  coagulation  necn)sis. 

Hen-  also,  in  passing,  it  must  1h'  emphasized  that  the  n-d  infan-t  is 


'  \Vc  liavc  on  two  occaHioiM  encountered  soft,  gray  infarcts  in  the  lung,  but  thcHC 
were  ol)\  iously  late  stages  in  the  resolution  of  a  red  infarct,  with  breaking  down  of 
•  he  en-throcytes,  and  diffusion  nut  nf  the  hrmnglnhin,  and  iti  one  of  the  two  cases, 
beginning  organization. 


42 


ARTERIAL  OCCLUSION 


1 


I 


.irr'.     .    •  f^'"."  "   ■"  •"   '"""t"  •"<    purpoac..,  i,|,,,ii™|    ■.ill, 

enH  to  rim    "tS;  ""  t*  ''I  T^^^"  anlrClC 
i«i.    TO  oe  extreme.     What  is  perhaps  the  best  example  of  this  form 

he^aZr  ^  encountered  in  infants  in  the  hemorrC^nfLtTf 
the  adrenal,  a  rare  cause  of  re  ativelv  sudden    lenth      'ri,        • 
disturbance  would  s^-m  to  be  tUromLtTtU^ltJ^inS 

d  fd  tlTTTs  stiiu'^m"?^  T"^"'  '"*^""'^  hemorrhagic"Ls.!o 
utau  tissue.    It  IS  still  a  matter  of  controversy  whether  some  «t  !..«.» 

of  the  red  mfarets  of  the  Jung  are  not  similarl/d^e  not  to  ^mb^  ism  of 

then*;,]!"^  '^"  P^'T".*""-'  ?'-'^'^'  *'"*  t«  th™mi;x;is  of  brancheTo 
the  pulmonuj-  vein     It  is  quite  possible  that  this  may  be  the  ca^.    but 

r/re°at'.s"th  '  "'*'  T*"  ^-^Vl'V''''-  P"'™— y  infaretare  s'u'dS 
V\V  17.    Tk  "iT'^r  •"  *''«^'>  «••»'■"■»•  embolism  is  encountered' 

s  Rcnerally  m-cepted  that  when  the  arterial  suppli  to  71,1™"  tl . 
;^nou.sd..scharKe-is. slowly  obliterat«l.  infaret  f„?Lti!m  d.iTno^^u 
lime  IS  then  Riven  for  the  establishment  of  collateral  cireulation      F^nr 

iont  fr"  "'if-rr-'i  'r  r'«"r'>- .-'''-  arrer;/'r  drc-S: 

even  wl.L^       •    !i  '^*'""«'P^'  «'•*'  th«t  infaret  formation  may  occur 


1 


THE  .\fODE  OF  PRODUCT lOS  OF  RED  AND  WHITE  INFARCTS     43 

that  white  infarcts  involve  just  those  tissues  wliich  either  have  U-en 
n'cogniz«Hl  as  most  rapidly  succuinhing  to  eirrulatorj'  am'st,  or,  on  the 
other  hand,  are  those  which  after  death  aifoni  the  most  abundant  pro- 
teolvtic  ami  other  ferments,  an<l  un«lergo  autolysis  most  rapidly.  Thus, 
for  example,  it  is  the  heart  musele  that  of  all  the  musc-les  in  the  body  first 
shows  rigor  mortis,  and  first,  through  autolysis,  passes  out  of  that  state ; 
the  ner\'ous  tissue  that  first  shows  laek  of  response  ((.  e.,  dies)  when  its 
blood  supply  i*  eut  off;  the  cortical  tissue  of  the  kidney  that  has  empiric- 
ally been  selected  to  ''emonstrate  the  necrotic  effects  of  temjxirary  arterial 
ligature  (Litten's  experiment,  vol.  i,  p.  Xoo);  the  liver,  kidney,  spleen, 
and  heart  tiuscle  that  most  rapidly  exhibit  autolysis.  Or,  otherwisi , 
it  is  just  tho.se  organs  that  either  are  most  susceptible  to  arrest  of  blood 
supply,  and  whose  cells  die  with  n-lative  ea.se,  r)r  again,  tho.se  which, 
dying',  discharj^  abundant  autolviic  enzymes,  that  may  exhibit  white 
infarct  formation.  Thus,  we  must  assume  that  the  essential  cause  of 
the  white  infarct  is  ihe  relatively  rapid  death  of  the  constituent  cells 
of  the  affectecl  area,  with  liberation  of  thrombin — or  prothrombin — and 
that  coagulation  ensues,  or  rigor  (for  the  two  processes  w«)uld  seem 
to  l)e  of  the  same  order),  before  t}ie  capillary  ana-itoniosea  have  widened 
mfficiently  to  itidwc  hemorrhage.  That  in  some  organs  we  encounter 
now  white,  now  re«l,  infarcts  would  .si-em  to  gain  its  simplest  explanation, 
not  primarily  in  variations  in  blood  pressure  anrl  in  the  rapi<lity  with 
which  blood  finds  its  way  into  the  ves.sels  of  the  infarctous  area,  but, 
as  Lubarsch  points  out,  in  the  state  of  the  cells  at  the  moment  when 
the  circulation  is  <ut  off.  He  gives  an  excellent  example  in  pn)of.  In 
the  healthy  rabbit  it  is  only  after  ligatun-  of  the  renal  artery  for  about 
an  hour  and  a  half  that  necrobio.sis  o.'  the  kidney  is  induced.  If,  how- 
ever, the  animal  Ik;  inoculated  with  diphtheria  toxins,  or  l)etter,  if  acute 
nephritis  be  .set  up  by  i.itruvenous  injections  of  anunonium  chromate, 
and  in  the  coursi-  of  the  next  day  the  n-nal  artery  l)e  ligated,  now  closure 
for  only  thn'c-fjuarters  to  an  hour  is  needefl  to  iiuiuce  complete  infarction 
of  the  whole  ki<lney,  recognizable,  not  imme<liately,  but  eight  hours  or 
so  after  the  temporary  ligature.  He  {X)ints  out  that  by  n-jK'ated  closure 
of  the  artery  for  half-hour  periods,  eventually  the  kidney  wUs  l)ecome 
so  susceptible  that  half-hour  closure  is  foUowetl  by  infarction.  We  may 
recall  the  parallel  observations  upon  the  great  variation  in  the  onset  of 
rigor  in  muscles.  Where  the  muscle  has  been  over»"xerci.sed,  as  in  the 
huntcfl  animal,  this  may  follow  immediately  upon  tleath;  in  other  cases 
putrefaction  may  ensue  before  it  can  show  itself.  And  so  it  has  to  be  kept 
in  mind  that  infarct  formation  does  not  necessarily  follow  upon  closure 
of  a  terminal  or  functionally  terminal  arterj*.  The  state  of  the  tissues 
determines  whether  coagulation  necrosis  does  or  <loes  not  become  de- 
velopetl.  This  is  particularly  noticeable  in  the  lung.  We  have  already 
pointed  out  that  here  infarction  is  often  incomplete,  but  in  addition  it 
has  to  be  noted  that  a  large  proportion  of  cases  of  embolism  of  branches 
of  the  pulmonary  artery  fail  to  show  any  sign  of  infarct  formation. 
This  is  more  especially  the  case  where  large  branches,  such  as  tho.se 
supplying  a  whole  lobe,  become  blocked.     In  these  the  most  we  obtain 


44 


]ii 


ARTERIAL  OCCLUSlOS 


i 


lif 


'•'•HKl  -supply  .su.Id?„Iy  out  off  rho7„..srrth  '"'^'/r"*' '""«  '"«  ■''' 
•nay  never  r.a,h  a  Sufficient  hL^^.^•^;u:"P'''^ 

"'an,fe«t.Hl  .hemi-lves,  and  mil  ;  '  '"''•^T'*  '"'^'^  «''^«d  " 
"'•'  »'-xplanat.o„   whv  infaR-tTomat  o     "'J'"'''"^""  »'«-•     Here  „,«v  .;. 

area«.  and  why.  wi.e'n  thrbl  JrsuDr  f  •  T^";"'^'  "''''"■^Hv  small 
-ml.,  for  example-then,  in  rZlo^l'"  7'  "V"""  ^""'^^  «"■««-« 

Active  nwrosi^  „r  gangp;ne  '  formation,  we  obtain  a  lique- 

1.  o«<l  n  the  vessels  of  ihe  ol  stnu  tH  ant  tir^r"^^*  "[  "''^"^  "^ 
"f  ml  or  white  infarct  r.-sw"thSv  Th  ^  "'"'''''''' *''''''*^""' 
experimental  infarct  formation  /,„//'  ".''servers  state   that  in 

fen- hours  sh,,ws  the  .listenS  oh      'T  ''"«'»' "«*'o»  ''"rn.ff  the  firl" 

fhjwhatdeterminestLX^et^SuHnT^^  ^''''^-'-' 

IS  the  rate  of  onsj-t  „f  the  fnaJ.l  .•  •    '"'"'^'  '>«-ome.s  develooed 

'"^^Ms^;:^--  as  a,.adv 

;.f  proteolytic  fermeSs:  I.n.aTv  o  a'^Str  ''"".'^r^^^-  "''  ««»'■" 
'VS.S.  It  ,.s  ,,,,sil,|,  ,h„s  that  Vapllar^tCmK-  •.''''""•'*•''  '"  ""'"- 
■YPf'/'n-that  the  hemorrhagic.  S^,tir,h  "."''^'•«"\ '^^Pl-te  ab- 
hkewise  ab.y)rlKNl,  that  with  The  I..V.  I  •  i  ^'  '""«  «'^'«'''  become 
ation  the  vas..„|„r  .n,lotM?u  '^."^s  S^^^^  1 1"  "''^l-'''  «'-"- 
the  a  veolar  epithelium  •KH.mes'S.r.^^t  1 1  '  •'  'l'''^""'  ^''"^ 

From  the  jHTiphentl  .one  <^  rntte;!  ca  ilL  '  ?""'.  '-^P'™'  -•''"»• 
Pa.ss  mto  the  nec,.,se,l  a«.„  vSythrlYT  "'"""'«"»  lenkoc-vtes 
partly,  i,  n.ay  Ik-,  thn.ugh  Jhe  ut  ,i  tlS  "  ''7'""*'>"'^  """^y^^^' 
pmivss  of  solution.  an.|  as  this  ,m„!    I  ""^'''  ""'''  "n.ler^.es  a 

from  the  priphery.and  «"h  v  tt^  I  iLrj  ;«P'''f  {  '-P'^  P^^s  i„ 
of  granulation  tissue  an.l  of  snl  J«  .  I  ■  ^"■'"'"'  "^  *'"'  ''«'Velopment 
a  fm,uent  ex,H.rien..,  S  „  hJTlen^  '"V- """•"  "^  ^''"  ^'"e.^t  is 
""•  ki'lney  and  in  the  spC„  P""""'*'  '"•«»""'  "'  "Id  infan-ts  in 

3.  ry/   Format  inn. —In    the   bru...    . 

organi^ation.  cyst  formation  nIvsWitX  P"'"",™'"'"'-^'   '"   P'«''*'  "f 

4.  Puirefarfinn      \vk  *     .       "■^"  (see  vo  .  i.  n  79.5^ 

'  Heattie  and  tJixon,  A  Text-book  of  l'atholo«-  r  •     • 

1  atnologj-,  Lippincott,  1908. 


MORTIFICATION 


45 


to  the  size  of  the  iiifan-t,  we  may  encounter  either  a  putrefactive  softening 
of  the  infarct,  with  liquefaction  of  necrotic  area  through  the  proteolytic 
hacterial  enzymes,  and  without  the  formation  of  true  pus,  or — 

.').  Suppuru'ion.-— In  small  infarcts,  true  abscess  formation  with 
abundant  leukocytes  attracted  into  the  area  fn)m  the  surrounding 
capillaries  may  Ik-  developed. 

(i.  Calcification. — The  conditions  favoring  calcification  of  a  necrosed 
iin-a  have  l»een  discussed  (vol.  i,  p.  jS"i2). 

Mortification. — '1\>  recapitulate:  where  (1)  there  is  inadequate  anas- 
tomosis, and  when>  (2)  the  area  whose  bloo<l  supply  is  cut  off  is 
extensive,  there,  in  place  of  coagulation  and  infarct  formation,  we 
encounter  mortification.  \V»-  employ  this  term  rather  than  what  is 
usually  reganltHJ  as  its  synonym,  gangrene,  In'catisi',  to  most  minds,  the 
latter  carries  with  it  the  implie<l  contrption  of  putrefaction  anil  decom- 
|M)sitiou  of  bacterial  origin.  More  recent  research  shows  that,  at  lea.st 
in  the  first  stages  of  cases  of  this  order,  then'  is  an  aseptic  softening  of 
the  tis.sues  due  to  autolysis. 

We  feel  some  hesitation  in  drawing  this  sharp  distinction  i)etween 
infarction  and  mortification.  It  may  well  b«>  that  in  the  majority  of 
cases  in  which  tissue  death  occurs  fn)m  the  cutting  off  of  the  blooil  supply 
of  a  part  there  is  at  least  a  preliminary  stage  of  rigor  and  coagulation 
uecn)sis.  Hut  if  .so,  this  may  Ih'  imperfect,  involving  certain  tissue  con- 
stituents mort-  than  others,  and  pa.ssing  off  with  n-lative  rapidity  as 
autolytic  pnnvsses  manifest  themselves.  We  approach  here  a  problem 
that  has  not  yet  to  our  knowledge  l)eeu  made  the  subject  of  investiga- 
tion, namely,  to  what  extent,  if  any,  <kH\s  the  development  of  coagulation 
necrosis  proj)er  inliibit  autolysis  within  the  living  Innly.  It  is  not  a  little 
striking  that  in  organs  such  as  the  kidney,  which  out  of  the  Inwly  exhibit 
rapid  autolysis,  we  en<t>unter  white  infarcts  which  evidently  are  many 
days  old,  but  which  have  remaine<l  firm  with  no  signs  of  autolytic  soft- 
ening, or,  at  most,  what  has  U'en  termed  heterolytic  softening  at  tin- 
IKTiphcry  through  the  agj-ncy  of  invading  leukocytes;  whereas,  in  other 
organs,  in  which  infarct  formation  is  not  so  noticeable,  softening  may 
ensue  witii  relative  rapidity.  Out  knowledge  of  the  whole  subject,  in 
fact,  of  c<)agulation  of  the  blcnxl  and  of  the  tissues  is  in  so  chaotic  a  condi- 
tion that  it  is  impossible  to  lay  dowai  with  any  clearness  why,  when  small 
areas  are  involved,  we  are  more  likely  to  get  infarct  formation;  when 
larger  areas,  the  process  of  mortification  with  softening.  We  see  ob- 
scurely that  for  <t)agulation  necrosis  to  en.sue,  there  nuist  Ih'  .some 
lil)eration  of  kinase  from  the  dying  c-ells,  which,  interacting  with  Itoflies 
afforded  by  the  surrounding  lymph,  favors  the  formation  of  a  thrombine 
or  ferment,  which  in  its  turn  leads  Ixnlies  of  the  nature  of  fibrinogi>n, 
Iwth  intracellular  and  extracellular,  to  undergo  solidification,  or  coagula- 
tion. We  cannot  lay  <lown  with  any  clearness  what  it  is  that,  for 
example,  brings  it  al»out  that  where  a  small  branch  of  the  pulmonary 
artery  In-comcs  blocked,  an  infarct  is  pitxiuced;  where  a  large  branch, 
such  as  that  supplying  a  whole  lobe  of  the  lung,  no  infarction  ensues, 
i)ut  only  mortification.     Presumably  the  capillary  pressure  in  the  two 


46 


VENOUS  OCCLUSION 


^■Ii 


il'^ 


ria.e 


caaes  and  the  extent  of  exudation  play  a  part— but  this  is  only  a  pre- 
sumption. '^ 

Ckngrene.— Under  conditions  in  which,  either  from  coincident  closur*- 
of  the  various  anastomosing:  arteries  of  a  re'atively  large  area,  or  absence 
of  anastomosinR  nrterics  in  the  .same,  it  may  lappen  that  little  blood  passes 

into  the  dead  art-a,  and  in  that  i-ase  in 
parts  that  are  exposed  and  subject  to 
evapora;i'»n,  there  is  gradual  desic- 
cation and  the  development  of  dry 
(jangrme.  Where  br.cteria  gain  en- 
trance, putppfuction  ensues,  and  thus 
a  form  of  moist  gangrene — a  form, 
it  may  In-  added,  not  so  extreme  as 
n-ganls  distension  of  the  vessels,  exu- 
dation, and  hemorrhagic  infiltration, 
n-s  is  seen  where  the  efferent  veins  are 
bK)cke<l,  the  arteries  still  conveying 
blood  to  the  part  (see  further  vol.  i, 
p.  (KXS). 


GuDgrrnp  of  thp  foot.     (Montreal  General 
Hospital.) 


V«N0U8  OOOLUBION. 

The  causes  of  closure  of  veins  are 
of  the  .same  orrler  as  those  of  arteries, 
although  certain  exceptions  are  to 
Ik"  noted.  Thus,  neurotic  or  spastic 
(Ktlusion  is  unknown;  the  condition 
also  of  endophlebitis  obliterans,  or 
prolifcrat-ve  overgrowth  of  the  intima 
sufficient  to  induce  obliteration  is 
almo.st  unknown;  at  most,  rare  cases 
__,.,,     ,  '''ive   lxH>n    reported.'     So   also   in 

regarrl  to  the  hematogenous  occlusion,  while  thrombosis  is  common. 
emboliMn,  from  the  nature  of  the  case,  is  singulariv  rare,  and  can  only 
iHj  due  to  a  retrograde  pa.s.sag«.  or  falling  of  foreigA  matter  into  a  vein, 
llns  retrograde  emlwli.sm  will  be  discusstnl  later.  And  obviously,  by 
i.se.f  this  can  scaree  induce  complete  occlusion;  by  inducing  a  surround- 
ing thrombo.sis  or,  where  of  the  nature  of  liberated  portions  of  new- 
growth,  by  subsequent  proliferation,  it  may  bring  about  not  an  immediate, 
out  a  gradual  complete  closure. 

Ju.st  as  the  primary  effect  of  closure  of  an  artery  is  to  pro<luce  local 
anemia  of  the  region  of  supply,  the  extent  of  the  anemia  depending 
upon  the  width  of  anastomosing  vcs.sels,  so  the  primary  effect  of  venous 
occliLsion  IS  the  production  of  congestion,  th.  corresponding  arterv  or 
artenes  jK.unng  blood  into  the  part  which  must  become  heaped  up  in  the 

'  See  Meigs,  Jour,  of  Auat.  and  rhysiol,  34: 1900:458 


hiM^ 


VENOUS  OCCLUSION 


47 


iin-a,  unless  there  be  adequate  anvstomoseo.  In  general,  venous  anasto- 
moses are  more  abundant  and  lar^r  than  are  arterial, and  thu  .,>n  general, 
where  we  deal  with  the  occlusion  of  a  single  venous  branch  in  an  organ 
the  effei'ts  are  little  noticeable.  It  is  thus  more  especially  when  all  the 
veins  coming  from  a  part  l)ecome  occluded  (as  in  the  case  of  an  incar- 
cerattHl  lM'mia),or  v  here  the  occlusion  affects  the  main  vein  coming  from 
an  organ  after  it  has  nn-eived  all  its  subsidiary  branches,  that  si-rious 
n-siilts  ensue  (as,  for  example,  when  the  common  iliac,  the  main  portal" 
trtnik,  or  a  main  renal  vem  Itec-omes  blocke«l  by  a  thrombus).  Even 
in  these  cases  the  results  are  apt  to  l)e  temporary  rather  than  permanent. 
.Vnastomosing  vessels  of  minute  size  undergo  a  progre.ssive  dilatation,  and 
an  aiiundant  <-«»llateral  cireulation  l)ecomes  developed.  How  abundant 
inav  1k'  the  paths  of  su<'h  c-ollateral  cireulation  may  l>e  indicated  from 
a  study  of  those  cases  in  which  there  is  <»bstruction  to  the  main  portal 
vein,  such  as  (K-curs  in  cirrhosis  of  the  liver.  To  those  various  collatend 
channels  we  have  already  referred  (Chapter  I). 

It  is  noticeable  that,  despite  these  uliundant  anastomoses,  it  may  be 
long  Ijefore  the  collateral  cireulation  is  adequate.  Thus,  when  the 
femoral  vein  In-comes  thrombosed,  it  may  l)e  long  months  before  the 
congestion  and  (pdema  of  a  lower  extremity  c-ompletely  disappear, 
and  longer  montlis  or  even  years  l)efore  any  increased  exereise  with 
iiicreastnl  pouring  of  arterial  bloo«l  into  the  part  is  not  followed  by 
indications  that  the  cireulation  is  still  imperfect  ond  only  able  to  do 
little  more  than  deal  with  the  usual  amount  of  bloo«l — evidence  in  the 
s\ia]te  of  swelling  of  the  limb  and  muscular  exhaustion.  And  in  portal 
cirrhosis  of  the  liver,  even  after  providing  additional  anastomoses  by 
<ausing  adhesions  between  the  omentum  and  the  liver  and  the  anterior 
alHiominal  wall,  the  congestion  and  accompanying  ascites  are  still  apt 
to  continue,  despite  all  the  paths  present  or  provide*!  for  the  drawing 
away  of  the  portal  blootl. 

Where  the  main  venous  trunk  coming  from  ai;  isolate<l,  encapsulated 
organ  is  suddenly  blockeil,  there  the  opportunity  for  the  carriage  of 
the  venous  blood  is  at  a  minimum.  The  organ  becomes  hugely  swollen 
and  tense;  there  is  complete  stasis  of  the  bloo<l  within  it;  interstitial 
licmorrhages  occur,  and  the  organ  untlergoes  either  infaretion  or  morti- 
fication. We  have  alreody  indicated  (p.  41),  and  here  repeat,  that 
hemorrhagic  infaretion  may  result  from  venous  obstruction.  Such 
mortification  may  give  place  to  gangrene  in  those  cases  in  which  oppor- 
tunity is  present  for  the  entrance  and  growth  of  bacteria,  as  in  a 
strangulated  hernia  of  the  intestine  or  thrombosis  of  the  veins  of  the  leg. 

Hence  to  recapitulate,  the  results  of  occlusion  of  a  vein  may  be: 

1.  Practically  nil,  when  the  vein  is  small  and  one  of  a  series  of  abun- 
dantly anastomosing  vessels. 

2.  Intense  passive  congestion,  with  exudation  of  fluid  from  the  vessels, 
•  I'dema,  etc.,  and  gradual  development  of  a  collateral  cireulation,  the 
congestion  and  dropsy  disappearing  as  the  collateral  cireulation  becomes 
more  and  more*  adequate. 

3.  Intense  passive  congestion  with  exudation,  etc.,  giving  place  to 


48 


h:MlMtLIS\f 


:i    ,: 


•Ij 


4.  He„K,rrlw«f,.  infanhon  ^      ' "     ^ ^" "'""  "^""*  '" • 

5.  MortiKiatioii. 
".  ftHiigrpiM-. 

acBOLini. 

«-ith«T  wholly  or  p..rfi„Tlv  S    ,1..     T'  T*"  "^  ""^••''-  *  'hat  it 

«Ih-  sl.a,H.  of  many  .soli,|  f„r,.i'.„,  ,«,,    fc  ^  "     ' ''."'  1"  ""'  ••••««'n<ial ; 

im-s..,./..  fa,';,,,  „  .       .,r;    1.  r"r  /'"  ,"•"'""'»'""/    thJ-ir    very 
s..  that  s,H„„T  or  la  ,r  Z      T""."'    fm.ini.us  ...ah-rial  ,,»,„,  the.,," 

a".l  '.Marri...!  to  ,1.,.  r i.        "  \     |       i;r^  "-    ^""TT  ''*-'«''^-'' 

arteriosus.  l.loVkitK    la  ■•  tn,,    T,  II      T"  "'""""'  '"  ""'  "'""-^ 
•"""""••"•<l   ......  i„.|,   ,.ar    Th'   I  •"'""•"a'-y  artery.     \\\.  hay,. 

iHT<.,tii,i;';;:;r.  ;  i;: 'h^'Zi  '"f  "r  ""^'" '---  -ry 

laart,,,r,,fpari,.tal,a,     l?'m   I  •''"*'""'   '''"""'"'■^  f"""  the  left 

•'"•""•"f-i^Hl  a  '•ri,li„„  einlKluT"  .-;;     i^  ".""■?•  *''  h^^'^'.  however. 

l«l  to  an  oMiterating  tl..^nl,"    fi  i''  i   TT  "'"'  •*"''"'•'  ''"'"^he,!.  ha.l 
then,  a.lherent.  ""^»'"'""'  hUmK  the  last  jxirtion  of  the  aorta  an.l 

vio...  .hapter-..nie.  '^'S^t  :::;;::^ « t^il^ts  tt^^ 


CARUIAV  l-:Mb(H.l3M 


AW 


tin-  n-.Mult.H  an-  iipt  to  Ik*  iirKlijfililr.  Hwi  (h.servers  an*  ({fiu-rally  aj^n-wl 
ilitit  th<>  iiHi.Ht  cuiniiM)!!  site  is  in  hraiichrit  of  the  puliiMinary  artery,  uiiil 
ilie  \\w*\  iitiiiiiMtii  cuii.se  there  i.s  lietachiiient  of  tliniiiilni.s  matter  fniin 
(Hie  of  tlie  .Hy.stemi<'  veins  or  fnini  the  rijjht  heart.  Sometimes — ami  this 
is  nM>st  (■unniM>u  (hiring  the  puerperium — the  <letaehe«l  thrombus  liU'r- 
iiteti  from  some  of  llie  iM-lvic  vessels  is  of  siuh  sixe  (hut  folded  upon 
itself  it  tills  the  main  piilnH>nary  artery  of  one  or  other  side  at  the  |M>int 
when-  it  divides  into  its  main  hranehes.  Here  upiin  the  n>sult  is  siulden 
death.  Wlien-  it  is  of  smaller  size  there  may  l»e  n'<overy  after  a  _  •riiKl 
(if  intense  respiratory  distn-ss  and  dyspn<ea.  It  is  |iossi>)le,  further,  that 
11  iwrietal  tlinimlMis  in  the  pnixinml  |>ortion  of  a  pulmonary  artery  may 
U-coine  detached  and  aet  as  emiNilus.  Next  most  fretjuent,  Welch  is  in- 
clined to  U'lieve,  on  jfcncr.i'  prin'  iples,  an-  eniU^li  ItHlgin^  in  the  arteries 
of  the  lower  extremitit-s,  alilh  j\  these  are  apt  to  atfonl  no  symptoms; 
ii  de  ''IhmI  cardiac  tlironilins  of  small  size,  or  liN>s«-!ied  cardiac  vegeta- 
tions, i.s  more  apt  to  Im-  carried  in  the  centn*  of  the  arterial  I>I<mh1  stream 
-is  mor«'  likely  thus  to  Ix-  conveyed  along  the  axial  cum-nt  into  the 
connnon  iliac  of  either  side  a!id  its  more  dinn-t  continuation,  the  external 
iliac,  than  to  Ik'  din-cted  into  a  side  branch  of  the  main  trunk.  Never- 
theless, it  is  ill  these  side  branches  that  the  effects  of  emUilism  are  most 
marked;  they  an-  most  fre«|iiently  <U'tect»sl,  therefon-,  in  the  n-nal,  splenic, 
cen'bnd,  iliac  and  other  arteries  of  the  lower  extremities,  axillary, 
and  arteries  of  the  up|M-r  extrt-mity,  c<eliac  axis  with  its  he|)atic  and 
gastric  branches,  central  artery  of  the  n-tina,  su|H'rior  mesenteric,  in- 
ferior ine.MMiteric,  alnloininal  aorta,  and  coninary  arteries  of  the  heart, 
'i'iiis,  according  to  Welch,  is  the  onler  nl  relative  fre(|ucncy,  of  emixtii, 
that  is,  leading  to  observable  symptoms  and  gross  disturbances.  These 
arterial  emiioli  ar»',  in  the  main,  |)orlions  of  detached  cardiac  timimbi 
from  the  left  side  of  the  heart  or  from  the  heart  valves  (vegetations), 
more  rarely  |N>rtions  of  parietal  aortic  thntmbi  or  calcareous  and  necnitic 
matter  from  aortic  atheromatous  ulcers.  It  is  |)<issible  also  that  detached 
thnimbi  fnim  the  pulmonary  veins  give  occasional  origin  to  cmlMili. 
Some  few  cases  are  on  M'cord  of  what  is  known  as  paradozica*  or  crossed 
embolism,  in  which  matter  originating  in  the  systemic  venous  .system 
(ir  right  auricle  has  lafn  found  plugging  the  systemic  arteries.  In  .such 
cases  there  is  a  n-latively  largi-  patent  fonimen  ovale.  Patency  of 
this  communication  l)etween  the  two  auricles  is  very  common;  in  almost 
one  out  of  ever)'  three  hearts  some  communication  exists,  but  u.sually 
very  small,  oblique,  and  valve-like,  so  that  increased  pressure  in  one  or 
other  auricle  only  .serves  to  do.se  the  pa.ssage.  In  a  certain  numlier  of 
ca.s«-s  the  pa.s.sage  is  wider  and  direct,  and  in  thes*-  any  increa.se  in  the 
right  auricular  blo<Mi  pressure  over  that  of  the  left  auricle  must  1h' 
H'-companied  by  flow  of  blood  from  the  right  into  the  left  heart.  As 
!i  matter  of  fact  throinlx)tic  material  ha.s  lieen  found  forming  an  arterial 
cniholiis  in  the  forasnen  ovale;  one  such  case  was  encountered  by  Dr. 
John  ^IcCrae  in  our  postmortem  service  at  the  Royal  \ictoria  Hospital. 
Vet  another  form  of  crossed  embolism  can  occur,  though  here  the  em- 
bolic masses  are  verv  minute.  The  capillaries  of  the  lungs  are  relatively 
4 


so 


EMBOLISM 


i 


larjcf  and  ilittftiMlilr,  sii  |«rKi'  thaJ  it  is  (MMsiblt-  for  |wrti(l..s  tlie  nise 
of  tissue  irlls  to  |M.<is  through  rrrtain  of  thew  witikjiit  Ih-iiik  urn'stwl. 
iTius,  we  have  stTajnil  the  «Mit  siirfa.-.-  of  a  fn-.thly  exii.<ie«l  rabWt's  liver, 
made  an  emiilsion  of  flie  serapingM,  injisttti  this'inlo  a  svstenui:  vein  of 
another  rohhit,  and  killing  thin  after  a  few  minutes,  and  n'laking  s«ftions 
of  the  different  organs,  Imve  eneouiitered  isolattsl  liver  cilis  und  minute 


Kiu 


S  hem«  f.f  crn,s«l  i.,„lM,|i,„i.  t„  i,„|i,.„i,.  the  ,.a,,a«e  „f  ,l,r l«,iir  ,„:,tprml  fr, 


furni  l'Il)lK>li  in  the 


mi  the  veiiiM 


-VKtemic  «iterie»  l,y  |,„.„ai«e  lliroiiKh  Ihe  feiieMm  c.vslis,. 


ma.s,s,..s  of  the  same  in  the  arterioles  (.f  tlu-  kidnev.  determining  at  th. 
same  tune  that  the  foramen  ..vale  was  <lo.s«'<l.  or,"nu.re  aecunitelv  was 
non-existent. 

CjipUlary  Emboli.  S,„l.  minute  ma.xM-s.  il  is  ,l,.„r.  .m-  t.n.  small 
to  H'  arn-st,.,i  .,,  the  arteri.-s;  at  most,  th,-y  <ar.  i.loek  tlie  eapillarits 
an<l  domg  this,  .s.  abundant  an-  the  capillarv  anastomoses,  that  in  th<' 
majonty  of  nistan<vs  they  must  cause  no  n-«-ognizal.le  disturbanc. 


VtNOUa  EMBOLI 


51 


Only  wlu'ii  (1)  tht'.'H'  cupilltiry  ciiiIm)!!  an-  i-xtnuinlinarily  abundant,  or 
(2)  liavi-  th«'  )u|Ntrity  t<>  |>n>pttf{ati*  thi-ni.iclve.s,  do  tht-y  liet-ome  mani- 
fest, n  hiis  Ufn  miticttl,  in  th*-  first  pla«r,  that  the  piKinrnteil  remains 
of  iniiliiriul  parasites  after  sp(irtilati<in  aw  p(>ciiliarly  apt  to  be  unvsteil 
uikI  lUfuniulate  in  the  tine  i-upiiluries  of  the  Itruin  anukiiinev,  so  that 
Inrfp'  numbers  of  tlie  ve>wi'l.s  U-<-ome  bliM-ke<l,  resulting  in  functional 
clislurbomr  of  tlies*-  iir^pins;  in  the  stittml  plae«',  we  encounter  Iwth 
iiiicnthic  uimI  neoplastic  <fil  enilioli.  'i'lie  former,  by  th«'ir  continued 
growth,  s»'t  lip  nil  inflamiiiatory  reaction,  uiui  thus  induce  the  formation 
of  multiple  iiH'tustatic-  al>s<-ess«'s,  heinatof{eiioiis  miliary  tubercles,  etc.; 
the  latter  form  the  <-«'iitr»'s  for  the  development  of  metastatic  new-growths. 
We  an-  doiilitfiil  whether  primarily  the  majority  of  so-calltnl  microbic 
emlioli .  Ifiiild  strictly  lie  n-ganlwl  as  such.  When  an  infecteil  thrombus 
breaks  down,  then  imdoubteilly  tlie  particles  of  .stifteneil  inutttT  form  true 
<upil!ury  emlMili;  they  l)l«M-k  tiu-  small  ve,ss<'ls,  and  the  cimtuined  bacteria 
continue  to  fjrow  un;-'  they  f<irm  a  den*-  mass  filling  anil  extending  along 
the  capillary;  but  in  many  cases  of  iiyeiniu,  what  we  deal  with  is  the 
transjMirt  of  individual  iiiiinilM-s  which,  U-coming  taken  up  by  the  capil- 
lary cndothcliinii  without  any  circulatory  arnst,  multiply  within  the 
iiidotliclial  irlls,  and  only  after  distending  anil  lin-aking  these  down 
;,'niw  into  and  along  the  lumen,  obliteruting  the  capillary.  The  chain  of 
events  is  more  akin  to  capillary  tliPomlHisis  than  to  enilMilism,  or  other- 
wise, the  cinlMilisin  is  si-t-ondary,  not  priiimrv. 

Venoos  Emboli.  We  have  to  distinguish  two  onlers  of  venous 
enilKilisin;  that  iM-ciirring  in  the  portal  ves.s«'ls  of  the  liver,  and  that 
atfecling  the  M>teinic  veins  pn)|KT.  The  [xirtal  vein  in  its  branching 
and  division  into  sinaller  and  smaller  vessels  is  strictly  comparable  with 
an  artery,  and  the  gi'iienil  priiic',jles  governing  arterial  emUilism  goveni 
it  also.  There  may  Iw  .xtciisive  <-mlM>lisiii  in  the  liver  through  the  liber- 
ation of  timiinlii  from  the  splcnii',  the  iiiewnteric.  and  other  contributory 
veins  of  the  pirtal  system;  the  forms  most  fn'(|iiently  encountered 
an-  inffctivc  and  multiple,  .s«-condary  to  suppurative  thnimlKjphlebitis, 
this  in  i(s«-lf  most  fn-ciuently  .secondary  to  acute  appendicitis.  The 
lilicration  of  the  bniken-dowii.  infectious  material  may  induce  Ixith 
venous  and  capillary  cnilioli.  Simewhat  h-ss  fre<|ueiitly  we  etuounter 
uialignaiit  enilnili  due  to  extension  of  malignant  di.s«-as«'  fnuii  the  stomach, 
IKiiicrcas,  and  other  alMlomiiial  organs  into  branches  of  the  jnirtal  .svstetn, 
and  delachnient  either  of  individual  ci-lls,  or  <-ell  inas,s4>s. 

Ill  the  (inlinary  veins  wliiih  j-ollect  into  larger  and  larger  trunks,  it 
is  iiiiiiicdiatcly  evide-it  that  masses  originating  in  and  lie<-oming  detachetl 
from  a  smaller  trunk  cannot,  under  normal  conditions,  form  an  embolus, 
tlie  lumen  of  the  vessels  thn>ugh  which  it  passes  iM'coming  progressively 
larger.  The  only  po.ssible  «-onditions  under  whi<-h  emlwlism  can  occur 
.n\-  wlitii  either  the  ciiirent  of  the  venous  bkxid  liecomes  reversed,  .so 
tiiat  foreign  lnMlies  an>  carried  by  the  .stream  into  smaller  and  smaller 
veins  until  they  In-come  arrestetl,  or  when  the  very  weight  of  the  fori-ign 
ImhIv  is  such  that  under  the  action  of  gravity  it  falLs  against  the  blood 
sti.am  into  some  more  dependent  ves.sel. "  It  may  be  thought  that 


lis 


ri9 


EMBOLISM 


Vw.  . 


llu'sc  ure  si-urtrly  )M).SNil)le  cuiulitions;  that  if  iiioineiitarily  the  blood 
furn-iit  were  n'ViTsed  or  liecame  slow  enough  for  gravity  to  exert  its 
effe<-t.s  upon  i-ontained  largiT  musses,  witli  the  arrest  of  a  muss  at  a  point 
where  two  or  mon'  smaller  veins  joined  to  form  a  larj»»"r  one,  within 
a  very  short  time  the  pressun*  of  the  venous  hlood  behind  the  obstruction 
would  liberate  it  and  earry  it  forward  towanl  the  heart.  Hut,  as  a  mutter 
of  fact,  several  <as«'s  are  on  record  which  can  only  Ih'  explained  as 

examples  of  the  retrograde  em- 
boUim.     Only  those  examples 
can  Ih-  taken  as  indubitable  in 
which  all  possibility  of  crossed 
cml)olism  is  excluded;  we  can 
deal,  therefore, only  with  cases 
in  which  the  embolism  is  Ux> 
large  to  huve  passed  through 
the  pulmonary  capillaries,  and 
in  which   there  has  been  no 
patent    foramen    ovale.     But 
when,    to    quote    Lubarsch's 
case,  there   is  encountered  a 
primary  ossifying  chondrosar- 
coma of  the  right  tibia,  with 
a  sarcomatous  mass  forming 
a  riding  embolus  of  the  hepatic 
vein,  and  no  other  secondary 
growths   in   the   liver;  or,   to 
instance  one  of  von  lleckling- 
httusen's   cases,   where   along 
with  a  primary  my.xcH-hondro- 
sarcoma  of  the  tibiu  invading 
the  veins  of  the  leg  there  was 
found  a  similur  niyxochondro- 
sjircomutous  mass  in  the  main 
renal  vein  extending  by  growth 
along    the    branches    of    the 
same,  confined  to  this  vess<l 
and  its  branches  with  no  other 
malignant  involvement  of  the 
organ;  then  the  only  (■onciii- 
sion  nuist  Ik-  that  there  ll:l^ 
btH'u  retrograde  emlmlism. 
•Vnd,  as  a  matter  of  fact,  Arnold,  Lubarsch,  and  others  have  ex|Mii- 
mentaily  <lemonstrated  the  j)os.sibility  of  such  retrograde  emlwlism  li\ 
the  slow  injections  of  thick  emulsions  of  «)arse  meal  into  the  ne<  k 
veins,  etc.    More  pjirticularly  when  death  occum'd  with  severe  dyspnoa, 
it  was  found  that  the  coarse  grains  had  mad-    .leir  way  into  the  coronarv 
veins  of  the  heart,  the  renal  and  hepatic  veins,  the  cerebral  sinuses,  eir. 
There  has  been  i-onsiderable  debate  as  to  the  exact  mode  by  which  tlu- 


S'henm  of  if tniKni'li-  pinl>uliMii,  ?<)inwjnK  retm- 
«r»ile  |iu>.siiirp  of  lliii.tiiluilii'  niuti-hul  to  fnnn  viiilN>li 
ill  the  hepatic  iinil  M'lial  xeiii-^  rei^iM'rtively, 


i 


THE  CONSTITUTION  OF  EMBOLI 


.W 


particles  make  their  way  against  the  normal  course  of  the  circulation, 
but  this  seems  to  be  evident  that  both  experimentally  and  in  the  cases  in 
man  so  far  recorde<l,  there  has  lieen  evidence  of  impe«led  respiration. 
This  suggests  that,  as  laid  down  by  Heller  and  von  Recklinghausen, 
one  essential  for  the  retrograde  transport  is  a  temporary  or  continuefl 
removal  of  the  negative  intrathoracic  pressure — a  condition  favoring  the 
existence  of  positive  pressure  in  the  veins,  with  its  accompanying  obstruc- 
tion to  the  onwanl  flow  of  the  venous  blood,  damming  of  the  same  in 
tlie  large  veins,  and  development  of  reversed  current  in  the  venre  cava; 
at  each  contraction  of  the  right  heart.  Both  Aniold  and  Lubarsch  have 
directly  observe<l  the  regurgitation  of  foreign,  liodies  from  the  inferior 
vena  cava  into  the  exposed  renal  vein  upon  the  onset  of  respiratory  con- 
vulsions in  animals  of  the  laboratory. 

Following  Iliblx'rt's  observations,  we  are,  however,  inclined  to  presume 
that  the  force  with  which  foreign  particles  are  driven  back  into  the  veins 
cannoi  lie  very  grt'at,  and  that  what  is  necessary  for  the  preservation  of 
the  foreign  IkmIv  In  nitii  is  a  relatively  rapid  adhesion  of  the  emlK)lus  by 
conglutination  or  the  pnxluction  of  fibrin. 

Lymphatic  Emboli. — It  is  appropriate  to  note  at  this  point  that 
what  applies  to  the  systemic  veins  applies  also  to  the  lymphatic  vessels. 
In  them  als«i  rt'trograde  eml)olism  is  apt  to  occur,  apparently  with  fair 
frequency.  Mon-  jwrticularly  d«K\s  this  explain  the  development  of  certain 
of  the  malignant  metasta.ses  in  tlu"  lymphatic  systein.  The  main  ca>is«' 
of  the  retrograde  current  would  .sc<'ni  to  Ih"  <'losure  of  the  main  lyinphati( 
channels  of  a  part,  with,  as  a  con.st'qucnce,  reversal  of  flow  in  the  branches, 
that  the  lymph  may  fin«i  an  outlet  by  anastomosing  ve.sst>ls  into  other 
lyinpli  chainiels  that  an"  not  impeded.  Such  retrograde  cmlwlism  is 
iH'st  fitted  to  explain  the  apjH-arance  of  cancTn)us  growth  in  the  head 
of  the  humerus  in  cases  of  mammary  j-anwr  with  involvement  of  the 
■ixillary  lymph  glands. 

The  Gonstitotion  of  Emboli. — Any  Ixxly  which,  free  in  the  blood, 
may  \w  carried  forwanl  tmtil  it  blocks  a  ve.s.sel  is  capable  of  acting  as  an 
ciiilioiiis.     Kmlioli  are  thus  of  very  varying  nature: 

1.  By  far  the  commonest  i-auses  of  emliolism  are  detache<l  masses 
of  thrombotic  materikl,  and  this  being  .so,  it  is  evident  that  when,  for 
example,  we  find  recent  cruor  thrombus  filling  a  vessel,  it  is  at  times 
iin|x)ssible  to  determine  whether  we  deal  with  emlwlism  or  kx;al  throm- 
lK>sis.  .So,  too,  when  the  condition  is  of  long  standing,  it  is  at  times 
scarce  possible  to  detennine  whether  the  whole  occluding  mass  is  throm- 
lM)tic,  or  whether  there  has  Ixn-n  a  primary  emlx)lus  with  subsequent 
thn)mlM>sis  <leveloping  u|)on  it.  In  general,  however,  a  ditference  in 
color  can  Ik-  made  out  Ix-twi-en  the  primary  ma.ss  that  has  acted  as  an 
enilM>lus,  and  the  stH'ondary  thn)mbus  that  has  fonned  u|M>n  it;  so  also 
the  emlxtlus  can  Im'  dctach«'d  from  the  ves.se'.  wall  and  the  .secondary 
thn>inbus,  and  at  times  it  is  pos.sible  to  .straighten  out  the  (t)ile<l-up 
(•inlK)lic  ma.ss  and  detect  the  surface  of  detachment  from  the  thrombus 
i)f  origin,  as  also  that  thrombus  of  origin  may  Ix-  di.scover<-d  elsewhere 
in  the  vascular  system,  and  its  broken  surfa<r  mav  U-  .s»'en  and  ctim- 


54 


EMBOLISM 


pared.  It  mus*  be  again  recalled  that  detachetl  vejjelations  from  the 
cardiac  valves  form  an  important  series  of  emboli  of  this  order  Of 
other  bodies  found  less  frequently  constituting  emlwli  we  may  make  a 
division  into  the  endogenous  and  the  exogenous,  or  otherwis<>  'into  sub- 
stances originating  in  an.l  from  the  tissues  and  those  of  «'xtran«>ou.s 
origin.    Of  the  former  we  may  have: 

2.  (teleweons  ud  atheromatoiu  matter  from  atheromatous  ulcers. 

3.  Tumor  maiui  and  calb  detached  from  luw-growths  which  have 
penetrated  into  the  vessels;  these,  forming  emboli,  may  continue  to  pro- 
liferate, thus  giving  rise  to  secondary  or  metastatic  new-growths. 

4.  Detached  tiaine  eelli  or  collections  of  the  same.     Of  such  more 
particularly,    there  have   been  encountered    plmrnM  cell    (Schmorl) 
and  liver  cell  emboli  (Turner).    The  natural  growth  of  the  chorionic 
villi  of  the  foetus  is  into  the  uterine  blinxl  simi.ses;  conditions  thus  favor 
the  detachment  of  c-ertain  of  the  cells  or  villous  prowsses,  which  then 
may  form  pulmonary  or  other  einlwli.    Ordinarilv  such  .-ells  undergo 
disintegration;  rarely  they  proliferate,  and  so  givl;  rise  to  the  chorio- 
epithelium  malignum  (vol.  i,  p.  610).    The  size  of  the  liver,  its  abundant 
and  large  ve.ss«'ls,  and  the  intimate  relationship  of  the  liver  cells  to  tin- 
vessels,  favor  local  dislocation  of  liver  cells  into  the  bloo.!  stream  followini; 
blow.s  upon  the  liver  region,  or  disease  in  whi«h  congi'stion  of  the  organ 
and  degenerative.  .Iistiirl)aii«'s  of  its  c^ells  an-  combined,  as  in  eclampsia 
Ihe^hver  cells  may  Ik-  found  in  the  heart,  piilmonarv  vesst>ls,  and  even 
in  tho.*  of  the  systemic  arterial  .system.     Thev  an-  to  Ik-  recognized  l>v 
their  shape,  the  size  of  the  nucleus,  and  the  diagnosis  bi-(t)mes  coii- 
\nncing  in  tho.st;  cas«-s  in  which  the  cells  t-oniain  bile  pigmt.'t.     A  thin! 
type  of  cell  is  occasionally  encountered  in  the  small  ves.s.-ls  of  the-  lung 
namely,  the  giant  cells  or  meg^caryocytes  of  the  lx)iie  marrow  (.\.s<li„ff )' 
often  in  a  state  <.f  characteristic  degeneration,  with  fusion  of  the  nuiltipl.' 
nuclei  into  a  single,  larg,-,  im-giilar  mass.     The  obs^-rvations  of  Aschotf 
l-ox,   J.iil)arsch,   and   Ijingi-maiin    throw  light   iijx)n   this   nnexiK-ctefi 
pro«-ss;  when-ver  tlier.-  is  pro<luct-<l,  either  naturally  or  experimentallv 

a  coiKiition  of  pnn.oiinciHl  leiikoeylosis,  with  |)oiiring  of  leiikocvtes  out 
of  blood  marrow,  then-  along  with  the  leiikocvtes  a  crrtain  niinilH-r 
of  these  giant  «-lls  Ik-coiir-  lilM-ratcd  into  flu-  delicate  capillaries  with 
wliicli  they  an-  in  intimate  association,  and,  |Kissing  thus  into  the  circu- 
lation Ix-comc-  arn-.^tcl  in  the  first  s«-ries  of  otlu-r  capillaries  into  which 
they  iH-come  carriwl.  ^ery  ran-ly,  and  in  cases  of  either  traumatic  or 
operative  injury  of  Iwne,  ostwclasts  and  fat  cells  from  the  marrow  hav 
been  noted  in  the  lung  <apillari(-s. 

5.  Leukocytes.— In  cas-s  of  myeloid  l.-iikeniia,  the  capillaries  of  tlir 
iver,  kidne>-s,  ami  other  organs  may  Ik-  found  so  densely  packed  with 

leukocytes  that  the  condition  must  Ik;  n-ganled  as  emlwlic. 

6.  F»t  EmboUsm.— Fat  may  Ik-  pn-.sent  in  the  circulating  blood  in 
one  of  two  forms,  either  a  fine  einulsion.  as  in  lipemia,  or  of  coar. 
droplets,  as  after  niptun-  of  fat  c«-lls  and  di.scharge  of  their  content^ 
either  directly  into  the  bloodvessels  or  into  Ivmph  channels  or  span  ^ 
Ihere  IS  doubt  whether  the  first  of  these  conditions  induces  true  capillarv 


FAT  EMBOLISM 


55 


(>inlN)lism.  It  is  true  that  in  those  dead  of  diabetic  coma  solid  masses  of 
fatty  matter  have  not  \»vn  infrequently  obsen-ed  in  the  lung  capillaries, 
forming  moulds  of  the  same,  but  (1)  thes«'  have  not  ben  detected  in 
autopsies  p'rforme<l  within  two  or  three  hours  after  death;  (2)  they 
are  apt  to  have  a  granular,  non-homogeneci's  appearance,  as  though 
formed  from  the  imperfect  fusion  of  minute  droplets;  and  (3)  there  is 
a  characteristic  absence  of  surrounding  hemorrhage  or  infiltration.  All 
these  signs  indicate  a  postmortem  accumulation  or  "creaming"  of  the 
line  fatty  particles  rather  than  an  antemortem  fusion  into  large  drops 
capble  of  acting  as  emboli. 

There  is  now  abundant  evidence  that  the.se  laip"  drops  or  ma.sses  of 
fat,  lil)erated  from  fat-«mtaining  cells,  cause  capillar}'  embolism  in  the 
lungs  with  fair  frequency,  and  in  more  extreme  ca.ses  plug  the  capillaries 
of  the  heart,  the  kidney  (here  more  particularly  the  glomerular  loops), 
the  brain,  and  other  organs,  setting  up  .severe  and  often  fatal  functional 
disturbani-e.  The  main  cause  would  .seem  to  be  trauma,  accidental  or 
o|KTative,  such  as  fracture  of  the  long  l)ones  with  accompanying  rupture 
of  the  fatty  marrow  cells,  fonible  breaking  down  of  immobilized  joints, 
section,  operative  handling,  and  ligature  through  a  large  panniculus 
adipo.sus,  operative  handling  of  the  fatty  omentum  and  mesenteries  or 
of  other  accumulation.s  of  fat  in  the  |)atient,  rupture  or  contusion  of  the 
fatty  liver.  \Vhen  ;  i-re  is  no  actual  fracture  of  the  l)ones,  sudden 
exten.sive  concu.ssion  of  the  lK)ny  skeleton,  such  as  follows  falls  from 
some  considerable  height,  has  been  ob.ser\ed  to  lead  to  fat  embolism  in 
the  lungs.  It  would  .s«'em  that  here  the  fatty  cells  and  fine  capillaries  of 
tlic  Iwne  marrow  Inconie  jam-d  against  or  violently  torn  away  from  the 
more  rigid  l)ony  framework.  The  fat  embolism  that  has  l)een  noted 
after  epileptic  fits,  eclamptic  convid.sions,  etc.,  would  seem  best  explainetl 
as  due  to  a  similar  liU'ration  from  the  \nn\v  marrow  (Lubarsch).  With 
Uil)bert,  then,  we  may  n-ganl  violent  .shaking  or  ct)ncu.s.sion  of  tones  as 
iiii  ini[)ortant  factor  in  priMlucing  the  condition. 

.\n  obstruction  of  a  few  capillaries  in  the  lung  by  fatty  globtdes  leads 
to  no  obvious  di.sturbancc,  or  at  mo.st  minute  areas  of  amgestion  and 
licniorrlmgi';  minute  infarcts  may  \w  induced  of  no  serious  import. 
Occasionally  thcs*'  capillary  emlx)li  an'  present  in  great  abundance, 
so  al)undant  as  to  .seriously  ob.struct  the  circulation  through  the  lung, 
.■siting  up  grave  and  .sometimes  fatal  dy.spnoea.  It  is  remarkable  that 
symptoms  of  disturban-e  either  manifest  themselves  within  a  few  minutes 
to  six  hours  after  trauma,  or  only  after  four  or  more  days.  In  the  first 
( as*'  we  .see  the  din-ct  effect  of,  more  particularly,  pulmonary  embolism; 
ill  the  second  \w  ar«'  incline<l  to  the  view  that  through  saponification  the 
original  fatty  plugs  in  the  capillaries  at  the  site  of  injury,  and  again  the 
cnilxjli  in  the  lungs,  have  become  diminished  and  loosened.  The  con- 
tracted pupils,  convulsions,  and  Cheyne-Stokes  respiration  .suggest  that 
now  the  fat  has  pas.se<l  to  the  left  heart  and  become  lo<lged  in  the  capil- 
laries of  the  brain.  For  the  fat  forming  these  emboli  tends  to  undergo 
uli.sorption,  and  that  in  more  than  one  way.  Lipolytic  enzymes  exist 
in  the  blood,  and  gradually  the  droplets  become  saponified  and  dissolved. 


56 


EMBOLISM 


l\ 


Ihe  fatty  state  of  the  endothelium  of  the  affeetetl  capillaries  in«litate,s 
that  these  cells  absorb  it  to  some  extent,  and  very  possibly  pass  it  on  to 
underlying  tissue  celb,  for  these  also  may  stain  deeply  with  Sudan  III. 
Add  to  this  that  there  may  be  some  accumulation  of  leukocytes  around 
the  fatty  masses,  suggesting  a  phagwytic  activity  on  the  part  of  these  cells. 
■mboU  dua  to  eztraneoni  matter: 

7.  Air  Embol inm. —(\i'nsional\y  during  the  (t)urse  of  operations  upon 
the  neik  a  suspicious  sucking  sound  is  hearrl.  dr  -  to  the  entrance  of  air 
into  a  severed  vein.  If  the  vein  Ik-  immetliately  closetl  before  any  large 
amount  of  air  has  l)een  inspire*!,  no  ill  results  mav  ensue,  but  at  times 
death  occurs  with  absolute  suddenness,  at  others  it  is  prece«le«l  by  extreme 
dyspnnea,  churning  action  of  the  heart,  cyanosis,  and  c-onvulsions.  The 
nearer  the  heart  and  the  larger  the  vein,  the  greater  the  danger  of  this 
event,  but  cases  arc  on  retard  in  which  sud«len  death  of  this  order  has 
followed  operation  upon  the  head,  upper  extremities,  and  uterus.  The 
condition  has  been  recognized  for  now  more  'han  a  c-enturj-,  although,  with 
Welch,  we  must  ascribe  many  of  the  earlier  cases  of  supposetl  uterine 
and  intestinal  origin  not  to  air  emlwlism.  but  to  gas  production  by  the 
Bacillus  aerogencs  capsulatus  (Bacillus  Welchii)  or  oih.-i  ga.s-pro<lucint: 
organisms. 

As  reganls  the  cause  of  the  sudden  death,  there  are  two  main  theories: 
(I)  That  it  is  essentially  cardiac,  due  to  the  churning  action  in  the  right 
heart,  so  that  a  relatively  small  amount  of  air,  as  it  l)ecomes  warmed  up 
expands  to  make  a  very  considerable  foam,  which,  accumulating  behind 
tiie  tncuspid  valves,  .-ffectively  arrests  their  activity;  (2)  that  the  essential 
caust'  is  multipl.-  airenilK)!!  in  the  pulmonary  capillaries.  That  bubbles 
of  air  do  not  pass  thn)ugh  the  lung  capillaries,  but  become  blocked 
there  has  U-en  pn.vt-d  by  experiments  on  dogs;  in  experimental  air 
<-nibolism  tne  left  heart  is  foun.l  practically  free  from  air.  and  the  lun<'s 
show  multiple  hemorrliag»-s.  suggesting  niost  significantlv  that  the  ob- 
struction of  a  iarg.-  inimi)erof  capillaries  has  le<l  to  profound  congestion 
and  rupture  of  some.  The  mon-  nn-ent  experiments  of  P.  Wolf  an' 
generally  acc«-pte<l  as  establishing  this  s»-con.l  thi-orv,  although  the  wi.lr 
difference  between  the  amount  of  air  that  can  exp«Timentallv  l)e  injected 
into  the  veins  of  a  healthy  dog  without  fatal  results  (under  200  c.c  ) 
and  the  much  smaller  amounts  that  have  l)een  estimated  as  «-ausin.' 
sudden  death  in  the  human  patient,'  suggest  that  the  right  heart  is  a 
factor;  that  a  vigorously  contracting  organ  mav  In-  able  to  propel  the  air 
out  into  and  through  the  lungs,  distributing  'it  thus  t«.  parts  when-  it 
may  wcoine  absorl)ed. 

8.  (la.i  /?mW/.— Appan-ntly  of  like  onler  are  the  cases  n-conied  l.v 
.laneway  and  Hun.  in  which  grave  cerebral  svmptoms  followed  the  in- 
jection of  |X'n>xide  of  hydrogen  into  the  alKlorainal  and  thoracic  cavities. 
A  more  common  cause  of  gas  emlwlism  mav  lead  to  fatal  results  in 
divers  and  thos,-  working  in  c-oinpn-sstHl  air;'  siic-h  gas  emlwlism,  in 

'  \ircho\v's  Arcliiv,  17-t:  V.HKi. 

'  .See  Greene,  .\mer.  Jour.  Med.  Sci..  1901. 


PLATE   I 


Fat-embolism  of  the    Kidney. 

The  tllobules  of  fal  are   impacted    wilhin   a   jilonieruinr  tuft   and    are   stained 
red    with   Sudan    III.      Reichert   i>l>.j     No.   7,  willi.,ut   ocular. 


(Kr.irn  tlii>  I'alliiiliiiiii'Hl  Ofp.irlrMiMit,  Mi.nlriMl  I'n'iii'ral  llo^>|lil:ll.l 


ANIMAL  PARASITES 


r>7 


fact,  wouW  appear  to  be  the  esiiential  causative  agent  in  the  so-calle<l 
eaiiMB  disMi*.  Workers  in  compresse<l  air,  who  have  for  considerable 
perio<ls  been  subjecte<l  to  pressure  of  more  than  two  atmospheres,  if 
thev  emerge  suddenly  into  the  ordinary  air.  are  liable  either  to  show 
symptoms  of  dyspnflea  and  asphyxia,  or  to  become  victims  of  a  series 
(if  intractable  nervous  disturbances,  often  fatal  after  a  few  days  or 
weeks.  These  are  of  the  nature  of  various  paralyses,  hemiplegia, 
etc.  Examinatitm  of  sections  of  the  spinal  cords  from  these  cases  shows 
the  presence  of  multiple  areas  of  necrosis  in  the  posterior  and  lateral 
columns,  without  hemorrhages,  but  with  ascending  and  descending  de- 
generations. Von  Schrotter  ami  others  have  pro<luc-ed  and  studied  these 
lesions  in  dogs  and  other  animals  subjecte(l  to  compressed  air.  The 
partial  pressure  of  the  gases  in  the  bk>o<l  is  <lependent  upon  the  atmo- 
spheric pressure;  increase  this  last,  and  the  blood  passively  absorbs  air 
from  the  lungs;  the  greater  the  pressure,  the  more  the  amount  ab.sorbe<l 
and  held  in  solution.  The  oxygen  of  that  air  liecomes  fi.xed  by  the  tissues, 
which  also  passively  ab.sorb  .some  of  the  nitrogen.  If  the  atmospheric 
pressure  l»e  re<luce<l  stiddenly,  the  bkxxl  now— and  the  tis.sues— can 
no  k)nger  hold  the  free  nitrogen  in  solution.  As  a  consequence,  the  gas 
separates  in  the  form  of  bubbles,  which  grow  in  .size  and,  carried  in  the 
blood  stream,  .set  up  gas  emlwli  in  the  various  ti.s.sues,  the  results  being 
most  serious  in  the  terminal  arteries  of  the  brain  and  .spinal  cord,  leading 
to  anemia  and  necrosis  of  the  an>as  of  supply. 

The  other  form  of  gas  emlNilism  we  have  already  indicated,  that, 
namely,  tlue  to  the  pro<hicts  of  activity  of  gas-pro<lucing  organisms. 
While' in  the  majority  of  <'a.ses  the  emphysema  and  gas  in  the  vessels 
is  a  po.stmortem  development,  then-  are  ca.ses  in  which  it  is  recognizable 
(luring  life,  and  ga.seous  emlK)lism  may  be  claimed  as  a  cause  leading 
to  the  fatal  event. 

0.  Pigment  emboli  (.see  p.  50). 

10.  Bacterial  emboU  (.see  p.  50). 

11.  Animal  Parasites. — The  symptoms  of  sleeping  sickness  are 
ascrilKHl  to  the  accumulation  of  trypanosomes  in  the  cerebral  capillaries, 
with  blocking  of  the  same,  although  it  has  to  be  admitteil  that  the  gradual 
development  of  these  symptoms  scarce  .suggests  true  embolism.  Never- 
theless, in  trypano-somiasis  the  capillaries  of  more  than  one  organ  have 
l)een  found  completely  blocked  by  den.se  accumulations  of  the  parasites, 
herein  corresponding  with  what  has  occasionally  l)een  observed  with 
that  other  widespread  protozoan  para.site,  the  orgiuiism  of  malaria. 
Metazoan  parasites  may  also  induce  embolism,  notably  the  abundant 
lai  vte  of  various  strongv'les.  The  classical  example  is  aflfordetl  by  the 
Stroiigylu^  armatiui  of  the  horse,  who.se  larvae,  becoming  arrested  in 
branches  of  the  abdominal  atHta  and  other  ves.seLs,  may  with  their  gn)Wth 
and  the  irritation  thereby  induced  cause  thinning  and  giving  way  of  the 
arterial  wall,  with  the  production  of  verminous  aneurisms.  Rare  cases 
are  also  on  record  of  the  rupture  of  echinococcus  cysts  into  a  vein,  with, 
as  a  result,  emlx>lism  of  the  ve.s.sels  of  the  lung  by  means  of  the  daughter 
cyst:  '^r  their  membranes. 


5S 


THROMBOSIS 


^jS    .. 


12   ProJ.etllti  -Some  thm-  uniloubhd  owes  aw  on  record  in  which 
Ijullets  entering  the  heart  or  larger  vesseb  have  been  eamVdin  the  bE 

♦hi.     .  "  »mbolUin.-Tht.s«.  have  alnaclv  U-en  <li.scnsse<J  in 

the  chapter  upon  the  effects  of  arterial  closure  and  infurer Son 
and  .ncdentally  m  the  pages  here  preceding.     One  aspect  of  the  sut 

vessel  wall.     Unefly    when  embohsm  does  not  cause   sudden  death 
and  ,s  not  associated  with  rapidly  fatal  disease,  the  cmbdus  ^^tinc  as' 

of  inflammation,  of  the  chitHiic  or  of  the  acute  tvoe   accordJnlnl*? 
whether  the  e.nl«.us  is  of  the  blan.l  or  of  ihol&^7.^'''Tj^ 

mjcotic  aneun.sn.;  .so  teiung  of  the  arterial  wall,  more  paniculX  n 
artenes  not  well  .s,,ppli«l  by  surmunding  tis.suc.  such  as'^he  ^rebml 
and  branches  of  the  me.s».„teric  vessels,  Ly  lead  to  gi  ^u/ wav  of  Se 
same,  with  aneurism  pn^luction.  A  for.i,  of  cn.iSic '^n^.^Vism  o5 
he  sc^x,nd  degree  may  Ik-  bn>ught  aliout  by  emlK.lic  absc™o"the 
vasa  vasorum  of  the  aorta  and  large  arteries,  'with  weakcni^gTd.e^Sl 
of  the  mam  artery  and  formation  of  a  sacxular  pou«li  upon  ft 

THROMBOSIS. 

"'"'.1  jK-rforming  autopsies,  it  is  a  familiar  experi.-iK-e  to  encounf,.r 
c  oa«.  .,„H>.I,  either  in  the  ..avities  of  the  heart  or'ln  the  v  "s^-l     Ss 
or  arteries,  and  imme<liately  it  In-omcs  essential  to  deternim-  "1^ 
the  clotting  has  occurre<l  before  or  after  death,  whether,  tha  Ts  we  dc' I 

Jowof  rh"^:i  ^■*"f"i  '""f  ^''"  '"^y  ""'t^^^  affe^^ted  tionwan 
How  of  the  bl,K>d,  an.l  have  Ix-en  a  factor  in  the  production  of  svmotom 

Kn^         ^       ■  '^"""''"•^;    '^^'  <>^P"'^sion  involves  a  contradiction 

of  the'Ct"''  *'"""?''";•  '"  '•"  ,""''■''  ^'J>'  "^  "««•'*  «i"'ated  in  the  c-avitv 
1  W    ?    «'  '"''""H'  ^°.""''''  ^"""ff  •'■'''  «f  constituents  derived  fni 

t  — riiis^"'  ""'']""""  ""'•'•  "•'''  '"  ""'^  definition,  ''"oTm^r 
"itu.       Ihis  wv  regarrl  as  a  nonH'sst>ntial.    The  product  of  int™  ,/ 
and  m  ravasc-ular  clotting  of  the  blood  is  no  less  the^r^  t  of  t^X "    ' 
an.l  still  remains  a  hrombus,  even  if  detached  and  carried  to  a  d  stam 
Here  at  the  most  it  is  necessary  to  distinguish  clearlylTwtl  a  ttb..: 


■HHi 


POSTMORTEM  CWTTlSd 


59 


and  an  embolus.  An  embolus  is  any  free  matter  which,  e-onveyed  alonft 
the  blood  stream,  l»et'«imes  am>ste<l  at  s«>me  point  where  the  <Hmini.shiil 
iliameter  of  a  vessel  Ix-ttimes  k>ss  than  its  own  «Hain«-ter.  Anything 
which  Is  capble  of  phig;(ing  a  vess»'l  constitutes  an  enil)ohis;  in  simple 
Knglish,  it  is  a  pluj?.  A  free,  solid  mass  of  clotteil  bkMHl  may  thus  l)e 
■arrieti  along  a  vessel  until  it  bkaks  it,  and  so  acts  as  an  embolus.  A 
thrombus  may  thus  form  one  order  of  emlN)lus,  and  that  a  very  fn-quent 
one,  but  by  no  means  all  emboli  are  thrombi.  What,  however,  is  of 
importance  is  that  thrombosis  is,  as  we  shall  point  out  later,  associate*! 
always  with  kK-al  disturbance  of  the  vascular  wall;  it  is  cknibtful  whether 
a  thrombus  ever  originates  as  a  process  of  free  precipitation  out  of  the 
circulating  blood;  it  devekips  in  connwtion  with  an  endothelial  surface, 
the  seat  of  some  abnormal  chang(>. 

Poitmortem  dotting. — Before  entering  into  the  description  of  the 
process  of  thrombosis,  it  will  be  well  to  have  a  perfectly  <'lear  under- 
standing of  the  appearance  and  characters  of  the  postmortem  cbt,  so 
that  they  may  be  differentiated  and  then  set  on  one  side.  Briefly,  such 
pstmor'tem  clot  differs  in  no  essential  n-spec't  fn)m  the  ck)t  that  forni.. 
in  blood  removed  from  the  ves.sels  during  life. 

I.  It  shows  no  stratification,  i.  c,  the  blooil  has  coagulated  en  manne. 
\t  most  it  may  show  two  layers— a  jmler  upjH'r,  and  a  dark  nnl  under 
layer.  This  is  an  indication  that  the  clotting  has  not  m-curred  immedi- 
ately after  the  circulation  has  cease<l,  but  some  little  time  later.  As  can 
l)e  seen  so  well  after  removal  from  the  Ixxly  of  a  slowly  coagulating 
i)lood,  like  that  of  a  horse,  the  lighter,  white  corpuscles  rise  to  the  sur- 
face ami  form  a  "huffy  coat,"  and  upon  coagulation  there  develops  a 
firmer  jMile  upper  layer  and  a  dark  rtnl  luider  layer,  so  here  the  iimH-r 
layer  is  composetl  of  a  fibrin  meshwork  enck)sing  leukocytes.  Acconling, 
therefore,  to  (1)  the  rate  of  coagidation,  (2)  tlic  numlier  of  contained 
leukoi-ytcs,  and  it  may  be,  (8)  the  more  or  less  hydremic  condition  of  the 
bl(M>d,  so  may  we  distinguish  three  forms  of  jjostmortem  clot,  which  jmjss 
one  into  the  other:  (1)  The  soft,  homogem-ons,  red  clot;  (2)  the  <'lot  with 
the  firm,  rather  dry,  adherent  upper  i-oat;  and  (II)  the  "chicken-fat"  ck)t, 
with  abundant  moist,  soft,  glistening  and  semitranslucent,  huffy  coat. 
This  last  form  is  foun<l  more  particularly  in  leukemia  and  other  states 
in  which,  along  with  increase  in  the  circulating  leukocytes,  there  is 
reduction  in  the  erythrocytes  and  some  hydremia. 

II.  Under  the  microscope  the  appearance  is  the  same  as  that  of 
cxtravascular  blood  clot.  There  is  an  abundant  network  of  fibrin  enclos- 
ing the  corpuscles  in  no  special  order,  save  that  the  white  cells  become 
more  and  more  abundant  towani  the  upjier  surface,  that  the  fibrin  is 
more  abundant  and  closer  set  in  the  upper  buffy  coat,  being  most  abun- 
dant in  the  thin,  upper  layer  of  the  second  tyjK'.  Blood  platelets  are 
characteristically  few  and  far  between,  save  it  may  Ih>  on  the  very  surface. 

III.  The  clot  is  loose  and  easily  reuioveJ  from  the  cavity  in  which 
it  has  developed.  At  most  it  may  encircle  the  chordie  tendinere  and  free 
columns  of  the  musculi  pectinati  in  the  heart;  it  encircles  these  loosely, 
without  being  attached. 


m 


THROMBOSIS 


i  .| 


as 


have  t,.  S  mit  That  ;..  ™1T      n  '■"'  «"''«"'•'•«»«••'"  thmmh,,..  we 
lH-f«n..,r after .leath      Welrest  II  thl/"    "'  ^T  ."".""'  ''"™'"''Ht.lv 

ring  .luring  the  death  aaonv  whirhT„v   °  i     .  '.      ?  'hn.niUisis  ,Kiur- 
»f  .leath.  *We  know  tZt  Irv  oL^^'  .T'^T''  'r"  '^•'  '"""«'i«te  cans,. 

pJay  a  fwrt   n  lilH-ratinff  the  .Vptnin  I.  1-  w  H'\e.  the  leukmytes 

wule.sprea.lc«ag,.|«L„7 Sli?^  T^^  '"^'  '-.r'^  ""«'"  '•«'""•  » 
who  ll„l,|  that  the  extend  hk;:r:k.ts'*'r"'T  "T'  ^"■"  •'^«'"P''-' 
pne..m..nia.  whieh  fill  tV- , anli^^- A.  i  "'"'-; ''.^'"K  f"""  ««"ite  k,lwr 
arge  vessels.  „„.  ,.f",£  1"  «"  i;''*''^^^^^  7'-''  "'«■"-  i"to  the 
in  this  disease  is  t-ertui.dv  Z  fi.Lnf  I  /  ..  .'  "•"""'«"'  Iei.k.Hyt<,sis 
must,  we  think.  ne««t  -e'  h7w  ^^  S.  '"'  ?  7"'  "'  ""•^'  '"•"'■""^'»" 
development.  "*  "'"'  " "^ """'"..rten, .,r  nioritural 

Con.siderations  of   si>a«i'   i>p<.f....»   .      / 

R"Kvss  at  length;  forTTdcG^  f^.t  i  r^^lS./'r  t;'"'"T"*"' 
ela.s,sieiis"  n  (iiir  laiiifiium.    P..  r  i.-  ■  ■  .  "'ferml  to  the  "  fK-us 

f..r«  ..,.„.,  un.lerstand!l,g:i;;;!!:Er"  "'  '""  '"""'  ''"' '^'^^ 

pail;;d:t''"l"rifti^;'UL':r'"""-'"'t/^  -■  '"••  '"'"-••k 

ve.s.s,.|wall.or  if  „„,„Hh™-t"       r,      r"!u"""  """i^"'""  *"  ""•  '"'"''  -r 
at  whieh  it  origi     v"       r.    hL     !^V^^^^  ""• -^i"" 

arrang..ment  of  '      .> Sm-nts^  wh  /h  "'  '"""T'"  ''  ^''"^•''  "" 

"i^jf"^.nth«.  ni,;r"oi.:;!;'^:L7;:L"'""  ""^^"  '^  "—'• 

.taterl^-mln^S  inixlT.^;;:,:''"''"'"!  ^•"«"' •  -  ■""^-  •'-  '-a.! 

^^^iJ^ithSS^^^^ 

there  n.av  (h-  some  .leilm  irnf  «.   •    "JI''  ""'""'•'''   "*    "»■'••  '"'K''^ 

fonnation  ..f  Zn  ,    oml  us'of '  !''  'T""'.'^  "■«'*"'"'"«  ''''  "-'-  '" 
that  o,,imon  is   nim  '  ,,«     '''" •""''''•=  .""l'  ''"^-er.  may  Ik-  ...i.l. 

I  a^^iutmation  or  eongliitination  nuher  than  tn 

embolism  is  ,,.„,.,  „,„,  .■•,,;,.l  tlLi;::;*''  """^  "■""•"  "-  •■'"-'  -^j-r  .„ 


THK  PURE  BUH)I)  PLATELET  THRffMBUS  61 

(iiu){ulution.    It  wuulil  <HMMn  thnt  w«>  ir<ay  di-ttinguish  at  leaitt  two  if  not 
thref  fomw. 

(a)  The  Pnr«  Blo«4  PUttlat  Thnabna.~A.s  first  .shuM-ii  hy  Khfrth 
iitul  Sfhimin«'ll>iis<-li  if  u  tM-wlli*  or  cithtT  fine  foivign  IkkIv  !*•  introduriHl 
throiiKii  tin-  Willis  of  a  \fsst'\  into  its  lunit-n.  u  thrombus  liecunici  formed. 
.Micn)sco|>ic  cxauiiiiation  shows  sui-h  a  throinhus  to  Im-  finely  );ranular 
ill  a|)|)»'unin<'<';  liijther  |M)w»ts  n-stilve  the  Kramiles  into  nia.s.sed  Uood 


Kiu.  » 


ll>aliiK;  tlironilrun  in  dilated  \rTiule  of  u  Iiciiinrrlioid.      Tlii^  wa^  lierfectly  htiliinicfiirtiiin. 
Keichert,  ohj.  7a,  ficular  4,     Camera  lu''ida,  retlnretl  nnr-tliipl. 

platelets,  which  in  general  take  on  ihe  eosin  stain  somewhat  deeply. 
Here  and  then'  a  leukocyte  may  l)e  include<i,  but  the  mass  is  composed 
(sseiitially  of  blcxnl  platelets.  Almost  imperceptibly  the  inort-  granular 
portions  of  such  a  thrombus  may  pass  into  a  completely  fused  hyaline 
mass. 

'I'hcre  can  be  no  doubt  that  the  majority  of  white  parietal  thrombi  in 
the  heart  and  larger  ve.s.sels  originate  thus  by  an  accumulation  of  blood 
platelets.  Those  blood  platelets,  we  may  recall,  are  nomially  present  in 
the  healthy  blood,  and  Wright  has  shown  that  .some  of  them  at  lea,st, 
and  the.se  perfectly  tyoical,  are  derived  from  the  megacarj-ocytes  of  the 
bone  marrow. 


02 


THfifmnnsis 


(In  Byttat  ThremU  da«  f  OMdatlaaiiM  a(  fcwtkMMt^      u  < 

,«r.in.I«rlv  in  th.  s,„ vei„?y:^rot^:nrS7f?h  ^^^^ 

...J  k.dn,.y  for  ,.xa,u,.le.  w.  ,.,M«„n.,.r  f^^rmlv    t«XTnt  hya  L 
hm.nl>..  .so„.H.m...s  «||i„jf  „p  „„•  whol,.  lu.neu.  m.m  of,  Jirtlv  SwT 

l«rlv  „I„„K  tl...  tn.,uU:  that  th^-.  ««  KleU.  wa.  el„.  fi«t  ^  «£  1 

..  ni  inoglolMi.  follov, , ,  I  bv  a»elutinat.on  into  a  hvalint-  mass.     Htxnt-r 

.am.,  an.  oefK-rs.  l,^.  ,,.,,,|ovinK  iH-molytic  „^„t,.  hav.  experi."  ,t«Hv 

|.md"ml    hr„.n.H  of  this  ty,.-  in  rhe  .;,nall.^v.4ls.     iTw     hi 

•.    aninwl  w..rM.     |i  ,.s  of  mwnst  to  note  that  in  man  thronil^i  of 
fh..  or,|..r  an. ..,.  .«•  ,H,r„Vnh,ri.v  ...<«unt..ml  in  (a)  i..fe.rusZM...^ 
-W-.st.nK   ha.  th..  l«M....riai  toxins  have  Ik.-,,  msp..„.siSX  JTh^nr^: 

s,s.  an,  ,/„  ,„  states  e  ha^eten..-.!  hy  .lestruetiS.  of  tl  "^thJ^^^'r 
in  oirholK-  a.ul  ,H,is<,ninK.  f.'r  exa.npl...  „„.J  „.|„,„p,i„  Sj^^'h' 
•nenta^v  l.y  the  ,.xhihi.io„  „f  nVin,  .liph.heria  toxin.  Z  ^"' 

<■)  Hyalin.  Thrombi  A.wdat«d  with  PUmoiehlita.-   Hut  .-^casionalK 
m  the  .ex,.u..,m,„,n  of  thes.-  s.nall  thm,nl.i  we  nu.-!  u^^Z™", 
«hKh  ,t  ,s  .I.Hk  Mit  to  tm,.sh.te.  .save  on  the  «»,„,„.„■„„  ,.f    KT.^  n  ■ 

K.rder.n,.  .,,h.„  tins  n.ay  U-  a  Kn.nular  L.  •.o.r.jK.s,.!     f    iii'f 

Mhne  ^ranuh  s  of  the  «pp«.an.„«.  of  hU.nl  ph.t,.|..,'s.  ai uLT,  „ 

at  times  In-  s..,.,.  now  the  tmnspar.  ,.t  sha.lows  of  „;i  ,..,SmIet  n  ^ 

So"'k  ^'l";'  '7'"-"''\-««  the..  pa.ss  .hr..tlvin,:.     ,n  a;er:f 
el<..s..i>  paek..,|   n.l  eor,,„.sc.|..s  of  whiVh  all.  save   t  n,av  U    an    Xt.J 
.•on>n..|..|u.,v..„.|  .lu.r.-.an-fa,l„|  a.„l  have  los,  -n,    -I.  iV.rot  all         he 

Xs   ,  t     ,;  ':  ::   /;  "— '"",^  -f  the  .lisnaeKnui.'.,,  „f  tl.,-  mthro- 

Mts  into  p.irti<  les  of  (li,.  siz,.  aii.l  appeannuv  of  M,hhI  Dlatdets"     W, 

have  o  .s.,,.,.,  „„s  „.,,  a  f.-w  .i,„,.- ,!,!, ,.,.  .^„„  ,,  .,^  .H  ;^;„ , ^^^; 

Am. .1.1  ■s...,rn.,.t.a,Hl  that  prior  :.  ..,„>;lH,i,u.tio„  th.M.mrseh     ,n 

.Sm,I.  .•.pp,.an.„,...s  a,v  ,.,.,1,1..  of  iM...n,r,.ta.ioni„  t«.,  vv.'s    S ''« 
"•'ist  ass.nn,.  that   not  ail   I,Io,k1   „ia...| -ts  •.„■  .l.-nV.  I   r  "      .. 

I-ro.n  th,.s..  .s,„all..r  .h,..nH.i  w,.  ,k.ss  „„w  to  the  l.r«.r  for-.,  nr-  :- 
■■"  »;-   arg.  r  s....s..N  an.i  .a.iiv  r..H.p„.able  bv  the  nake.1  eve";, ,?(,":  ." 

we  ln..l  a  ........s  ..f  transitional  form.  I..a.linff',ip  to  a  ^  .d    ii.n      1^    ' 

nt^^s  we  ..xanm...  oan-fully,  we  fin.l  .liffionlt  I  di^t.^         L. 


THB  "WHITE  THROMBUS" 


6S 


li.  The  "WhiU  Thrombin."— In  the  rhambers  of  the  heart  or 
it(lhprr*nt  to  tlu-  parieti's  of  the  lareer  vesseU  we  may  encounter  sessile 
nr  subpiilunrulate  thrombi.  In  the  iieart  the  surface  of  these  poIy[>- 
like  mastse-s  is  not  smcKith,  but  irregular  ami  ridged,  with  intervening 
(Icpnssions:  in  the  large  vessels,  wlu-re  tlu-  masses  are  more  plaque-like, 
till'  siirfH(>  IS  apt  to  be  siiKmth.  Set-t'ons  of  these  thrombi  sliow  a  surface 
luvcr  <'om|)os«'<l  iiuiinly  of  whiti'  rorpuseles  lying  upon  and  intermingle<l 

Fm.  Id 


lIuHi  -biir.    •fitf      -iiiu         till*  l«-ft  iiiiriciilar  ii|it>4*ci<lix  uiul  iixreu^iiiic  in  r^ize  iinlil  ii  (lus.  laricrly 
.liulii-  lUr  Mill        ..r  If    I-  iK^liili.  iiC  itll:i>linimt  ill  (lif  u|i|K-iiili\  Imuiiip  lir.kpn  arroi.» 

..  lilKnitc.)  in:ii      ".       vmil.l  h  .1111 .1  li.ill  tlii'iiiil.ii-.     I  I'lilliiirmirnl  Mu-i'iiin.  Mr(  iill  I      npr.-ity.) 


with  iiiou>  liiv.r.     The  interior  of  the  mass,  when  it  has  not  iiiKJcr- 

;,^)iii  iitaiitdUx,,  1(1  tie  pn'sentiynotiHl,  exhibits  a  clmracferistif  struetim-. 
.Staiii'd  -Mteiifi  sh<!v.  min-i  wliich  •■wiUr  f'tr  low  power  appear  to  !it 
lioiiii  IK  .11-.,  iiider  (lie  liij;li  jxiwer  are  s,  ■  n  to  Ix-  (t>inposeil  of  elost-ly 
jKick.  il  lAtfx]  I  iilifs.  Among  thes*-  iiuiy  u-  relati'  -ly  rare  kMikof-ytes. 
riit'si  an'--  a>  -  H)  be  coral-like  bands  or  st  ds  cut  in  various 
directions     he     iiay  Ik-  separated  from  each  othei  '»y  a  close  ni-twork 


i  ^« 


^  I 


H 


THROMBOSIS 


of  fibnn,  or  by  fibrin  and  leukocytes,  or  ajpiin,  by  uecuniulatioii  of  red 
«)rpiistkvs.  leukocytes,  and  fibrin.  We  ihus  eneounter  various  grades  of 
the  white  thrombus,  from  (a)  that  eomposed  in  the  main  of  blo«Hl  platelets 
with  <H-casional  strands  of  fibrin,  through  (b)  that  in  whieh  leukocytes  in 
(lusters  alteniuting  with  masses  of  blinxl  platelets  are  the  characteristic 
featims  to  (c)  that  in  which  the  admixture  of  red  and  white  corpuscles  is 
very  noticeable,  where,  in  fact,  we  have  "the  niixeil  thrombus."  M„r,. 
particularly,  it  would  seem,  where  there  is  anv  extensive  admixture  of 
leukocytes,  the  central  area  of  the  thrombus  is  apt  to  undergo  autolvsis 
or  heterolysis  (vol.  i,  p.  :«»).  and  so  to  exhibit  solution,  the  thrombus 
bec-oming  niluced  to  a  thin  shell  of  still  solid  fibrinous  matter  with  iiiter- 
minglwl  leukocytes,  which  is  very  friable,  breaking  verv  easilv  under 
the  fingers,  and  then  «lis<hargiiig  a  dirty  creainv  fliiidi  the  msult  of 
self-digestion  and  solution. 

4.  The  Red  Thrombus.— Fn>in  ihe  alK)ve  we  pass  t)n  to  states  of 
more  rapid  and,  in  gi'iieral.  more  extensive  thnnnlwsis,  cimracterized 
by  a  more  abundant  imprisonment  of  red  corpuscles  lietween  the  strands 
or  layers  of  fibrin,  .so  that  the  ma.ss  is  of  re<lder  c-olor,  and  with  this  the 
blood  platelets  iK-come  less  and  less  evident.  We  approach  nearer 
that  IS.  to  the  picturi-  with  which  we  are  familiar  in  extra  vascular  dottinj;' 
>Ne  rec-ognize  two  forms  of  the  red  thrombus: 

(a)  The  Umiutod  Bed  Thrombiu.-This  we  find  in  ancurismal  sues 
that  have  underg.)iie  progn-ssive  filling  up  with  thrombus,  as  again  in 
the  larger  veins,  siirh  as  the  feuionil  and  its  branc-hes,  that  have  under- 
gone eventual  occlii.sion.     What  has  happenc-d  in  these  ca.ses  is  th-t  over 
some  one  area  necrosis  has  taken  place,  or  removal  of  the  endotti.lial 
hmng.     Here  it  would  .seem  that  at  first  the  blcx«l  platelets  have  col- 
lected and  undergone  conglutination,  next  a  fibrin  laver  with  impri.s.,iiH| 
leukoc-ytes  has  formed  over  this,  aixl  as  some  of"  these  have  broken 
down  and  lil)erated  their  fibrin  ferment  more-  fibrin  has  l)een  formed 
enmeshing  red  corpuscles;  more  leiikocytc-s.  and  it  iiiav  U',  blcKnl  platelets' 
have  Ih-c-oiiu-  arr.-sted  on  the  surfacr  of  the  clottc-d  mass,  and  in  this  «av 
layer  after  layer  is  laid  down,  each  laver  consisting  of  a  .leiiser,  iiion- 
fibrinous,  deeper  jx.rtioii  repn-senting  the  zone  of  eariier  deposit  of 
leukcK-ytos,  and  a  Icniser  fibrinous  mesliwork  enclosing  abundant  m- 
tliroc-ytes.     'I'lie  breadth  of  these  layers  is  determined  largelv  bv  the 
rate  of  the  blcHMl  stream;  when-  this  is  rapid,  as  over  a  parietal  throiiilMis 
in  the  aorta,  the  layers  an-  very  thin  and  ckr.se  jwckeil.    We  have  placHi 
on  nn-onl  a  case- of  dissecting  aneurism  of  the  aorta  in  which  througli 
niptun-  of  the  intima  in  the  lower  thoracic  region,  the  blood  di.s.se(  ted 
a  channel  betwc-en  the  layers  of  the  media,  until  it  gained  n>entrv  into 
the  original  channel  through  the  femoral  on  the  one  side,  the  iliacs  m 
the  other     This  channel  was  lined  by  a  relativelv  thin  laver  of  d<  use 
mamlv  fibrinous,  thnimbus,  which  had  l)ecome  c-ovew.1  bv  a  coai  of 
endothelium.     Once,  that  is,  the  channel  had  become  patent  and  .„in- 
municating,  with  rapid  flow  thn.ugh  it,  the  verv  nipiditv  of  that  flo« 


.\daiiii,  Momrwd  .Mtil.  .)„iir.,  24:  1,S'J.5-<M):  iH.i  an,!  a.'i:  l«9fW»7 


2:i. 


THE  ACUTE  RED  THROMBUS 


65 


we  must  presume,  prevented  the  arrest  of  leukocytes  and  platelets 
on  the  exposed  surface  of  the  thrombus,  and  with  this  arrest  of  fibrinous 
deposit  the  endothelium  had  spread  over  the  surface.  There  had  been 
some  dissection  also  from  the  original  rupture  in  an  upward  direction, 
but  here  no  second  communication  had  been  establ'sned;  no  current 
had  become  developed.  As  a  result,  this  upper  cul-de-sac  was  com- 
plftely  filled  with  a  red  thrombus  of  the  type  now  to  be  mentioned. 


Fra.  II 


Sjtcculatetl  aiwuritm  of  the  aMendinc  aorta,  largely  filled  up  by  firm  laminated  red 
thrombua.     (HeGill  Medical  Huaeum.) 

(t)  The  Acute  Bed  Thrombw.— Where  there  is  complete  arrest  of 
blood  current,  as  in  the  above-mentioned  case,  or  as  occurs  when  a  vessel 
is  ligatured  with  injury  to  the  endothelial  lining,  then  the  column  of 
stagnant  blood  undergoes  clotting  throughout  its  whole  mass,  and  if  it 
Ih!  examined  soon  after  the  occurrence,  before  secondary  changes  have 
taken  place,  no  distinction  is  to  be  made  between  the  mass  and  a  post- 
mortem or  extravascular  clot,  save  perhaps  this,  that  at  the  region  of 
origin  and  attachment  of  the  thrombus,  a  collection  of  bk)od  platelets, 
nr  more  hyaline  depo."»it  with  some  accumulation  of  leukocytes,  is  to  be 


66 


THROMBOSIS 


t 


made  out.  Fhe  origin,  that  is,  is  of  the  same  oider  as  in  other  forms  of 
hrombosis,  but  in  the  absenee  of  bkHxl  current  there  has  been  no  arrest 
to  the  process  of  fibrin  formation,  which  thus  has  extended  throujrh  th.- 
whole  mass  of  stagnant  bkxxl.  The  thrombus  in  an  artery  exten.ls 
upwanJ  to  the  next  branch  of  any  size;  once  again  its  growth  is  arreste.1 
I  "'^.'"^'^^b-  'noving  bkxHl  stream;  in  a  vein  it  extends  downwani 
along  the  branches  until  a  region  or  regions  of  anastomosis  and  (bilateral 
circulation  is  reachetl  (see  Fig.  12,  p.  71). 

We  have  hen-  descril)e.!  the  different  forms  of  thmmbus  in  the  reverse 
order  of  that  usually  t-mployed,  and  have  done  this  in  ortler  to  lav 
emphasis  upon  the  diveiyenc:es  between  the  main  forms  of  thromlwsi's 
and  extravascular  coagulation.  It  is  obvious  that  although  the  en.l 
result  I.S  the  same,  namely,  the  production  of  .solid  matter  in  the  place  of 
fluid  blwKl.  that  result  is  attained  in  inon-  than  one  way.  As  to  the 
relative  frequency  and  importance  of  these  different  modes  of  formation 
nanie^j-.  by  the  conglutination  of  blood  platelets,  bv  the  conglutination' 
of  red  corpascles.  and  by  the  development  of  a  fibrinous  network  en- 
meshing the  corpuscular  elements  we  are  still  undecided;  at  most  it  can 
l)e  stated  that  the  conglutinative  forms  are  being  more  and  more  recoir- 
nizod  as  the  more  usual.  For  ourselves,  judging  from  the  specific 
staining  reactions,  we  believe  that  fibrin  and  the  hyaline  matter  ofVhi... 
thrombi  are  chemically  closely  allied  and  of  the  same  oitler.  and  .so  an- 

Zu^-  '"•*^*'  u"^"'l°^  ''"'•'"■  '«**=tio'«-  The  constant  attachment 
of  the  beginning  thrombus  to  an  area  of  the  vascular  wall,  which  in  most 
ca*s  can  be  seen  to  have  undergone  injury  or  degenemtion,  indicates 
that  either  the  damaged  endothehum  or  the  umlerlying  cells  supply 
somethmg-probabK-  of  the  nature  of  fibrin  ferment-which  initiates 
the  conversion  of  the  substance  of  the  blood  platelets  or  erythiwvtes 
into  fibnn-like  material,  and  that  once  started,  the  rnxess  would  .s^^n. 
apt  to  continue  into  the  plasma  outside  and  beyond  as  true  fibrin  fonna- 
tion.  VVhit  part  the  blood  platelets  play  in  the  onlinarv  proce.s.s  of 
magulation  is  as  >-et  undeterinine<l;  at  mo.st  it  is  .significant' that  in  <.,m- 
di  ions  in  which  their  numln-r  is  .liminished.  as  in  purpura,  the  coaLn,- 
lative  power  of  the  bkxMl  is  likewLse  seen  to  Ik-  diminLsLl.  But  unL 
we  accept  the  observations  of  \\1a,^s«w,'  that  in  onlinarv  fibrin  fonna' 
t  on  in  she.1  blood  the  conglutination  of  blcKxl  platelets  is  the  first  staire 
It  M  .lifficult  to  bring  into  line  with  the  prevalent  theories  of  c-oagulatb,; 
these  observations  upon  thmmbus  formation,  observations,  be  it  n«.,.i 

i^m  vl"^^  7c"t*'"'''';\  ^"'."^  * '«"« *"'-« «' »«!"«!  path„io^ns,s: 

trom  hlierth  and  Sthinimelbu.sch  in  18«8  onwanl 

Itde|«>rves  note  that \Vooldridge,lerive<l  his  AfibrinogenfrtMnthe  l.l..,,.i 

dm     n  K  '"'' •  "".'  "'™  '■''  ^"'•'"•"'  (^'">'""  intervention  of  (il.ri,, 

ferment)  by  a  jiin.tion  In^tween  this  and  other  fibrinogen.:  pre.sent  in 
the  plasma.  His  view.s  have  never  gained  general  acceptaixr,  :,.,<] 
practically  all  mo<lern  physiologists  recognize  the  part  played  by  a  fil  rin 
ferment,  even  if  most  reganl  this  as  not  liberated  direct  into  ;he  p'ts„,a 


'  Ziegler's  Ueitrage,  1,5: 1894:543. 


THE  ACUTE  RED  THROMBUS 


«7 


hut  require  a  prothrombin,  present  in,  and  capable  of  liberation  from, 
leukocytes  and  most  body  cells,  which,  under  the  action  of  a  zymoplastic 
substance,  liberated  from  red  corpuscles  and  other  celb  proper,  gives 
origin  to  thrombin,  or  fibrin  ferment  proper.    This  thrombin  in  its  turn 
is  regardeil  as  acting  upon  the  paraglobulin  of  the  plasma,  converting 
it  into  fibrinogen,  or  metaglpbulin,  and  eventually  into  soluble  fibrin, 
and  this  in  the  presence  of  calcium  salts  becomes  converted  into  th? 
more  solid  fibrin.  So  many  and  so  diverse  are  the  theories  of  coagulation, 
that  we  do  not  in  the  least  believe  that  the  process  here  indicated  is  what 
actually  occurs.    No  one  appears  to  be  satisfied  that  we  have  as  yet 
gained  a  sure  knowledge  of  the  process.    We  have  a  certain  satisfaction 
in  living  to  the  physiologists  the  teaching  of  a  subject  which  they  have 
for  k)ng  years  made  peculiarly  their  own.'    At  most,  we  would  urge 
that  evidently  somethmg  is  involved  which  is  common  to  the  blood 
platelets,  to  the  erythrocytes,  to  the  white  corpuscles  (for  it  is  where 
these  are  aceumulatetl  in  greatest  numbers  that  the  fibrin  is  laid  down 
most  densely),  and  it  may  be  also  to  the  plasma  (for  in  rapidly  de- 
veloping thrombi  the  fibrin  threads  extend  ir.to  the  plasma  between 
the  cells),  and  this  something  would  seem  to  be  of  the  nature  of  a 
globulin  or  gkbulins,  for  such  are  common  to  both  cells  and  phisma, 
and  there  would  appear  to  be  an  agreement  among  the  physiologicaJ 
chemists  that  fibrinogen,  the  precursor  of  fibrin,  is  a  metagbbulin. 
The  fact  that  the  normal  cireulating  blood  does  not  coagulate,  and 
that  the  ordinary  thrombus  is  seen  to  devebp  in  c-onnection  with  the 
vessel  wall  at  a  region  of  disease  or  injury  or  toss  of  the  endotheUum, 
TOuld  su^st  that  something  not  ordinarily  present  in  the  circulating 
Wood  IS  given  off  at  such  an  area,  and  initiates  the  c-onversion  of  the 
dissolved  protein  into  its  more  solid  modification,  fibrin.    The  whole 
process  points  to  the  liberation  of  an  enzyme.     We  do  not  pretend  to  say 
that  the  blood  pUtelets  are  absolutely  essential  for  the  process;  but  the 
wav  in  which,  once  the  process  has  started  in  .stagnating  blood,  the  strands 
of  hbnn  spread  rapidly  through  a  relatively  large  mass,  and  the  abun- 
dance of  dense  fibrin  m  immediate  relationship  to  clusters  of  white  cor- 
puscles on  the  surfac-e  of  ordinary  wliite  thrombi  and  elsewhere,  prepare 
IIS  to  .see  that  other  cells  liesides  those  of  the  vessel  walls  mav  liberate 
the  enzyme  or  initiator  of  the  c-onversion  of  soluble  protein  into  fibrin 
•Nay,  more,  although  this  is  contrary  to  the  generallv  receive.1  doctrine 
just  as,  e-xpenmentally,  by  the  injection  of  certain  tis-sue  extracts,  it  is 
|K)ssible  to  induce  an  almost  universal  thrombosis  throughout  the  vascular 
sy.stem,  .so  is  it  possible  to  imagine  the  existence  of  conditions,  such  as 
extensive  di.si.itegration  of  the  circulating  leukocytes,  which  would  lead 
(o  a  process  of  thrombosis  independent  of  any  disturbance  of  the  ve^l 
wall,  conditions  in  which  the  multiple  thrombi  or  masses  of  ctotted 
>lood  w-ould  have  no  primary  attachment.    Admitting  this,  it  has  also 
lo  Ik.  admitte«l  that  the  more  we  study  actual  cases  of  thrombosis,  the 

•■  A  very  iuU  review  of  the  daU  and  theories  of  coaguUtion  is  given  by  Buck- 
master  m  Snence  Progress,  2: 1907:51  8  .         V» 


68 


THROMBOSIS 


I 


ill 


more  we  bec-ome  impressed  by  the  co-existence  of  lesions  of  the  vascular 

The  Factors  ravoring  Thrombosis.— The  analyses  made  thus  far 
of  the  incidence  of  thrombosis  in  man  in  various  conditions  of  disease, 
and  the  experiments  made  upon  the  lower  aniraab,  indicate  that  very 
diverse  oitters  of  disturiiance  favor  the  development  of  thrombi— so 
diverse,  in  fact,  that  it  is  a  matter  of  extraordinary  difficulty  to  arrive 
at  any  sure  conclusion,  and  as  a  result  we  find  that  different  obse^^'e^s 
arrive  at  verj-  different  conclusions  regarding  their  relative  importance 
We  will  here  record  these  factors,  giving  the  more  important  data  and 
the  conclusions  that  have  been  drawn,  and  then  proceed  to  weigh  the 
evidence  in  the  light  of  what  has  already  been  laid  down  concerning 
the  actual  process.  ... 

1.  Slowing  and  SUgnation  of  tlw  Blood.— Thrombosis  is  more  comm«)n 
in  the  venous  system  than  in  the  arterial- according  to  Lubarsch,  in 
the  proportion  of  more  than  4:  1— as  also  it  is  pecuUarly  apt  to  occur 
in  rcj^ons  of  dilatation  of  the  channel  where  the  current  necessarily 
becomes  slow,  e.  g.,  in  the  auricular  appendages,  in  the  sinuses  or  depres- 
sions between  the  muscular  bands  of  the  heart  chambers,  in  vancose 
veins,  and  in  aneurisms.  Where  the  blood  stream  is  rapid,  despite  the 
existence  of  other  favoring  factors,  thrombosis  does  not  necessarily 
sliow  itself,  e.  g.,  then-  may  he  an  extensive  atheromatous  ulceration  of 
the  aortic  wall,  with  loss  of  endothelium,  and  no  sign  of  thrombosis. 
This  led  Virchow  to  reganl  slowing  of  the  blood  stream  as  the  pnmc 

2.  Eddying  of  the  Blood.— A  factor  upon  which  von  Recklinghausen 
would  lay  great  stress  is  the  formation  of  eddies  rather  than  the  existence 
of  simple  stagnation  in  regions  in  which  the  vascular  channel  undergoes 
expansion.  There  is  not,  he  urge<i,  absolute  stagnation  in  the  pockets 
of  the  valves  of  the  veins;  nevertheless,  tbrsc  are  peculiarly  favorable 
seats  for  the  origin  of  venous  thrombi.  If  we  conceive  an  eddy  as  a  whirl, 
our  first  idea  is  that  in  it  the  blood  flow  is  faster,  and  that,  therefore, 
the  conditions  are  unfavorable  rather  than  favorable  for  the  deposit  of 
blo.).l  platelets  and  other  cells.  This,  however,  is  not  a  complete  coii- 
c-eption;  while  at  the  edge  of  an  eddy  there  is  relatively  rapid  flow,  at  its 
centre  there  may  be  n-lative  stagnation.  What  is  more,  the  very  whirliiifr 
nature  of  the  flow  does  away  with  any  peripheral  cell-free  layer  of  the 
plasma,  so  tliat  once  cells  become  arrested  in  the  quiescent  area,  the 
n)iiditions  distinctly  favor  the  adhesion  and  accumulation  of  other 
platelets  or  cells. 

3.  Hemolysis  and  Destmction  of  Corpuscles.- It  is  those  agents,  exogen- 
ous and  endogenous,  which  lead  to  corpuscular  disintegration,  whidi 
characteristically,  when  exhibited,  bring  about  extensive  thrombo.sis. 
There  is  a  long  list  of  exogenous  poisons  having  such  properties— salts 
of  mercury,  lead,  arsenic,  etc.,  potassium  chlorate,  sulphates  and  sul- 
phites, nitrobenzole,  tohiylene<liamin,  and  other  toluvlene  compoiinds, 
various  aniline  derivatives,  phenylhydrazin,  etc.,  carbolic  and  salicylic 
acids,  various  compounds  of  vegetable  origin,  ricin,  extracts  of  amamta 


PREDISPOaiSQ  CAUSES  69 

and  other  poisonous  mushrooms;  others  of  animal  origin,  e.  g.,  snake 
venom  and  sundry  enzyn^es,  pepsin,  etc.  Of  the  endogenous  poisons, 
the  diffusible  products  from  extensive  bums,  the  (unknown)  toxic  agents 
in  eclampsia  and  possibly  toxic  substances  present  in  the  blood  in  severe 
secondary  anemias  (e.  g.,  that  accompanying  cancer)  may  be  mentioned. 
In  all  these  conditions  there  is  a  marked  tendency  to  thrombosis,  either 
multiple  and  small  in  the  capillaries,  or  sometimes  of  larger  size  in  the 
larger  '  ..as.  Stress  is  laid  upon  these  data  more  particularly  by  those 
upholding  conglutination  as  a  main  factor. 

4.  Baetuia  and  TlMir  Prodoeti. — But  it  has  to  be  admitted  that  intoxi- 
cations pure  and  simple,  whether  endogenous  or  exogenous,  are  rela- 
tively infrequent  compared  with  infectious  and  bacterial  intoxication. 
Most  people  die  from  terminal  infections,  and  attention  is  being  increas- 
ingly drawn  to  the  fact  that  even  in  what  are  recognized  as  bland  thrombi 
bacteria  are  to  be  detected,  or  cultures  gained,  while  conversely,  as 
shown  by  Welch  and  Lubarsch,  if  known  cases  of  infection  be  carefully 
studied — suppurative  cases,  k>bar  pneumonia,  typhoid,  appendicitis, 
diphtheria,  acute  rheumatism,  measles,  influenza,  etc. — capillary 
thrombi  in  the  brain,  lungs,  kidneys,  and  intestinal  walls  are  found  to 
be  remarkably  frequent. 

There  are  different  views  as  to  how  the  bacteria  act.  Thus,  certain 
observers  have  dwelt  upon  the  hemolytic  action,  and  have  pointed  out 
that  the  pyococcus  aureus  is  most  actively  hemolytic,  and  is  found 
associated  with  thrombi  very  frequently.  But  thrombi  are  frequent 
in  acute  tuberculosis  and  in  typhoid,  and  the  microbes  of  neither  of  those 
iJiseases  have  pronounced  hemolytic  powers.  It  is  true  that  as  Professor 
Welch  points  out,  in  many  of  these  cases  exammation  reveals  not  the 
microbes  of  the  main  dbease,  but  those  of  some  secondary  infection, 
streptococci,  bacillus  coli,  etc.  There  b  diversity  of  opinion,  again, 
regarding  the  actual  presence  of  the  bacteria  in  the'  blood  stream;  some 
()bser\'ers  point  out  that  the  Rltered  culture  fluids  of  forms  like  bacillus 
tN-phosus,  bacillus  coli,  and  bacillus  diphtherite,  when  injected  into  the 
veins,  have  little  effect  in  inducing  thrombosis  (Jakowski);  others,  like 
Talke,  demonstrate  that  parenchymatous  inoculation  of  pyococci  leads 
in  the  majority  of  cases  to  thrombosis  of  the  vessels  in  the  immediate 
neighborhooi-,  and  this  without  of  necessity  any  1  teria  being  present 
in  the  thrombi.  In  our  laboratory  Leo  Loeb  d.  onstrated  that  the 
addition  of  cidttiras  of  certain  organisms  accelerated  the  rate  of  coagula- 
tion of  extravascular  blood,  while  cultures  of  other  species  had  no  effect. 
Hut  accepting  his  data,  his  results  bear  little  apparent  relationship  to  the 
ilata  of  disease;  thus,  for  example,  the  feebly  pathogenic  Micrococcus 
prodigiosus  was  found  to  have  a  greater  accelerating  power  than  the 
typhoid  bacillus,  and  the  streptococcus  was  without  affect.  Nor,  so  far 
as  we  can  see,  did  his  results  tally  with  the  hemolytic  powers  of  the 
species  tested. 

.1.  DiMue  and  Injury  of  the  Vaiculur  WaU.— We  have  ah-eady  laid 
str^s  upon  this  as,  in  our  opinion,  a  most  important  factor,  but  must 
again  impress  upon  the  reader  that  it  is  not  everything.     It  is  quite 


'§ 


70  THROMBOSIS 

true  that  when  we  mevhankiilly  injure  or  destroy  the  endothelium  of 
the  living  vessel,  there  we  surely  gain  thrombus  formation  over  the 
region  of  injur}'.  But  the  extent  <l«pen<ls  very  largely  upon  the  rair 
of  blood  flmc  over  the  injured  area;  the  more  rapid  the  rate,  the  less 
the  resulting  thronilxwis.  Nevertheless,  we  t-an  recall  no  observations  in 
which  destruction  or  grave  injury  to  the  previously  intact  endothelium 
has  not  been  followed  by  some  grade  of  thrombosis.  Here  a  fine,  but 
what  must  be  considered  an  important,  distinction  must  be  made.  We 
do  not — because  we  cannot — hoki  that  the  thromlxisis  follows  the  ex- 
posure of  what  Ls  dead  or  foreign  material  to  the  circulating  blood.  We 
know,  for  example,  that  the  exhibition  of  foreign  matter  in  the  blood 
is  not  necessarily  followed  by  coagulation.  It  is  possible  to  place  balls 
of  perfectly  smooth  glass  in  the  larger  ves.sels  or  heart  cavity  without  any 
clot  forming  round  them.  Guthrie,  of  St.  liouis,  has  affonleil  the  most 
remarkable  instance  to  the  point.  Taking  a  length  of  the  vena  cava 
of  the  rabbit,  he  has  hardened  this  in  formalin  solution  for  several  days, 
wa.shed  out  the  formalin  ami  dehydrated  with  strong  alcohol,  and 
then  impregnated  the  piece  with  liquid  paraffin,  following  upon  which 
he  has  implanted  the  segment  in  the  course  of  the  rab!»if 's  carotid  artery. 
And  notwithstanding  the  piece  of  dead  vein  has  apparently  functionate<l 
perfectly  for  twenty-two  days  with  no  sign  of  thrombosis.  It  is  true 
that  foreign  bodies  with  rough  surface  introduced  into  the  bloixl  stream 
become  covere<l  with  a  layer  of  fibrin;  blood  platelets  and  leukocytes 
adhere  to  the  surface  irregtdarities,  and  their  disintegration  leads,  we 
suggest,  to  the  liberation  of  the  substance  which  initiates  coagulation  and 
fibrin  formation.  If  the  circumstances  are  .such  that  this  sulxstance  is 
not  given  off,  or,  being  given  off,  Is  carried  too  rapidly  by  the  blocxi  stream, 
then  thrombosis  cannot  en.sue.  It  Is  in  this  way  that  we  would  account 
for  the  absence  of  thrombosis  over  exposed  (dead)  calcareous  plaques 
and  ulcers  of  the  aortic  wall.  But  admitting  this,  we  have  to  acknowleflge 
that  there  Is  a  group  of  cases,  more  especially  of  capillar}'  thrombosis, 
in  which  microscopic  examinations  reveal  no  recognizable  departure  of 
the  endothelium  from  the  normal,  or,  at  most,  a  grade  of  fatty  degenera- 
tion which  is  common  in  infectious  proces.ses,  and  mast  often  fomid 
unaccompanied  by  thrombosis.  Here  we  again  revert  to  the  .same 
order  of  phenomena  noted  in  connection  with  the  coagulation  occurring 
around  foreign  bodies;  it  is  in  the  slighter  cases  of  this  order  that  we 
occasionally  encounter  ves.sels  in  which  either  des(|uamated  endothelial 
cells,  or  leukocytes,  or  what  are  apparently  clumps  of  blood  platelets 
lying  isolated  in  the  blood,  away  from  the  vessel  wall,  are  surrournhni 
by  a  coarse  radiation  of  fibrin  filaments.  Evidently  all  these  orders  of 
cell  substance  can  give  off  the  body — ferment  or  pro-ferment — whi<li, 
interacting  on  substances  in  the  plasma,  gives  origin  to  fibrin. 

Localiiation  of  Thrombi. — ^They  may  occur  in  any  portion  of  ilie 
blood  .system.    Here  we  distinguish : 

1.  OardlM  Thrombi. — (a)  Of  these,  the  commonest  form— althoti^'li 
we  are  apt  not  to  regard  them  as  such — are  the  ▼•gatettons  upon  tlic 
valves  in  acute  endocarditis.     (6)  The  more  typical  thrombi,  globuliir. 


CARDIAC  THROMBI 


71 


Fill.  12 


sessile,  or  pedunculate  are  found  more  particularly  in  the  auricular  ap- 
i)eiulire9  and  at  the  apices  of  the  ventricles — found  in  obstructive  heart 
tlisease  leading  to  canliac  insufficiency  with  retardation  of  the  blood 
How,  and  chronic  diseases  of  the  hings,  arteries,  and  kidneys,  as  amin 
in  cachectic  states.  We  deal  in  these  cases  with  retanlation  rather  than 
with  actual  stasis  of  the  blood,  and  this  retanlation  is  most  manifest  in 
the  "pockets"  of  the  heart.  Along  with  this, 
microscopic  examination  reveals  d^eneration 
of  the  endocardium,  (c)  Another  group  of 
more  flattened  mural  thrombi  may  be  found 
in  various  positions  either  in  the  auricles  or 
ventricles.  ITiese  are  situated  over  localized 
areas  of  necrosis  or  ulceration  of  the  endo- 
cardium, due  either  to  infection,  infarction  of 
the  wall,  or  partial  aneurism,  (d)  A  form 
apart  is  the  baU-thrombu,  found  loose  in  the 
left  auricle;  some  score  of  cases  of  this  condi- 
tion have  been  described.  The  condition  is 
that  01  a  relatively  firm,  globular  mass,  vary- 
ing in  size  from  that  of  a  walnut  to  that  of 
a  hen's  egg,  lying  loase  in  the  cavity,  and 
eventually  causing  sudden  death  by  acting  as 
a  ball  valve  over  the  stenosed  mitral  orifice. 
Some  examples  have  shown  a  rough  area, 
indicating  the  recent  detachment  of  a  globular 
thrombus  from  the  auricular  endocardium, 
upon  which  a  thrombotic  area  of  origin  lias 
l>een  detected;  others  have  been  smooth  or 
homogeneous  over  the  whole  surface,  indi- 
cating that  the  thrombus  has  been  free  for 
some  considerable  time  before  the  fatal  event, 
and  that  by  the  deposit  of  successive  lamince 
of  fibrin,  it  has  increased  in  size  while  rotat- 
ing in  the  auricle.  Von  Recklinghausen  has 
doubted  whether  these  necessarily  cause  sud- 
den death,  and  much  is  to  be  said  in  favor  of 
liis  arguments;  we  may  conclude  that  they 
<io  not  necessarily  bring  aliout  sudden  death, 
but  that  at  the  same  time  they  must  be 
regarded  as  producing  it  in  the  majority  of 
cases.  In  only  one  other  region  do  we  know 
of  the  existence  of  similar  ball-thrombi,  and 

lliis  is  an  individual  observation  of  our  own.  In  a  case  of  sudden  death 
we  encountered  a  firm,  oval,  free  mass  occupying  the  cavity  of  the  left 
coronary  cusp  of  the  aortic  valve,  and  occludmg  the  left  coronary  orifice. 
\\'e  have  recently  encountered  an  almost  identical  case  of  sudden  death, 
but  in  this  the  globular  nwss  was  still  attached  by  a  delicate  pedicle  to 
the  eroded  aortic  wall  immediately  above  the  left  coronary  orifice. 


Acute  red  tliniinbUM  uf  iliac  vein. 
(Mc(iill  Medical  Htueum.) 


f 


72 


THROMBOSIS 


2.  JMuial  ThremU. — Such  may  be  found  either  parietal  or  occluding; 
in  the  aorta  or  any  of  ita  branches,  and  then  in  general  as  the  result  of 
either  mechanical  injury  (t.  e.,  ligature)  or  of  arteriosclerotic  changes, 
or  lastly,  as  secondary  to  embousm.  Most  frequently,  however,  they 
are  encountered  in  the  arteries  of  the  extremities,  and  more  especially 
of  the  lower  extremities.  An  important  group  occur  in  connection  with 
atheromatous  degeneration  of  the  cerebral  arteries;  another  group,  often 
but  not  always  <A  embolic  origin,  in  the  pulmonary  arteries. 

3.  Veaoiu  TtanmU. — These  are  in  many  respects  of  the  greatest 
medical  interest  and  the  most  widespread.  Indeed,  many  factors  com- 
bine to  make  the  veins  the  seat  of  election  for  thrombosis — the  poorer 
quality  of  the  blood,  its  slower  flow,  the  absence  of  pulsation,  the 

Cresence  of  pockets  behind  the  valves,  the  thinness  of  the  walls,  and  low 
lood  pressure,  leadbg  easily  to  local  arrest  of  the  blood  flow  in  con- 
sequence of  pressure  from  without.  As  Welch  points  out,  thrombosis 
most  often  begins  in  vesseb  where  these  conditions  are  together  most 
operative,  namely,  in  the  middle  sized  veins  rather  than  in  the  smaller, 
or  those  unprovided  with  valves.  Thus,  characterbtically,  thrombosis 
shows  itself  first  in  the  femorals,  and  not  in  the  smaller  veins  of  the 
lower  extremity,  or  in  the  vena  cava,  in  the  cerebral  sinuses  more  often 
than  in  the  cerebral  veins.  Once  they  originate,  they  are  apt  to  extend 
progressively  in  both  directions,  although  the  smallest  veins  of  a  part 
usually  do  not  become  involved.  It  is  the  left  common  iliac  vein  that 
has  the  larger  and  more  obstructed  course,  the  left  innominate  vein  that 
is  the  larger  and  the  more  oblique  channel  for  return  flow;  thus  we  find 
thrombi  more  common  in  the  veins  of  the  left  leg  and  arm. 

4.  Oapillary  Tbrombi. — We  have  already  referred  to  the  frequency  of 
small  hyaline  thrombi  in  the  smaller  vessels,  evidently  of  local  origin; 
it  is  interesting  in  this  relationship  to  call  attention  to  what  has  been 
stated  above,  namely,  that  tlic  ordinary  retrograde  thrombus  does  not 
in  general  extend  back  into  the  small  veins  and  capillaries.  Thrombosis 
of  the  ordinary  type  can,  however,  show  itself  in  capillaries,  and  that 
in  inflammations,  and  more  particularly  in  infectious  conditions,  as  in 
the  zone  surrounding  a  focal  infectious  condition,  an  abscess,  or  evfii 
a  granuloma. 

Effects  of  Thrombosis.— To  discuss  the  effects  of  thrombosis  of  tiic 
arter'es,  veins,  and  capillaries  is  to  pass  in  review  the  results  of  closnrc 
of  a'!  the  vessels  of  the  body,  as  that  affects  the  different  imlividiml 
parts  and  organs.  That  i.".  impossible;  at  most  here  it  may  be  staff*  1 
m  the  broadest  way  that  there  are  certain  main  factors  that  deterniiiu- 
those  effects,  namely,  first  .  '  foremost,  the  extent  to  which  the 
obliteration  of  a  given  vessc-i  iffects  the  nutrition  of  a  part;  iind 
secondly,  and  of  yet  greater  impv .  lance  for  the  organism,  the  amount  of 
tissue  thrown  out  of  gear  relative  to  the  importance  of  that  tissue.  Tlius, 
for  example,  a  very  small  vessel  supplying  just  one  small  collection  of 
uer\'e  cells  in  the  brain,  if  thrombosed,  by  leading  to  the  destruction  of 
an  important  centre,  may  have  very  profound  if  not  rapidly  fatal  efTci  t>, 
whereas  thrombosis  of  one  renal  vein,  although  leading  to  almost  com- 


CANALIZATION 


78 


plete  destruction  oi  the  whole  kidn^,  through  the  compensating  activity 
of  the  other  kidney  may  be  followed  by  very  little  general  disturbance. 
Remembering  that  here  we  deal  with  phenomena  that  are  the  common 
end  results  not  only  of  thrombosis,  but  also  of  embolism,  and  in  addition, 
of  obliteration  of  vesseb  by  very  many  means,  it  has  seemed  wise  to 
discuss  the  broad  general  results  of  closure  of  vesseb  in  an  earlier 
chapter. 

ne  OhangM  that  Occur  in  the  Thromboi.— Whatever  the 
cause — whether  the  greater  relative  amount  of  fibrin  entering  into  its 
composition,  or  its  very  architecture,  whereby  the  contraction  cA  the 
fibrin  is  more  effective  in  driving  out  the  serum — the  thrombus  is,  even 
when  recent,  of  a  drier  nature  than  the  ordinary  blood  clot.  If  of  long 
continuance,  various  changes  may  occur,  some  leading  to  greater  firm- 
ness, others  to  softening,  which,  however,  is  quite  distinctive.  These 
changes  are  of  the  following  orders: 

1.  AbMrption. — When  a  thrombus  is  of  moderate  size,  we  have 
evidence  that  it  may  wholly  disappear,  the  vascuUr  channel  becoming 
restored.  The  main  agent  at  work  in  such  cases  is  apparently  leukocytic 
activity,  with  solution  and  absorption  of  the  fibrin. 

2.  Ouitnl  Astoljiit. — ^This  would  seem  to  be  closely  allied  to  the  pre- 
vious change.  It  is  most  commonly  encountered  in  old  globular  and 
mural  cardiac  thrombi.  The  thrombus  apparently  solid,  with  character- 
Lsti(r  netted  surface,  is  found  to  be  a  mere  brittle  shell  filled  with  a 
discolored,  puriform  fluid.  But  this  fluid  is  in  no  sense  pud.  It  contains 
granular  debris,  fatty  globules,  red  corpuscles,  and  occasional  fat-con- 
taiiiing  leukocytes,  and  is  the  result  of  self-digestion  of  the  thrombus, 
or,  perhaps  more  accurately,  of  heterolysis,  by  the  agency  of  leukocytes, 
both  those  originally  present  and  those  wandering  in  from  the  surface. 

3.  Organiation. — litis  is  yet  another  natural  process,  llie  presence 
of  foreign  matter  in  the  lumen  of  the  vessel  acts  as  a  chemiotactic  irritant, 
so  that,  in  the  first  place,  leukocytes  are  attracted  into  the  substance  of 
llie  tlirombus  from  the  vessel  wall,  not  so  much  where  the  lining  endo- 
thelium is  intact,  as  where  it  is  damaged  and  wanting,  at  the  site  of 
adhesion;  and  here  also,  following  the  leukocytic  invasion,  there  would 
seem  to  be  a  similar  chemiotactic  entrance  <A  capillary  processes  and 
loops.  In  this  way,  the  leukocytes  first  digesting  the  fiorin,  there  is 
an  entrance  of  granulation  tissue  into  the  thrombus,  and  this  may 
advance  and  progress  until  the  whole  thrombus  undergoes  in  part  a 
slow  heterolysis  and  absorption,  in  part  replacement  by  well-formed  and 
va-(  iilarized  connective  tissue.  Through  the  absorption,  or,  again, 
thriiiigh  the  contraction  of  the  "cicatricial"  tissue,  what  had  been  a 
large,  obliterating  thrombus  comes  to  be  represented  by  a  small  con- 
traded  mass  of  fibrous  tissue. 

4.  Canalintion. — Nor  does  this  necessarily  completely  occlude  the 
vessi  I.  On  the  contrary,  an  old  thrombus  may  come  to  be  represented 
by  u'!<-  or  more  bands  or  bridles  crossing  the  almost  completely  restored 
liimiMi  of  a  vessel.  Or  the  vessel  may  be  narrowed  and  contracted  at 
the    i'e  of  the  old  thrombus,  presenting  one  or  more  narrow  channeb 


I 


74 


THROMBOSIS 


through  which  communication  ia  regained  l>etweeii  the  proxinuil  ami 
distal  portioan  of  the  hitherto  obitructed  vessel.  lliU  process  of  "  canal- 
ization" presents  not  a  few  pointi  of  intereMt.  'I1ie  channels,  large  or 
small,  are  lined  with  endothelium  which  w  in  direct  continuity  with 


Ki«.  1.1 


Krheliia  of  m«Mte  of  raiialiiat ion  nf  h  t!ir<ilnhu^;  1,  thnunbus  nci'ludinx  s  v«r<Kel;  2.  dJMHii^'l 
intiras  of  vr'*>*rl  to  which  th«  throiiihu^  ix  adherent;  3,  endothelium  of  vewel  above  the  ttmimhii^. 
growing  over  the  thrnmhuK  an<l  at  -I  paiu*inK  downward  into  defirefmion  on  itn  8urfari>,  one  rif 
itti  celln  at  5,  Hendiufi  downward  a  proeesH  to  join  with  similar  endothelial  piticeiM  from  one  of  tiif 
capillarieii  enterinx  the  thrombus  at  6.  in  the  proceaa  of  orsaniiation  of  the  name.  The  pnH-f:<- 
at  A  will  ultimately  form  a  capillary  channel  of  coimnunicatiun,  which  will  uaderRo  procreHx  in 
enlaritenient. 

that  lining  the  normal  ve^isel  al>uve  uiitl  below.  How  have  they  coin'' 
to  be  formed?  It  Ls  easy  to  understand  that  a  parietal  non-obliterating' 
thrombus  should  become  covered  in  process  of  time  by  an  ectensinn 
of  the  endothelium  lining  the  vessel  immediately  beyond  the  site  til' 


J 


CALUtFICATlOS 


75 


wlhntiuii.  'ITiw  WIM.VI  expUin  the  foriniition  of  a  UiteraJ  rlwiinel; 
it  .Iocs  not  expUin  the  pr«««Ke  of  c«itr«l  clmniiek  tor  these  the 
«,ly  wiequate  expUnation  waiVcl  !*eem  tt)  Iw  the  rxtahlinhment  of  free 
.•cnmunicatioiM  between  certain  irf  the  capilUries  of  the  replaoement 
granulation  tUsue  ami  the  lumen  of  the  ohliterate.!  vessel  aUn-ean. I 
hel(»w  Onre  MUth  t-onimunicati.>n  w  estal)lishe«l,  awl  the  Wo«l  hnds 
M  way  from  the  lumen  above  to  the  lumen  l>el«.w.  then  along  the 
lines  .»f  'llioma's  principles,  the  cliffereme  in  l.loocl  pres-siire  l-rtween 
the  two  partu  and  the  rate  of  flow  through  the  new  channel  wouUI  lead 
to  its  progressive  diUtation,  until  from  a  mere  capillary  a  wide  channel 
liecomes  developed.  •       i    » 

'.  ?BtnfMttT*  iottoBlBf .— We  have  already  notwl  that  even  m  what 
are  erf  the  nature  irf  bland  thrombi.  l)atteria  have  In^n  <leteited;  it  is 
not  therefore,  all  bacteria  that  lead  to  disintegration  (rf  thrombi.  More 
particularly  when  we  Isolate  the  pyogenic  Iwcteria.  more  partaularly 
again  in  the  condition  of  thromlwphlebitLs.  do  we  meet  with  a  true  sup- 
purative softening  of  a  thrombus  and  replacement  by  true  pus.  It  is 
not  merely  that  these  bacterU  multiplying  in  the  thrombus  cau.se  .soften- 
ins  of  the  same  thniugh  the  action  of  their  proteolytu-  enzymes,  hut  in 
addition,  through  the  disease*!  walls  of  the  vein,  leukocytes  are  attracte.1 
in  itreat  numbers  Streptococci  and  bacilhis  <oli  are  m.wt  fre<iuently 
found  in  these  conditions,  although  the  latter,  with  others  of  the  group  of 
intestinal  bacteria,  may  also  be  found  in  conditions  in  which  there  is 
not  so  much  an  attnwtion  of  leukocytes  as  pure  putrefactive  .lisinte- 

"^i  LooMBiaff  of  Thrvmbi  and  iU  Mactt.— Such  s..fteiiing  of  thrombi, 
M«.re  particularly  in  the  heart  (endcnardial  vegetations)  and  in  the 
veins,  leads  to  liberation  of  the  whole  or  portions  erf  the  same,  and  so 
to  the  fdrmati.  ,n  of  MnboU.  But  embolism  may  be  due  also  to  portions 
of  hlandthrombi-^idiac  vegetations,  and  polyiKiid  thrombi  of  theheart. 
un.l  mural  thrombi  of  the  aorta;  these-  may  Ixwme  dislodged  nmhan- 
icallv  bv  the  force  of  the  blood  stream  or  unusual  movements  either  in 
tlic-  blcHxl  or  the  containing  vessel.  Similarly,  the  cases  arc  fairly  fre- 
(lutiil  in  which,  through  some  forced  or  unusual  movement,  relatively 
loiiL'  thrombi  in  the  sy.stemic  veins  l>ecome  broken  a<ross.  The  super- 
vention erf  pulmonary  embolism  and  .sudden  death  is  the  gravest  dange- 
in  lliese  cases.     ITie'  effects  of  embolism  will  be  considered  in  another 

(■li;il)ler.  II-       u 

:  Odeifleatioii.— In  certain  regions  erf  the  iHnly.  iiotaldy  in  the  pros- 
tati.  and  uterine  plexu.ses,  and  to  a  less  extent  in  the  spleen,  thrombi  of 
ninl.rate  dimensions  becomt  the  seat  of  calcareous  deposits,  and  so 
form  phlebolitlis.     ITiis  change  ha.s  already  been  discussed    (vol.   i. 

|).  Mi'-'). 


CHAPTER    III. 


\  W  T 


THE  BLOOD— HEMORRHAGE. 

Stbictly  sw  ■  ing,  Itemorrhage'  is  a  "blood  burst,"  or  b  the  prures.s 
of  eocapc  of  tr  wl  <iut  of  the  vesseb  in  whit-li  fiormally  it  is  i-onfiit«<l ; 
in  Drsctice  th  -  i  t  cc  'ers  not  only  the  act  of  eacspe,  but  also  the  stalf 
of  bkwd  ««'  »  t,  and  thus  in  diacussinf;  hemorrttage  we  takt-  into 
aaxNint  noi  the  meana  <rf  eaeape  and  the  reskilu  to  the  or|^nisnis 

at  large  of  escape,  but  abo  the  (hanffes  that  oiTiir  in  the  extravn- 

wted  fluid. 

Omum.— We  recoenise  two  orders  of  escape:  (1)  That  brougiif 
about  by  gross  breach  of  continuity  of  the  vessel  walU— hemorrhag*- 
per  rkexin — and  (2)  that  occurring  in  capillary  vesseb  without  gro^s 
breach  of  continuity,  through  interstices  of  the  wall— hemorrhage  ji^r 
diapedenn.  The  causes  of  the  first  of  these,  of  nipture,  (o)  may  art 
from  without,  through  injury  or  trauma,  through  iiiHamniation,  through 
atrophy  secondary  to  pressure  from  tumws  in  appwition,  etc..  ami 
througii  removal  of  the  normal  pressure  upon  ami  support  exerted  In 
surrounding  tissues;  (6)  may  be  due  to  disease  aii<;  weakening  of  the 
vessel  wall;  and  (c)  may  act  from  within  through  inrreaseii  l)lood  pres,suri'. 
Two  of  these  may  be  in  action  at  the  same  time,  us  when  in  an  artery 
sudden  rupture  occurs  when  the  wall  has  become  ■  eakened  through 
dbease,  the  immediate  cause  being  a  sudden  increa.s*'  in  bloori  pres- 
sure, through  exertion  or  other  cause;  or  again,  the  Hrst  and  tliinl 
may  be  involved,  as  in  the  multiple  hemorrhages  of  high  elevation.s, 
when  there  may  co-exbt  heightened  pressure  within  the  vesseb  of  certain 
areas,  together  with  great  Towering  of  the  external  pressure  upon  llie 
vesseb.  Mere  increase  of  blood  pressure  will  not  cause  rupture  of  tlie 
healthy  arteries,  or  larger  veins,  nor  again  of  the  heart,  but  only  of  the 
capillaries  and  smaller  veins;  sudden  increase  in  pressure  has  been  kndwn 
to  lead  to  rupture  of  the  heart  when  the  muscle  b  dbeased.  Tlnis, 
our  museum  at  McGill  contains  a  specimen  contribute<l  .by  I>r.  O.slcr 
of  a  heart  exhibiting  advanced  fatty  degeneration,  in  which  ruptun 
occurred  when  the  late  owner  was  walkbg  up  a  hilly  Montreal  street. 

Hemorrhage  per  diapedesin  occurs  in  the  capillaries  ar  f!  venules  as 
a  result  of  dilatation  of  the  same  in  conditions  of  hypereni< .,  eiti^r  active 
or  passive.  ITie  nature  of  thb  has  been  studied  more  f  rficuiarly  bv 
j\rtJold,  who  first  tau^t  the  exbtence  of  special  spaces — stigmata  and 
stomata — occurring  here  and  there  between  the  pavement  endothelial 
celb.  From  thb  view  he  has  withdrawn,  and  following  hb  studies  it  is 
generally  held  that  the  passage  occurs,  between  the  endothelial  celb,  it 

•  From  a'l/ia,  blood,  and  the  gt«m,  pa', ,  from  iu/yn/u^  to  bunt  or  break. 


CAPILLARY  HKMnRf  'lAOr 


77 


U  true,  but  a«  a  ret>    t  of  .itretchuig  »nd  enUisemait  of  the  spaces 
Irt-Jween  th.   uomuJly  Mcisting  bridges  joining  the  endothelial  cdls  (see 
vol.  i,  p.  33;,  'w.  more  probably,  with  distension  of  the  vessels  some  of 
tln^  briilges  l»real  'lowii,  and  Ur^n  openings  are  thus  provided,  through 
whWli   under  the  blood  pressur*    the  fluid  and  coT)Uscle8  of  the  blood 
art-  forced  thrwigh  between  the  cells.     When  the  endothelium  is    l<  »«ly 
in  a  stt.te  of  lowered  nutrition,  iw  happens  ii>  passive  hyperpiuia,  the 
luMiinrrhage  is  still  more  apt  to  «tur.    So,  wlso,  a  favoring  factor  a 
lurk   tf  ade<\uate  support  to  the  capillar!*  ■<.    Thux,  hemorrhages  of  this 
iiiitiire  »rv  iMx-uliarfv  apt  to  occur  under  conditioim  of  great  \'ascular 
.lilatufioii  III  r««ions  where  '  apilUry  networks  exist  imiurtliately  benewth 
II  deli>  .1  ••  pavein'-nt  endothelium,  e.  g.,  into  the  alveoli  of  the  lungs,  in 
.-oudii  ioin  of  pro.iOunce<    |»tts.-iive  congestion,  or  pneumonic  coii«li(i.,ns; 
Iromthi    iiucou.s  tiH^br,iiie  of  the  nostrili;  from  the  pleural,  peril  ardial, 
ai'c I  ii'-ritoncal  surfaces. 
Capillary  BemorrhAge      Studying  the  different  forma  of  i  apdUiry 
,.  iiiorrhagf,  i«  ha-  to  be  a.    nittwl  that  time  und  again  ii  is  difficult  if  not 
,     MHsil.h'  to  (lifTercnliiiic  <  a-arly  between  ca.ses  du*-  to  rh»  vis  and  those 
,|.i,-  lo  ili,i|>i(lcM  .  'lim'  apix-ars",  indet-d,  tobeeviil.  ncethat  in  the  samt- 
ana  an.l  tin'lei   ili"  same  i  ir<-unistance»  lajfh  may  wctir.     It  is  nmre 
suii>fa«tui\.  llierefor. .  :vtnemliiring  that  Inith  processes  may  occur,  to 
(■oiisi.1.1    >h    e  rapillary  heniorrhsiges  in  the  light  of  their  causation. 
\)uws  tl  IS  wc  CUM   tiistinguisb  several  griHips,  actortling  a.s  we  < leal 
will!  iiKTeas«l  internal  pressure  and  no  previous  disease  of  the  capillary 
riidoilieliuin;  a  combination  of  increased  internal  pressure  with  morbi«i 
4atf  of  the  cnilof helium;  and  ilisease  of  the  endothelium  without  iii- 
rf,   sed  internal  pressure.     Examples  strictly  of  the  Hr.st  order  are  rare. 
IN  r(  .ips  the  couunonest  example  is  met  with  in  the  h»»:norrhages  of  the 
^ciill)  atnl  nuMubranes  of  the  brain  which  acc<>ni,)ai.y  f  • 'iiigcd  labor, 
aii'l  'liii   to  the  iiiten.se  congestion  involving  tlie  •  >v  Cis  is  free 

iiii.l  \w  rest  of  the  infant  .still  tightly  conipre.  >•'      .^nally  the 

Miiiill  vessels  rupture  as  the  result  of  some  vigorous  edort,  witti  consequent 
;;rtiit  rise  of  blo<Kl  pressure,  but  this  more  often  in  the  eUirly  than  in 
i^hc  Noiint;,  so  that  in  general  the  existence  of  soint  pre\  ions  wealness 
.)i  (iisen-e  of  the  wall>  may  be  suspected.  Very  closely  allied  are  the 
pttechial  hemorrhages  of  serous  surfaces  seen  when  death  has  been 
.iiic  to  asphyxia;  these  must  almost  certainly  be  attributed  b  the  main 
Id  intense  capillary  congestion,  although  the  accou-'panying  extr»-me 
venous  state  of  the  bloo<i  and  its  effects  upon  the  capillar/  endothelium 
.jiimot  be  wholly  left  out  of  account.  Of  the  second  order  are  the 
cipillary  hemorrhages  of  chronic  passive  congestion,  in  which  we  have 
«. ll-inarled  indications  of  malnutrition  of  the  capillary  walls.  Here 
arc  to  be  in.lii(!ed  the  hemorrhp<i5Rs  of  the  lungs,  kidney,  and  other  or^ns 
!!i  ii!>  Mii<(vf>  !3=»rt  disea.se,  ;..>mnrrhagic  infarcts,  and  the  multiple 
niiinii>  Kviiiu  rhagcs  which  result  from  multiple  capilUry  emboli  (p. 
M').  Hemorrhages  of  a  similar  character  found  in  n»-ny  of  the  acute 
inl'ti  tions  are  f.  ind  to  be  associated  with  the  presence  of  hyaline  thrombi 
Ml  the  capillaries,  which  obviously  have  the  same  obstructive  effect, 


78 


HEMORRHAGE 


arresting  the  ?)loal  stmim,  leading  to  local  atasis  at  either  side  of  the 
block,  and  producing,  in  fact,  minute  hemorrhagic  infarcts.  In  many 
of  the  cases  of  idiopathic  purpura  similar  thrombi— or  emboli— have 
been  detectetl,  an<l  this  in  the  absence  of  any  bacteria;  in  cases  of  bums 
and  frastbite  (here  in  the  kidneys  and  stonuwh.  Such  are  a  possible 
explanatinn  of  the  ulcers  of  the  duo<Jenum  sometimes  encountered  in 
the  f«»rmer  of  diese  ci>n<litions);  in  certain  cases  of  emimlism,  by  boily 
cells,  placental  cells,  liver  cells,  etc.;  in  leukemia  by  leukocytes.  In 
many  infections,  however,  we  have  to  deal  with  events  of  the  third  order, 
namely,  with  «lirect  toxic  injury  to  the  capillary  endothelium  and  with 
nothing  else.  To  such  must  be  ascribed  the  multiple  capillary  hemor- 
rhages of  the  acutest  types  of  the  acute  exanthemata— of  hemorrhagic 
smallpox,  scarlet  fever,"etc.  The  course  of  events  in  the^e  cases  may  be 
of  one  of  two  onlers— either  ioxic,  due  to  the  specific  action  of  toxic  suIk 
stances  up<iii  the  capillary  endothelium,  with  giving  way  of  the  .same, 
or  iiifecflowi,  due  to  actual  growth  of  the  l>acteria  or  infectious  agents 
within  the  endothelial  cells  and  lumen  of  the  capillaries,  destruction  of 
the  cells,  and  escape  of  the  blood.  We  meet  with  Iwth  events— the  latter 
more  particularly  in  cases  of  bacteriemia,  in  streptococcal,  an<l  in  other 
terpiinal  infections.  .\s  reganls  the  former,  it  Is,  indeeii,  «loubtful  whether 
many  of  the  hemorrhages  of  infectious  cases  ai-companied  by  hyaline 
capillary  thrombi  are  not  of  this  nature— whether,  that  Ls,  the  localized 
coagulation  rf  the  blood  is  not  secondary  to  epithelial  degeneration. 
Similar  toxic  capillary  hemorrhages  may  accompany  certain  exogenous 
intoxications  (phosphorus,  mercury,  etc.),  and  these  also  must  be  attri- 
bute<l  to  direc't  action  of  the  agents  upon  the  endothelium,  ami  lastly, 
the  purpura  and  hemorrhages  <»f  those  renmrkable  conditions,  .scurvy 
and  Barlow's  di.sea.se  (or  infantile  .scurvy),  wouUl  .seem  to  be  due  to 
endogenous  intoxii-ations— either  to  the  presence  in  the  blood  of  toxic 
allniniinous  ho<lies,  the  prmluct  of  malnutrition,  or,  on  the  other  hand, 
to  tlie  absence  from  the  blo«>d  of  certain  elements  necessary  for  the  due 
nutrition  of  the  capillary  endothelium.  Both  conditions,  it  may  i>e 
notes!,  are  seen  t(»  be  due  to  (jualitative  deficiencies  of  the  food,  and  that 
<lefi,iency  is  of  the  same  onler  in  the  two  c-ases,  .scurvy  being  due  to  a  con- 
tinued diet  of  what  nmy  be  termed  preserved  or  dead  foods.  Barlow's 
disease  to  u  iong-i-ontinued  feeding  of  infants  upon  .sterilized  milk  ami 
|)repMred  milk  products.  Both  are  re«-overed  from  by  giving  fresh 
fcMsl— in  the  adult,  more  particularly  fresh  vegetables;  in  the  infant, 
unsterilized  milk,  and  both  may  be  wanled  off  by  the  administration  of 
small  anmunts  of  vegetable  acids,  lemon  juice,  etc. 

It  is  the  custom  to  refer  tcj  hemorrhages  in  different  regions  by  different 
iianies.  Thus,  punctate  capillary  hemorrhages  are  known  as  petechia 
or  eccbymoui;  more  diffuse  suln-utaneous  or  interstitial  hemorrh.i^"^ 
as  saggillatioiu;  c  erebral  hemorrhage  as  apoplaxy;'  escape  of  blcxxl  frum 

'  ThiH  term  more  accurately  tleiiolcn  tlic  clinical  symptoms  that  follow  such  heni"i- 
rhuKP,  the  stnike  or  loss  of  oinHciousncss  and  power  {artmiJioou,  arlirr.  to  strikf  m 
earth;  paMtrr,  to  be  Htnick  or  to  lose  one's  semes).  It  is  thus  utterly  incorreci  i'> 
refer  to  pulmonary  hemorrhage  as  piilmonar)'  apoplexy 


lit 


LOCAL  EFFECTS 


7S 


the  stomach  as  temaUmMifl.  from  the  lungs  as  lumoptTrii,  from  the  nose 
«s  .Diituli,  from  the  urinary  channek  as  hMMtwia.  from  the  uterus 
us  iMBonhHte  and  m«tr«rha«la.  from  the  sweat  gUnds  as  hwiati- 
drodL  Accumulation  of  blood  in  the  various  spaces  of  the  body  is 
",„wn  as  li.mop«l«»rdiii«.  htmatothorax.  li.iiiatoc.la.  Th>s  last  term 
is  l.v  prescription  more  aifurately  confined  to  accumuUtion  m  the  tunica 
vaginalis  twtLs,  but  is  also  employe.)  for  limite.1  accumuUitions  of 
exirnvRsate.!  blocxl  elsewhere.  When  the  blood  forms  a  cyst-like  acru- 
Mu.lation  in  t!ie  subcutaneous  tis.sues.  the  term  haiiiatoiiia  ls  not  infre^ 
Muently  employe,!.  Parpura  is  the  name  given  to  relatively  small  multiple 
,„tan«.us  heinorrhages  not  due  to  injury,  but  to  various  diseased  states; 
BMUna.'  to  blood  which,  escaping  into  the  stomach  or  int«stmes,  is  so 
.handed  bv  the  action  of  the  digestive  juices  as  to  be  discharged  in  a 
Llack  con.{ition.  The  localized  infiltration  of  tis.sue  with  blood  forming 
a  hsmoirhagie  infarct  we  have  alreaily  noted. 

Local  Meets.— A.S  the  result  of  rupture  close  to  one  of  the  surfaces 
„f  the  IkkIv,  or  of  trauiim.  whereby  deeper  lying  ves.seU  are  exposwi  to 
tlie  surface,  the  m..in  effect  is  escape  of  I.UmxI  and  complete  loss  of  the 
same  to  the  «on»niv.   Acconling  to  (I)  the  nature  of  the  nipture.1  vessel, 
,  '>  the  extent  of  the  rupture,  ami  (3)  the  duration  of  the  escape  of  blood, 
s,,  does  this  escape  tell  (a)  upon  the  nutrition  of  the  region  supplied  by 
„r  simplving  blo^l  to  the  ruptured  vessel,  and  (5)  upon  the  system  at 
larse     Verv  similar  results  fViio^-  rupture  of  vessels  into  one  of  the  b<>dy 
.avilies.  though  lere,  in  addition,  the  changes  taking  place  in  t .-; 
.xtrava.sate.1  I.I.kmI  Imome  ^  feature.    Even  in  the  first  onler  of  events, 
tlu-  hlcKKl  coming  into  contact  with  tissues  other  than  the  normal  endo- 
(heliul  lining  of  the  vessels  tends  to  undergo  coagulation.      1  his  cojigu- 
lati..n.  with  the  progressive  lowering  of  the  blcKxl  pres.sure  and  diminution 
„f  nitc  ..f  flow,  with  the  contraction  of  the  ruptured  vessels  as  the  internal 
,,r.s.sure  is  removed,  and  in  the  case  of  arteries  c-iit  tran.sversely.  with  the 
rHra.ti..ii  and  curling  up  of  the  nii.ldle  coat,  all  together  tend  to  bring 
il,..  iicinorrhage  to  a  natural  termination.     Whether  this  natural  arrest 
is  ,>,T.,iiu,li.shed  or  not,  depends  upon  several  factors-  the  nature  of  the 
m|.ture.l  vessel  or  »««els;  the  direction  of  the  rupture  (e.  g.,  m  arteries, 
rnntiire  in  the  .lirection  of  the  longitudinal  axis  cannot  undergo  closure 
In  !rlructi(.n.  whereas  this  can  take  plac-e  when  the  rupture  is  tran.syerse) ; 
tl,..  f.,r.e  of  the  heart  beat  C.  e.,  where  the  circulation  is  powerful  there 
Mu.v  be  s„  rapid  a  lass  of  Moo.1  that  death  ensues  before  the  natural 
:,r.. s.  ,an  come  into  play);  and  again  the  state  of  the  blcKxl,  since,  a.s 
«ill  1„>  .lisc-overed  later  (p.  S.^).  the  coagulating  power  of  the  blocx! 
vui.s , ,m.si<lerablv.     Blood  extravasate,!  into  the  cavities  of  t"*"  »'o«Jy. 

i il„.  pericardial  or  pleural  cavities,  for  instance,  if  not  dischargecl 

in   iiilideiit  quantities  to  lead  to  death,  may  renvo.  fluid  for  some  iittle 

111.,  iiiul  in  this  fliiiil  state  may  undergo  some  reabsorption  through  the 

i     ipliatics,  as  regards  both  its  fluid  and  its  corpuscles.    The  tendency, 

.  X ,r,  is  to  undergo  coagulation,  and,  following  upon  this,  a  slower 

'  From  fi^f,  fern.,  iu?mvu,  black. 


iii 


80 


HEMORRHAGE 


process  of  Bbs(>rption  under  the  combined  action  of  autolysis  (vd.  i, 
p.  337)  and  leukocytic  action. 

Where  we  deal  with  suffusion,  infiltration  of  the  tissues,  or  hematoniu 
formation,  there  we  have  to  recognize  both  local  changes  in  the  tissue 
involved,  and  changes  in  the  extravasated  blood.  Not  only  does  the 
diversion  of  the  hXooA  from  the  normal  channeb  bring  about  malnutrition 
of  the  area  involved,  but  the  presence  of  the  blood  under  pressure  in  that 
area  compresses  the  capillaries  of  the  same,  and  arrests  the  circulation 
within  them;  while,  thirdly,  the  force  with  which  the  blood  esc-apes  may 
lead  to  extensive  laceration  and  destruction  of  the  tissue.  This  last  is 
particularly  well  seen  in  organs  of  a  soft  consistence,  in  cases,  for  example, 
of  cerebral  hemorrhage.  Where  the  infiltrations  are  general  and  local, 
as  in  petec-hiw,  purpura,  etc.,  and  due  to  diapedesis  rather  than  rupture, 
the  local  effects  m;y  be  of  the  slightest  onler;  there  may  be  relatively 
rapid  absorption  with  little  tis.sue  injury  (although  even  here  there  is 
local  deposit  of  pigment  from  disintegration  of  the  escapetl  erythrocytes, 
which  pigment  uii<lergoes  slow  renn)val,  .so  that  for  long,  cutaneous 
petecliia>  leave  behind  them  small  brownish  flecks).  Where  more  exten- 
sive, we  recognize  a  series  of  changes,  of  which  the  more  important  are: 
(1)  Escape  of  henit^lobin  from  the  extravasated  erythrocytes,  causing 
a  hemoglobin  imUUtion  which  is  accompanied  by  increased  venasity 
and  darkening  of  the  .suffu.sed  blood;  (2)  disintegration  of  the  escaped 
hemoglobin,  with  production  of  bemoiideiin,  and,  it  may  be,  in  more 
central  parts  of  the  infiltrated  area,  of  henutoidin  also  (vol.  i,  p.  882). 
The  successive  stages  in  the  «iisint^ration  of  the  hemoglobin  cau-se  the 
suwession  of  vivid  tints  seen  in  the  not  unfamiliar  "black  eye."  (:{) 
Progressive  absorption  of  the  extrava.sated  blood  and  its  mo«lified  con- 
stituents. Again,  it  has  to  be  observed  that  the  extent  of  this  ab.sorp(ioii 
depends  ujMin  the  extent  and  nature  of  the  extravasation.  In  cases  of 
even  extensive  snlK-utanetnis  suffusion  it  may  be  complete;  in  ca.ses  ()f 
hematoma-like  atcumulations  it  may  be  incomplete  and  at-companie«l 
by  formation  of  granulation  tissue  replacing  the  destroyetl  ti-ssue.  Tlie 
result  may  be  either  the  formation  of  a  firm  fibrous  cicatrix,  or  of  a 
cyst  with  fibrous  wall  and  fluid  contents  (vol.  i,  p.  795),  whose  contents 
at  an  early  stage  are  deepiy  pigmented,  but  eventually  through  diffusion 
and  leuktK-ytic  action  become  a  clear  colorless  serum. 

Ctoneral  Effects. — .\ccording  to  the  extent  and  rate  of  the  Iieinor- 
rhage  so  may  we  observe: 

1 .  Sudden  death  within  a  minute  or  two,  as  after  rupture  of  the 
heart  or  burst  nig  of  a  thoracic  aneurism  into  the  pleural  cavity,  traclna, 
or  <i'.sopliagus. 

2.  Death  preceded  by  collapse  and  all  the  symptoms  of  grave  cerebnil 
anemia. 

3.  Collapse  followed  by  hydremia  and  eventual  recovery. 

4.  Svncope,  or  temporarj'  cerebral  anemia  with  rapid  recovei^-. 

5.  No  disturbances  due  to  cerebral  anemia,  but  (in  cases  of  internal 
extrava-sation)  the  development  of  a  febrile  state  due  to  diffusion  of 
disintegration  products  from  the  extravasated  blood  (vol.  i,  p.  44.'>). 


HEMOPHILIA 


81 


C.  In  cases  of  multiple  repeated  hemorrhages  of  moderate  grade  there 
may  be  eventual  exhaustion  of  the  hematopoietic  tissues,  and  the  develop- 
ment of  a  condition  of  the  blood  resembling  that  seen  in  true  pemicMHis 
anemia,  with  poikilocytosLs,  presence  of  normoblasts,  etc.,  but,  unlike 
that  condition,  showing  in  the  liver  and  other  organs  no  indications  of 
the  results  of  excessive  dbintegration  of  the  erythrocytes. 

We  have  in  our  first  book  and  in  other  cliapters  of  this  discussed  most 
of  these  conditions.  Here,  therefore,  they  need  but  be  called  to  mmd. 
At  most,  it  is  necessary  to  add,  as  giving  the  basis  of  a  scale  for  deter- 
mining the  incidence  of  sundry  of  these  sequelie,  that  according  to  the 
eeiierally  accepted  estimate,  th«  organism  can  withstand  the  loss  of  about 
:{ per  cent,  of  the  body  w»ight  without  death  ensuing,  and  that  when 
"bleeding"  was  in  vogue  it  was  not  unusual  to  remove  thirty  ounces 
from  healthy  adults  without  the  supervention  of  any  grave  effects. 

Hemophilia.— In  this  relationship  reference  must  be  made  to  the 
very  remarkable  condition  of  the  hemorrhagic  diathesis  or  hemophilia, 
a  condition  conveyed  from  one  generation  to  another  in  a  very  striking 
manner  (see  the  genealogical  table  given  in  our  first  volume,  facmg 
p.  144).  and  one  in  which  the  slightest  trauma,  e.  g.,  slight  bruising  or 
contusion,  or  some  insignificant  surgical  operation,  such  as  the  removal 
of  a  tooth,  is  apt  to  be  followetl  by  almost  intractable  bleeding,  lastmg 
for  days.    It  is  still  undetermined  what  is  the  essential  cause  of  this 
coinlition.    Virchow,  it  is  true,  obser\'ed  a  characteristic  smallnew  and 
thinness  of  the  walls  of  the  aorta  in  these  cases,  and  supposed  an  incom- 
plete development  or  abnormal  thinness  of  the  vessels;  but  that  has  never 
been  absolutely  proved.     What  would  seem  more  definite  is  a  lowered 
power  of  coagidation  of  the  blood.    Just  as  in  Barlow's  disease  and  in 
s(nrvv,  we  see  nowadays  an  explanation  of  the  multiple  hemorrhages 
in  the  presence  in  or  absence  from  the  blood  of  some  element,  owing  to 
defective  nutrition,  so  the  tendency  favored  by  the  recent  abundant 
studies  upon  immunity  and  cytolysis  is  to  regard  hemophilia  as  due  to 
some  iidierited  deficient  reaction  between  the  blood  and  the  endothelium 
of  the  smaller  vessels,  leading,  it  may  be,  either  to  a  state  of  weakness  of 
that  eiidotheliura  or  to  excessive  development  of  bodies  of  the  nature 
of  iintitlirombin.    Tlie  injection  of  horse  serum  has  recently  been  noted 
to  be  followed  by  arrest  of  hemorrhage  in  these  cases. 

There  is  yet  another  form  of  capillary  hemorrhage  that  must  not  be 
o\  ( rlooke<l  ;'we  refer  to  the  nervoai.  Examples  of  this  are  seen  in  certain 
(iis.s  of  hysteria  in  which  apparently  almost,  at  will,  the  individual 
(h\.li.l)s  hemorrhagic  suffusicm  of  the  skin  or  mucous  membranes; 
.1,.  .Iv  allied  to  this  would  seem  to  be  the  "stigmata"  produced  upon 
iIm  liiinds  and  feet  in  cases  of  extreme  religious  exaltation  or  ecstasy, 
"m1  other  cases  of  bloody  sweat  or  hematidrosis.  Lulmrsch  would 
i>!e  here  the  hemorrhage  of  menstruation,  pointing  out  that  it  is 
K  iiited  with  definite  nervous  phenomena.  It  is  a  matter  of  present 
:  iite  whether  the  menstrual  flow  is  or  is  not  intimately  associated  with 
(ii\elopment  of  an  internal  secretion  from  the  ovary,  or  again  is 
i1(h1  by  degenerative  changes  in  the  endothelium  of  the  submucous 


ii.'  'inle 


82 


HEMORRHAOE 


Teasels  of  the  endometrium.  While  admitting  the  very  possible  presence 
of  a  nervous  factor,  we  are  inclined  to  doubt  whether  this  be  the  control- 
ling agent.  In  the  other  uncomplicated  cases  the  course  of  events  \% 
problematical;  the  suddenness  with  which  the  hemorrhages  may  be  in- 
duced by  hysterical  patients  would  seem  to  militate  against  local  trophic; 
changes;  on  the  other  hand,  it  is  difficult  to  ascribe  the  escape  of  blood 
purely  to  local  action  of  the  arterial  vasodilators. 


li: 


CHAPTER    IV. 

THE  BLOOD-QUALITATIVE  BLOOD  CHANGES. 

The  study  of  the  qualitative  changes  in  the  blood  has  now  become 
.so  sperial  and  so  specialized  a  branch  of  pathulo^v,  with  text-books  and 
joiirnaLt  devoted  to  it,  that  to  enter  into  the  subjeit  in  all  its  modem 
detail  wcmld  in  itself  <lenmnd  a  volume  of  fair  size.  Under  the  circum- 
stances, the  sense  of  proportion  demands  that  we  lay  down  at  most  the 
nmin  outlines,  at  the  same  time  emphasizing  the  fact  that  these  are  but 
the  outlines,  and  that  for  a  fuller  knowledge  the  student  must  master 
such  works  as  Ewing's  Clinieal  Pathology  of  the  Blood  or  Cabot's  Clini- 
cal Examination  of  the  Blood,  and  for  the  latest  developments  must 
consult  that  excellent  journal,  the  Folia  Ilematologica. 

In  such  a  rapid  survey  we  have  to  take  into  account,  first,  modifications 
in  the  different  constituents — in  the  constitution  of  the  plasma,  and  in 
the  relative  proportions  of  the  corpuscular  elements,  erythrocytes,  leuko- 
cytes, and  blood  platelets,  and  then  pass  in  review  certain  of  the  more 
important  bloo<l  dyscrosias  as  separate  entities  (chlorosis,  secondary 
aiuMiiias,  pernicious  anemia,  etc.). 


THX  PLA8BIA. 


It  is  no  false  humility  to  state  that  despite  the  amount  of  research 
that  hiis  been  devoted  to  the  blood  during  late  years,  we  are  but  at  the 
lH';;iiuiing  of  a  knowledge  of  its  pathology.  We  have  gained  some 
knowledge  reganling  the  red  corpuscles  and  their  function,  and  the 
si;;iiili('uiice  of  disturbances  affecting  the  same;  our  knowledge  of  the 
white  corpuscles,  their  mode  of  origin,  relationships,  functions,  and 
iii<)rl)i(l  states  has  been  materially  widen«l,  though  much  has  yet  to  be 
iletirmiiied;  but  as  regards  the  plasma,  the  main  medium  of  nourish- 
nii'iit  iiiid  interchange,  the  data  we  possess  are  painfully  deficient.  That 
plii^iiia  is  the  great  medium  of  interchange;  from  it  are  constantly  being 
alp^t^a(•ted  materials  nee«ied  for  tlie  elaboration  of  the  different  tissues; 
iii'i>  it  are  poured  many  products  of  cell  activities,  internal  secretions, 
eii/\riies,  hormones,  etc.  The  evidence  is  very  clear  that  despite  this 
ii>ti>taiit  change,  the  composition  remains  in  health  remarkably  con- 
-*tii  I.  \Vc  are  apt  to  attribute  to  the  liver  and  kidneys  the  main  function 
ot  riiiioving  the  <leleterious  substances  that  woukl  otherwise  tend  to 
in  <  iiiiiiilate — and  here,  it  may  be,  we  are  correct,  although  we  must  take 
ii  I  1  a'count  how  other  organs,  like  the  ductless  glands,  evidently  play 
u  :  art  in  neutralizing  certab  bodies  of  a  toxic  type  circulating  within  it. 


l!    i 


■I 
.1   • 


g|  THE  BLOOD 

But  the  staAv  rf  immunity  litt>i  revealetl  the  existence  of  substances 
in  the  plasma  in  minute  amounts— enzymes  anil  proteins— possessing 
properties  obviouaJv  of  extreonlinary  importance  for  the  general  well- 
being  of  the  organism  as  a  whole;  we  camiot  isolate  these,  we  can  only 
conclude  that  thev  are  of  protetd  nature;  we  cannot  surely  state  what 
Is  their  origin— we  repeat  glibh-  that  the  solid  matters  of  the  blood  serum 
constitute  9.2  per  cent.,  and  of  this  7.6  per  lent.  is  protein,  in  the  main 
serum  albumin  and  senim  globulin.  But  having  said  this,  we  are  igno. 
rant  of  the  exact  source  of  these  ol>vioualy  mcwt  important  constituents, 
of  the  respective  parts  plaved  by  the  two  m  nutrition,  and  consequently 
of  the  significance  of  disturbances  in  their  relative  proportions.  We  are 
only  slowly  realizing  that  those  names,  smiva  albumin  and  serum  globu- 
lin, cover  "not  single  entities,  but  groups  of  substances.  And  if  this  is 
true  of  the  most  abundant  as  well  as  the  mast  .sparse  constituents  of  the 
plasma,  the  povertv  of  our  real  knowledge  stands  revealed. 

Briefly  we  may  divide  the  con.stituents  of  the  plasma  into  water, 
proteins,  and  salts.    The  proportion  of  water  maintains  in  health  a 
remarkable  constancy,  so  that  the  sjiecific  gravity  varies  but  .slightly 
In  disease  greater  variations  show  themselves,  and  the  condition  of 
hydiemU  is  not  infrequent.    But  here  it  has  to  lie  notetl  that  a  hydremic 
condition  of  the  blood  may  be  brought  about  (1)  by  actual  iner^se  in 
the  amount  of  blood  by  increase  in  its  watery  content  (true  hydremic 
plethora),  as  in  obstructive  heart  disease;  (2)  by  no  increase  in  the  total 
amount  of  blood,  but  actual  deficiency  of  proteins  of  the  plasma,  as  after 
severe  hemorrhage;  and  (3)  by  increase  in  the  salts  of  the  blood,  uttnu  t- 
ing  more  fluid  out  of  the  tissues  in  onler  to  preserve  the  normal  "  tone" 
of  the  plasma.    As  alivadv  pointed  out,  this  retention  of  salts  is  by  some 
held  to  explain  the  hyilremia  of  nephritis.     Not  until  we  possess  a  fuller 
series  of  simultaneous  observations  on  the  total  amount  of  blood  (by 
HaUiane  and  Smith's  or  other  method)  an«l  of  the  proportions  of  the 
diiferent  main  constituents  of  the  blood  shall  we  be  able  to  speak  with 
decision  about  these  matters.     In  short,  with  our  present  lack  of  kiuwi- 
edge,  it  is  difficult  to  do  other  than  consider  together  those  three  possible 
variants,  water,  proteins,  and  salts.    A  more  watery  condition  of  the 
blood,  however  brought  about,  is  encountered  in  obstructive  heart  and 
lung  and  in  kidney  diseases,  in  severe  infections  ami  malignancy,  ami 
after  extensive  hemorrhages.    It  must  not  be  thought  that  in  every  case 
manifesting  these  particular  morbid  states,  the  condition  of  hydremia 
necessarily  manifests  it.self.     In  by  no  means  all  cases  of  cant.r  or 
sarcoma  is  there  re<luction  of  the  circulating  proteins,  and  as  (irawilz 
has  shown,  in  the  different  stages  of  tubercuU.sis  marked  variation-  are 
to  be  made  out  in  the  composition  of  the  bloo.l  serum;  not  nifre«iii<  uly, 
instead  of  being  hvdremic,  the  blood  is  fouml  more  concentrate  I  and 
viscid.     In  conditions  of  nephritis  it  is  more  particularly  the  acute  i);ircn- 
chymatoiis  ca.ses  that  exhibit  hydremia  (which  it  is  to  be  notetl  is  asso- 
ciated with  extensive  loss  of  albumin  through  the  kidneys);  it  ni.iv  Iw 

'  Deutsch.  med.  Woch.,  19:1893:1347. 


THE  PLASMA 


85 


wholly  absent  in  caaes  of  chronic  interstitial  nephritis,  and  is  not  neces- 
sarily present  in  those  of  chronic  parenchynuitous  nephritis.'  And 
as  regards  obstructive  heart  and  lung  disease,  a  word  of  oiution  needs 
to  be  given.  Where  there  is  passive  c(Higestion  there  is  coincidently  an 
iwreased  passage  of  fluid  from  the  blood  into  the  lymphatics,  with,  aa 
a  result,  a  marked  concentration  of  the  erythrocytes  m  the  capillaries 
from  which  the  exudation  takes  place.  In  Uiese  cases,  as,  indeed,  m  all, 
it  is  wrong  to  make  any  conclusions  as  to  the  quantity  or  quality  of  the 
plasma  from  an  estimation  oi  the  number  of  erythrocytes  per  cubic 
millimeter.  So  also  in  this  same  series  of  cases  the  fact  of  this  escape  of 
fluid  into  the  tissues  has  to  be  taken  into  account.  By  the  (ndmary 
means  of  piqure  to  gain  capillary  blood,  that  blood  may  be  gained  exten- 
sively diluted  with  oedema  fluid.  This,  however,  has  been  definitely 
determined,  that  the  blood  serum  deprived  of  corpuscles  obtained  from 
those  cases  of  cardiac  insufficiency  in  the  stage  of  imperfect  compensa- 
tion presents  a  recognizable  reduction  in  its  .solids. 

(.){  the  proteins  of  the  plasma  as  contrasted  with  the  serum,  flbrinogan 
must  not  be  overlooked.  To  the  modem  views  regarding  this  protein 
and  its  relaticmship  to  the  coagulation  process  we  have  already  referred 
(p.  CO).  Here  it  has  to  be  noted  that  the  amount  exhibits  very 
( onsiderable  variation,  as  evidence*!  by  the  varying  quantity  of  fibrin 
obtained  from  different  bloods.  From  the  normal  amount  of  0.1  to 
0.4  !)er  rent,  by  weight  there  may  be  a  rise  to  1  per  cent,  and  higher. 
Such  hyperino^  is  met  with  more  particularly  in  certain  infections, 
notahly  in  acute  lobar  pneumonia,  in  acute  rheumatism,  and  in  some  cases 
of  acute  pleurisy.  In  other  infections,  notably  typhoid,  there  is  found 
a  condition  of  hypinoiif ,  or  reduction  of  the  fibrin.  The  fact  that  hyperi- 
iiosis  and  hypinosis  in  these  febrile  states  show  a  remarkable  parallelism 
with  the  presence  or  absence  of  leukocytosis  suggests  that  it  is  not  so 
nnuh  the  fibrinogen  as  the  fibrin  ferment  that  undergoes  variation. 
ThU,  however,  would  not  seem  to  be  the  case.  The  fibrinogen  itself 
■uidergoes  variations  indepentlently  of  the  leukocytosis  in  leukemia'  and 
ill  phosphorus  poisoning,'  where  it  may  l>e  completely  absent.  Varia- 
tions in  the  amount  of  the  ferment  affect  the  coagulation  time  of  the 
iiloiHJ  rather  than  (so  long  as  any  fibrin  ferment  is  present)  the  amount 
of  iiUrin  produced. 

As  regards  the  salts  of  the  plasma,  again  it  has  to  be  noted  that  we 
]i(isMss  scattered  data*  rather  than  a  full  knowledge  of  their  variation 
ill  (litfcrent  morbid  states.  These  salts  consist  in  the  main  of  sodium 
>iilis,  of  chlorides  and  phosphates.  They  evidently  bear  an  intimate 
r.liiiioiiship  to  the  state  of  solution  of  the  proteins.    Their  nature  is 


I !:immerschlag,  Ztsch.  f.  klin.  Med.,  21 :  1892: 475. 

I  iritTer,  Til.  Zentrbl.  f.  innere  Mod.,  2.5 :  1904 : S()9. 

Iiikoliy,  Zeitschr.  f.  phys.  Chemie,  30: 1900: 174. 

I  I.esc  data  will  be  found  collected  and  discusaed  in  Hamburger,  Osmotische 
'  I  und  lonenlehre,  1906,  and  Limbeck,  Pathologie  des  Biutes,  2d  edition, 
..I,  1H96. 


•' 


I 


i 


:H 


86 


THE  ERYTHROCYTES 


such  that  the  normal  blooil  Ls  definitely  alkaline,  and,  as  already  pointeil 
out  in  dwcuiwing  atidosw  (vol.  i,  p.  34«).  reduction  in  this  alkalinity  is 
aasociatMl  with  the  gravest  metabolk-  disturbances. 

Upoida.— One  other  constituent  of  the  blood  plasma  desenits 
notk-e.  There  w  always  to  be  isolateil  from  the  fluid  of  normal  blocxl 
a  minute  quantity  of  fat.  As  to  the  exact  .state  in  whk-h  this  is  present 
there  is  still  debate,  the  evklence  on  the  whole  favoring  the  view  that 
some  at  least  is  in  the  form  of  the  more  soluble  salts  of  the  fatty  acids 
or  soaps.  What  we  have  already  sakl  reganling  the  absorption  of  fats 
from  the  intestine  (vol.  i,  p.  79)  prepares  us  to  fin«l  that  after  meals 
rich  in  fats  the  amount  Ls  ilefinitely  increase<l.  Occasionally  there  is 
encounteretl  a  condition  of  UpamU— of  extraordinary  increase  in  this 
fat.  In  some  cases  of  dialwtes  there  may  be  as  high  a  content  as  20 
per  cent.,  the  bkxxl  taking  on  a  milky  appearance,  an<l  the  fat  lieiiig 
present  in  an  emulsified  state  in  the  form  of  fine  glol)ules.  Once  more 
It  has  to  be  acknowledge«l  that  we  know  little  or  nothing  about  the  con- 
ditions leading  to  this  lipemia— whether  we  deal  with  the  absence  of  a 
lipolytic  ferment  either  from  the  blooil  or  from  the  tissue  cells  whi<h 
normally  absorl)  the  fat,  or  again,  of  some  constituent  which  converts 
the  absorbe*!  fat  into  a  soluble  salt,  thereby  preparing  it  to  be  taken 
up  by  the  cells,  or  lastly  to  the  presence  of  acids  splitting  up  the  .soluble 
soaps  present  in  the  blood  and  lik-rating  thus  the  fatty  acids  and  fiils. 
In  addition  to  dialwtes,  lipemia  has  been  ohserve<l  in  conditions  charac- 
terized bv  defective  oxidation  (and  increase*!  carlton  dioxide  content  of 
the  bloo<i),  such  as  pneumonia,  pho.sphorus  poisoning,  and  anemias. 


n    r 


THE  KRTTHBOOrm. 

Of  the  physiology  of  the  red  corpuscles,  much  may  l>e  said;  reganiiiig 
their  •  'tholog)-,  we  must  be  comparatively  brief. 

7jM,iation8  in  Number.— We  have  emphasized  alrea«ly  that  modenite 
increase  or  decrease  in  the  miml)er  of  erytlirocytes  per  cubic  miiliinetrr  in 
itself  tells  us  little  without  at  the  same  time,  there  \\e  present  indications 
of  either  increase*!  produrrion  or  exces.sive  tlestruction  of  the  corpuscles, 
rather  than  variation  lii  tlu  amiMUit  of  the  fluid  of  the  blood.  Wlitre 
there  is  great  (le|>nrture  from  tli»>  normal  it  is  difficult  to  believe  thiil  in 
all  cases  the  concentration  or  dihition  of  the  bloo<l  alone  is  at  funlt. 
That  it  may  be,  is  .shown  by  the  great  apparent  increase  in  the  nuintier 
of  re«l  <or{)u.scle.s  seen  in  c-jises  of  cholera  nostras,  cholera  asiatica.  imd 
other  conditions  in  which  there  is  great  drain  of  fluid  from  the  intestinal 
canal.  But  in  sucli  ciisos  there  is  abundant  clinical  evidence  of  lo-  of 
fluid,  as,  for  example,  the  difficulty  in  obtaining  blood  from  the  tini.'er 
or  pinna  of  the  ear,  the  feeble  heart  action,  the  tarry  con<lition  of  (he 
blood  itself— all  imlicatiiig  reduction  in  the  quantity  of  the  blool  md 
concentration  of  the  more  soli«l  constituents  of  the  same. 

Polycythemia.— The  polycythemia  of  high  altitudes  has  been  stmlixl 
by  a  large  number  of  ob.servers  (Paul  Bert,  Miescher,  Mosso,  At  ■! -r- 


POLYCYTHEUIA 


87 


hahlen.  and  others),  ami  ia  vny  striking.  It  affects  all  vertebrates, 
'nms,  in  the  South  American  Cordilleras,  at  a  height  of  more  than  12,(XH) 
fwt,  Viault'  found  that  the  count  in  the  llama  was  as  high  as  16,0(10fl00. 
Tlu're  has  been  great  <Ichate  as  to  its  meaning,  but  this  setias  to  be 
established:  (1)  ITiat  the  total  amount  of  bloal  remains  unaltered, 
Slid  thus  the  increase  is  not  due  to  concentration;  (2)  that  the  arterial 
bItKMl  shows  the  increase,  and  thus  we  do  not  deal  with  concentration 
ill  the  superficial  capillaries;  (3)  that  it  supervenes  with  relative  rapi«lity 
((iftule  records  increase  to  8,500,000  in  a  balloon  ascension);  (4)  that 
it  soon  disappears  upon  descent  toward  the  sea  level. 

Making  Jue  allowance  for  variations  in  indiviilual  reaction,  it  Is  diffi- 
cult to  reganl  the  increase  as  other  than  adaptive,  than  a  reaction  to 
the  need  for  more  oxygen  carriers  in  an  atmosphere  in  which  the  amount 
of  oxygen  is  diminished.     A  similar  increase,  it  may  l)e  noted,  has  lieen 
oJ).served  by  Nusmith  Bn<l  draham'  in  animals  made  to  breathe  air 
containing  carbon  monoxi<le.    ITiat  carlion  monoxide  Is  useless  to  the 
wonomy,  but  has  a  far  greater  affinity  for  hemoglol)in  than  has  oxygen; 
the  organism  evidently  proilnces  more  hcnioglol)in  and  hemoglobin 
holders  to  counteract  the  using  up  of  part  of  the  circulating  hemoglobin. 
We  do  not  pretend  that  there  are  not  facts  in  connection  with  the  phe- 
nomenon that  are  difficult  to  explain.    When  the  condition  supervenes 
rapidly  we  have  to  pastulate  a  rapid  production  of  hemoglobin  and 
rapid  discharge  of  young  erythrocytes  from  the  bone  marrow,  and  so 
fur  only  one  observer,  (iaule,  has  reco«le«l  the  presence  of  (immature) 
niicleateil  reil  corpuscles  in  the  circulating  blood;  others  have  failed 
to  find  them.    So  also  what  becomes  of  the  excess  of  erythrocytes  upon 
return  to  lower  levels  remains  unsolvwl.     These  are  matters  regarding 
whirh  we  have  incomplete  knowle«lge,  rather  than  facts  absolutely 
oi>iK)He«l  to  the  view  here  taken.*    This  may  be  spoken  of  as  physio- 
lojlicai  polycythemia;  pathologk-al  polycythemia  is  a  condition  which 
has  come  "into  recognition  only  «luring  the  last  few  years,*  some  fifty 
(UMs  l>elng  on  reconl.     In  these  cases  counts  of  8,000,000  are  common, 
a.i.l  those  of  10,000,000, 13.000,000,  and  even  14,000,000  corpuscles  have 
lietii  determined.    There  Is  an  accompanying  duskiness  or  cyanotic 
aiiitearanoe  of  the  skin,  and  frejiient  (thou^  not  constant)  pronounced 
eiilartjemeiit  of  the  spleen.     Cases  have  been  reportetl  of  all  ages,  most 
friM|uently  in  advancing  life.    ITie  presence  of  normoblasts  and  megalo- 
lila^is  show  clearly  that  there  is  an  active  production  of  ci^throiytes, 
aiicl  M)me  of  the  few  pastmortems  have  demonstrated  increase  of  the 


'  I  uinpt.  rend,  de  I'Acad.  des  t^i.,  112: 1891 :  29.5. 

■  .U.nru.  of  Phywol.,  35: 190e:.'«. 
A  tlioughtrul  study  of  this  problem  is  afTonlcd  by  Krchl,  r;i..iiol.  Physiologie, 
".III  iHrinaa  edition,   Leipzig,   1907:193.      See  also  .\.  W.  Hewlett's  translation, 
I   .i  iMcc.it.  1907. 

'  I  lit  first  ca»e  was  recorded  by  Rendu  and  Widal  in  1892.  For  bibliography, 
.-'  I  rigi'lliach  and  Urown,  Jour,  of  .\nier.  Med.  Assoc.,  October  20,  1900,  and  for 
1 L'  III  rul  description,  see  '.'abot,  Osier  and  McCraeV.Systemof  Medicine,  4:  1908: 678. 


a 

:  I! 


:ri 


I 


g§  THE  LRYTHKOCYTBS 

marrow,  and  one  at  lea-st  bus  ronfirmeil  WHial's  virw  that  the  splenic 
enlargrmmt  u  <lue  to  resumption  by  the  spleen  of  its  fatal  propertip?* 
of  production  of  er>'throhlast.s.  With  thiM  there  is  in  some  cases  a  imxler- 
ate  >rra<li-  of  iieutr<M>hihc  leukocyto<(is.  ITie  cause  of  the  comiition  is 
wholly  undetermined. 

VuialiMII  In  Uia  tad  lh*p«. — The  normal  erj-throcyte  is  from  5  to 
8.5  ft  in  diameter.  In  condition!*  of  anemia  ami  «listurbed  erythrocyte 
l-roduction,  notably  in  pemicit)i.-  anemia,  cells  10  to  20  ^  in  diameter 
are  encountered  (flMffaloeTtM)  iilong  with  others  which  may  be  but 
2  to  3  p  in  diameter  (mlerccyta*).  In  these  cases  of  extreme  anemia 
cells  of  very  irreguktr  form  are  aUo  encountered — poildlMjrtas,  pear- 
.<(hupc<l,  elongated,  an<l  sausage-.shaped,  etc. 

lltentioDf  in  Stnctnre  and  Staining  EeMtioni.— 'Hie  normal  en- 
fhrot-ytc  is  homogeneous,  its  hemoglol>in  .scattereil  evenly  through  it,  and 
granules  are  absent  when  the  ordinary  processes  of  staining  are  employctl. 
In  a  mixture  of  acid  and  basic  aniline  dyes  (as  in  Ilomanowsky  s  stain 
and  its  many  modifications)  it  takes  up  the  acid  dye. 

If,  however,  (lie  development  l)e  followed  in  the  red  marrow,  a  .suc- 
cession of  stages  may  be  maile  out,  from  the  large  erythrobkist,  with 
large,  loosely  .skeinp<l  nucleus  and  without  hemoglol>in  in  its  cvtoplasni, 
through  forms  with  scuttertxl  granules  and  masses  of  hemoglobm  ami 
smalt,  condense<l  nucleus,  the  hemoglobin  in  these  younger  cells  taking 
up  the  basic  stain  with  more  or  les.s  intensity  an<l  api>earing  pur))lish 
or  even  blue,  to  forms  whicii  have  lost  their  nucleus  and  have  tne  henio- 
globin  diffused  evenlv  throughout  them,  but  still  tend  to  take  a  purplish 
rather  than  a  red<lls(i  or  orange  color.  These  various  immature  forin-s 
of  reil  corpuscles  may  lie  encounter.'<l  in  disease,  ami  then  in<iicate  a 
pouring  into  the  bhxxl  from  marrow  or  spleen  of  imperfectly  develo|H>d 
erythroc-jtes;  indicate,  that  is,  a  condition  of  such  stiniuUtion  of  the 
hematopoietic  system  that  with  active  proliferation  of  the  erythrol>last.s 
the  immature  cells  are  discharged  into  the  blood. 

PolycbromatophiUa  and  the  presence  of  nnelaated  red  eorpoKles,  of 
megalobiusts  (as  the  krge,  j»ler  forms  are  terme<l),  and  of  normobhists 
(hemoglobin-holding  cells  of  the  normal  size  but  nucleated)  must  then 
be  reganle<l  as  evi«ience  of  excessive  demand  made  ujHjn  the  bliKxI- 
producing  tissues.  Such  conditions  are  most  frequently  seen  in  grave 
anemias.  At  the  same  time  it  has  to  be  recognizeil  that  l«sic  and  irrcpi- 
lar  staining  of  the  erythrcx-ytes  in  another  but  widely  different  series  of 
conditions  is  evidence  not  of  regeneration,  but  of  degeneration;  in  areas 
of  interstitial  hemorrhage,  as  again  in  areas  of  fresh  thrombosis,  >ii(h 
polychromatophilia  is  to  be  distinguislie«l. 

In  the  latter  case  it  is  asstxiate*!  with  indications  of  disintegration.  < H 
this,  two  forms  have  been  distinguishe*!  by  AnioUl,  namely,  naunorrbexii 
and  Plasmoiebisia.  The  former  is  the  condition  often  observe<l  \\lieii 
erythrocytes  are  studieil  in  tilin  under  the  microscope,  namely,  the  (i<\  »■!- 
opmtiit  of  crenation  and  of  a  niulberrvlike  appearance  with  forma' ion 
of  peripheral  ^'lybnles  of  varying  size,  some  very  minute  (reseiiillMii? 
Miiller's  '  insl  bwlies"),  others  it  may  be  as  large  as  blood  plati  I'ts; 
and  thestf  l;r(-ome  liberated,  with  progressive  diminution  in  size  of  ilie 


!    .  a. 


VARIATIOS  IS  AMOUST  OF  IIEMOOWBIN 


iwmit  (i)rpuscle.  In  pkanKMchwU  what  in  obstrved  is  ■  rapkl  breaking 
nil  of  the  whole  Uxly  of  the  corpu'tole  int<»  small  globules,  which  as 
thev  !)e|)an»te  are  seen  to  he  free  fn>in  hemoglobin  and  to  be  imlittinginsh- 
ttliff  from  blooil  platelets.  Another  m«KiiH(ation  of  which  the  stignifi- 
cBiice  is  not  understood  w  seen  in  certain  rases  of  lead  poisoning  in 
which  ring-like  accumulations  of  matter  toking  on  the  basic  stain  are 
swii  within  occasional  erythrocytes.  Since  in  this  condition  we  are  apt 
to  meet  with  "stippling"  at  free  granules  of  l«sic  staining  matter  within 
the  ml  corpuscles,  with  normobla.sts  and  megBloJ)lasts,  the  in«lic«tions  are 
that  we  deal  with  an  anemia  ami  accompanying  overstimulation  of  the 
reil  marrow;  and  the  suggestion  is  that  here  we  deal  with  cells  in  which 
the  conversion  of  the  prehemoglobinic  matter  is  not  complete. 

VariAtion  ija  Amoant  of  Bamoglobiii;  Honudyiif .— By  the  use  of  the 
heinojtioliinometer  we  can  «letermine  the  amount  of  hemoglobin  in  a 
pivcii  (|uantity  of  blood  by  comparing  its  c-olor  with  that  of  a  sample  of 
normal  bloocl  of  known  dilution  (or  its  coloreil  equivalent).  By  the 
henioc-ytometer  we  can  determine  the  numl>er  of  erytlirocytes  per  cubic 
niillinu>ter  of  the  same  blowl.  Utilizing  these  two  enumerations,  we  can 
arrive  at  the  color  index,  e.  g.,  at  the  ratio  of  hemoglobin  per  corpuscle, 
taking  the  normal  corpuscle  with  normal  luinogloliin  content  as  1.  A 
liiiNxl,  for  example,  c-ontaining  the  normal  .'),()(K),(KK)  <orpuscles,  but  only 
7.'i  jM'r  cent,  of  tne  normal  hemoglobin,  would  huvea  <'olor  index  of  0.75; 
having  only  2,.'iOO,000,  with  a  hemoglobin  content  of  75  per  cent.,  would, 
(III  the  other  Imnil,  liave  a  color  index  of  1.5,  i.  e.,  each  corpuscle  would 
|Hissess  half  as  much  hemoglobin  again  as  does  the  normal  corpu.scle. 
.\n(l,  as  a  matter  of  fact,  we  find  very  considerable  variations  in  this 
color  intlex.  In  chlorosis,  for  example,  it  is  reduced,  in  pernicious  anemia 
nuirke«lly  increased.  And  these  findings  tally  with  the  clinical  ol)serva- 
tion  that  in  chlorosis  very  slight  exertion  brings  on  breathlessness— 
through  lack  of  adequate  oxygenation— whereas,  in  pernicious  anemia 
the  (Hitient  in  general  only  c-onsulu  his  doctor  for  weakness  when  the 
iiunilier  of  red  corpuscles  has  fallen  to  2,(XX),000  or  less. 

Re<luction  of  the  color  index  may  either  intlicate  (as  in  chlorosis)  a 
priiiiiiry  inadequate  proiluction  of  the  hemoglobin,  or,  on  the  other  haml, 
a  tlilTusion  of  the  same  out  of  the  cor|>uscles  into  the  plasma.  Such 
himdysiii  occurs  under  a  variety  of  conditions.  Our  attention  has  been 
iltawii  to  it  of  late  years  more  particularly  by  the  studies  upon  cytolytic 
:ii  lion,  and  the  remarkable  eifects  produceif  both  by  foreign  sera  from 
iiomuil  animals,  an<l  by  the  sera  of  animals  of  the  .same  or  other  spec-ies 
uhiili  liave  received  injections  of  cells  of  various  orders.  Such  sera 
i.Miif  to  contain  botlies  which,  both  in  the  removed  blood  and  when 
i'ljii  It'll  into  the  vessels,  cause  a  markwl  "laking"  of  the  blood,  so  that 
till'  corpuscles  become  representetl  by  colorless  shadows.  There  are 
iiLiiiy  other  agencies  which  have  a  like  effect — cold,  as  in  paroxysmal 
'iriiiojjloliiniiria;  heat,  as  in  bums;  and  many  chemical  agents — pota.ssium 
I '.  liute,  ricin,  toluvlenediamin,  glycerin,  pyrogallic  acid,  etc.  VNTiat  is 
'  i  articular  interest  as  possibly  explaining  some  at  least  of  the  second- 
iineinias,  is  the  hemolytic  action  of  not  a  few  of  the  pathogenic 
;  .  MM)rganisms — streptococcus,  pyococcus  aureus,  bacillus  pyocyaneus, 


MKTOCOrr   RESOIUTION   TBT  OMRT 

(ANSI  and  ISO  TEST  CHART  No.  2) 


IM 

>         1^ 

^ 

|2.2 

36 

H^H 

4.0 

12.0 

i£ 

APPLIED  IIVMGE    Inc 

^.         16S3   East  Uo.n  Sir»t 

^S         Roch«ter.   N««   York         U609       USA 

(716)   *82  -  0300  -  Phof>« 

(7)6)   298-  5989  -  Fq« 


90 


THE  ERYTHROCYTES 


f 


bacillus  coli,  the  pneumococcus,  etc.  These  organisms  may  be  grown 
in  defibrinated  blood  sc'utions,  when  the  laking  can  be  readily  observed 
by  the  change  in  the  appearance  of  the  medium,  or  laking  may  be  directly 
induced  by  the  addition  of  the  fluids  of  culture. 

In  all  these  cases  it  would  seem  that  we  deal  with  more  than  the  mere 
diffusion  out  of  the  hemoglobin.  Some  changes  must  occur  in  the 
physical  state  of  the  corpuscles  before  the  pigment  becomes  liberatp<l, 
and  once  it  is  liberated  the  corpuscle  is  rendered  useless.  We  possess  no 
evidence  that  the  erythrocyte  has  the  power  to  regenerate  hemoglobin 
after  loss.  The  fate  of  the  affected  corpuscles  is  to  be  removed  from 
the  circuUition  by  the  agency  of  the  spleen.  Any  condition,  therefore, 
bringing  about  severe  or  continued  hemolysis  causes  with  it  a  condition 
of  (so-called)  anemia,  i.  e.,  a  reduction  in  the  number  of  circulating 
erythrocytes.  The  anemia  so  produced  has  been  studied  in  our  labora- 
tory by  Charlton,  who  injected  over  long  periods  into  rabbits  non- 
lethal  doses  of  a  relatively  non-virulent  colon  bacillus  isolated  from 
the  intestine  of  a  normal  rabbit.  Bunting  employed  similarly  repeated 
small  doses  of  ricin.  Charlton  was  able  in  several  instances  to  bring 
down  the  number  of  erythrocytes  to  1,000,000,  and  found  that  so 
soon  as  the  number  reached  2,500,000,  poikilocytosis  with  occasional 
megaloblasts  became  developed;  he  found,  however,  little  obvious 
change  in  the  bone  marrow.  In  Bunting's  cases  the  evidence  of  increased 
activity  of  the  bone  marrow  was  well  marked,  the  marrow  closely  resem- 
bling that  seen  in  pernicious  anemia.  Other  observers,  like  Hunter  with 
his  researches  upon  the  effects  of  toluylenediamin,  have  studied  the  more 
immediate  effects  of  hemolytic  ager  ts,  as  shown  by  the  excretion  of  tlie 
liberatetl  hemoglobin  through  the  liver  and  kidneys,  in  the  former  case 
as  bile  pigment. 

Chlorosis.' — Here  it  will  be  well  to  pass  in  review  certain  of  the  more 
important  disorders  characterized  by  altered  states  of  the  red  corpuscles. 
And  first  we  may  consider  chlorosis,  a  condition  form,  ly  very  common, 
but  now,  according  to  Cabot,  becoming  relatively  uncommon,  at  least 
in  North  America.  It  affec-ts  young  women  (94  per  cent,  of  Cabot's 
cases  were  between  the  ages  of  fifteen  and  thirty  years);  rare  cases  liave 
been  recorded  in  young  males,  so  rare  that  many  writers  doubt  their 
existence.  Save  that  the  onset  suggests  some  disturbance  of  the  recently 
established  menstrual  function,  and  that  the  majority  of  cases  are  of 
girls  in  household  service,  who  have  exchanged  the  freer  life  in  the 
country  for  one  spent  largely  indoors  under  not  the  best  hygienic  con- 
ditioi.s,  we  have  practically  no  indications  suggesting  the  causation  of 
the  disease— which  ir  itself  is  not  fatal,  although  it  may  predispose  to 
tuberculosis  i  .id  other  more  fatal  contlitions. 

The  characteristic  features  are  the  cachexia,  the  bloodless,  jiale 
complexion  ("green  sickness"),  with  pallor  of  the  lips,  the  weakness 
and  lassitude  following  upon  slight  exertion,  the  dyspepsia,  capricimis 

'  The  fullest  recent  study  of  this  condition  is  by  Cabot,  in  Osier  and  Mcri:ie'« 
Modern  Medicine,  4:  1908:  039,  baaed  on  the  study  of  407  cases. 


CHLOROSIS:  SECONDARY  ANEMIAS 


91 


appetite,  with  gastric  acidity,  constipation,  and  palpitation,  and  the 
state  of  the  blood.    There  is  a  slight  but  definite  reduction  of  the  number 
of  erythrocytes,  a  marked  reduction  in  the  amount  of  hemoglobin  per 
corpuscle;  the  color  index  averages  about  0.5,  but  may  be  as  low  as  0.1. 
With  this,  as  clearly  demonstrated  by  Haldane  and  1-orrain  Smith,  there 
is  pronounced  increase  m  the  amount  of  blood  plasma,  an  increase  more 
than  sufficient  to  explain  the  reduction  in  the  number  of  erythrocytes 
per  cubic  millimeter.    There  is  a  true  serous  plethora.    Save  that  more 
might  have  been  said  regarding  the  symptoms,  there  is  little  to  add  that 
is  definite  in  our  knowl«lge  of  the  disease,  with  the  exception  that  the 
rapid  general  improvement  which  follows  the  proper  administration  of 
iron,  accompanied  by  improved  hygienic  conditions,  suggests  that  we 
deal  very  largely  with  a  deficient  building  up  of  iron  into  the  iron  con- 
taining hemoglobin  of  the  developing  erythrocytes;  that,  in  shoit,  the 
reduction  of  the  color  index  is  the  central  feature  of  chlorosis.    Several 
ol)servers  have  called  attention  to  the  accompanying  constipation  and 
the  imprcvement  that  follows  when  this  is  overcome;  thus  possibly  an 
intestinal  toxemia  may  play  some  part  in  the  production  of  the  condition. 
Secondary  Anemias. — With  the  exception  of  the  above  condition, 
when  we  can  determine  what  appears  to  be  a  satisfactory  cause  for  the 
diminution  in  the  number  of  erythrocytes,  we  speak  of  a  secondary 
anemia,  and  doing  so,  we  leave  as  a  class  apart  one  condition  of  unknown 
rausation,  namely,  idiopathic  or  primary  pernicious  anemia.    Such  sec- 
ondary anemia  may  be  acute,  as  after  profound  loss  of  blood.     In  these 
rases  what  has  already  been  said  will  have  prepared  the  reader  to  find  a 
bhxxl  greatly  diluted,  owing  to  passage  into  it  of  lymph  and  tissue  fluids, 
in  order  to  preserve  the  amount  of  circulating  fluid.    The  erythrocytes 
at  first  are  normal  in  appearance  and  hemoglobin  content,  but  eventually, 
if  tiie  loss  of  blood  has  been  great  and  the  pouring  of  new  cells  out  of 
the  hone  marrow  excessive,  there  may  appear  a  few  immature  erythro- 
cvtcs  and  cells  of  the  megaloblastic  type.    With  this  there  may  be  a  tem- 
|)()rary  actual  increase  in  the  number  of  circulating  leukocytes  (mainly 
iKiitrophile)  and  a  lowering  of  the  color  index,  due  to  the  fact  that  the 
innnature  erythrocytes  do  not  contain  the  normal  amount  of  hemoglobin. 
JAtensive  hemolysis  may  also  bring  about  an  acute  anemia ;  this  may  be 
iiKhiced  by  severe  infections,  and  cases  are  on  record  in  which,  without 
the  supervention  of  hemorrhage,  the  blood  count  has  dropped  to  1,500,000 
witliin  a  few  days  of  high  fever.     Certain  drugs  taken  accidentally  (e.  g., 
iici'lanilide)  may  induce  active  hemolysis  and  give  a  similar  picture. 

Chronic  Seeonduy  AumiM. — In  these  acute  cases  we  have  in  the  main 
tlif  picture  of  great  reduction  in  the  number  of  erythrocytes,  followed 
li\  stages  of  an  imperfect  hematopoiesis.  In  the  chronic  forms  imperfect 
Ih  ii;itopoiesis  may  be  said  to  hold  the  field.  The  main  features  are 
1  abundance  of  cells  smaller  than  normal,  and  a  low  color  index. 
^!'i(h,  however,  depends,  both  as  regards  the  erythrocytes  and  the 
'  ik(K"ytes,  upon  the  grade  of  the  anemia,  as  agam  upon  the  cause.  Thus, 
111  the  anemias  due  to  intestinal  parasites  the  milder  cases  show  at  most 
i:'i(  rwytosis  with  a  characteristic  eosinophilia,  but  grave  cases,  notably 


92 


THE  ERYTHROCYTES 


those  due  to  the  Dibothriocephahis  latiis,  the  fish  tapeworm,  present 
a  picture  indistinguishable  from  pernicious  anemia.  Lead  poisoning, 
again,  presents  an  undue  proportion  of  nucleated  reds  vith  "stippling," 
i.  e.,  with  basic  granulation  of  the  erythrocytes.  In  splenic  anemia, 
the  leukocytes  are  characteristically  diminished  in  number,  and  tiie 
color  index  is  very  low.  In  infancy,  the  anemias  present  aberrant 
characters.  In  accordance  with  the  other  tissues,  the  regeneration  of 
the  blood  cells  is  very  active,  with  the  result  that  abundant  cells  of 
erythroblastic  type  gain  entrance  into  the  blood,  and  the  color  index, 
instead  of  being  low,  is,  as  a  rule,  high. 

As  a  general  principle,  it  may  be  laid  down  for  these  secondary  anemias 
that  the  more  severe  and  the  more  long  continued  the  causative  condi- 
tions, the  greater  are  the  signs  of  exhaustion  and  uf  ng  up  of  the  erythro- 
blastic mother  tissues,  imtil,  in  the  advanced  cases,  we  obtain  pictures 
verj'  similar  to,  and  in  fact  at  times  indistingui^-hable  from,  those  of 
pernicious  anemia,  to  be  presently  notetl. 

Pernicious  Anemia. — The  picture  presentetl  by  the  sufferer  from  per- 
nicious anemia  is  striking:  the  peculiar  yellow  cachexia,  the  absence  of 
emaciation,  and  in  its  place  the  laying  on  of  flabby  fat,  the  weak  heart 
action  and  pulse,  and  str'Ving  general  weakness.  At  autopsy,  the  bright 
yellow  color  of  the  fat,  the  bloodlessiiess  and  anemia  of  all  the  organs, 
the  pale  color  of  what  blood  there  is,  the  pronounced  fatty  degeneration 
of  the  heart,  the  presence  of  inereasetl  iron,  more  particularly  in  the 
liver,  shown  by  cither  Quincke's,  or  Perl's  test,  the  increased  red  marrow 
of  the  bones,  and  the  frequent  presence  of  evidence  of  a  chronic  gastritis, 
all  combine  to  form  a  combination  that  cannot  be  mistaken. 

The  most  striking  of  these  disturbances  is  the  blood  condition.  Tliat 
blood  is  both  diminished  in  amount  and  characterized  by  a  marked 
diminution  in  the  number  of  erythnx-ytes.  The  number  may  fall  fo 
below  500,000.  We  have  at  the  same  time  evidence  of  active  disinte<;ni- 
tion  of  the  reil  corpuscles  (indicated  by  the  increased  storage  of  iron  in 
the  liver)  an<l  of  active  regeneration  (indicated  by  the  hyperplasia  of  itie 
red  marrow  and  the  relatively  abundant  nucleated  red  corpuscles  of 
tlitt'erent  orders,  in  the  circulatuig  blood).  But  the  regeneration  does 
not  proceed  at  a  rate  sufficient  to  compensate  for  the  destruction.  \Vliat 
is  characteristic  is  that  the  individual  erythrocytes  are  many  jf  tliem 
larger  than  normal,  and  they  contain  increased  hemoglobin;  so  that  a 
main  feature  is  the  very  high  color  index.  That  the  corpuscles  are  not 
healthy  is  indicate<l  by  the  marked  poikiloryiosis;^  they  are  flabby  and 
assume  various  shapes.  But  despite  the  high  index,  owing  to  the  i;reat 
re<luction  in  the  number  of  corpuscles  and  reduction  in  the  amount  of 
blood,  the  total  amount  of  hemoglobin  is  greatly  lowered.  To  iliis 
lowered  oxygen-carrying  capacity  of  the  bl«MHl  must  be  ascrilxil  lii'' 
diminishe<l  metabolism  and  the  storage  of  fat  (a  similar  tenden  lo 
lay  on  fat  is  often  observable  in  chlorosis),  and  possibly  the  contiiiied 
mahmtri' .       'n  itself  is  responsible  for  the  fatty  degeneration  of  the  In -irt 


'  ffo/K/?.«f,  varied  or  various  (referring  to  shape). 


PLATE    II 


Pfr'fni'  i'  >ii-  A 


n ,  i '  1  m ;  I .      < 


Ciibot. 


lli-  fi-M  -h- 


ilkt-d    HUl-'«-\  1i 

;ili-.!i-  .il   f!ir  liM-i:.'iinl,|:iv|    >rri.- ;    >  >  >,  "M  i| 'plcd"  rM  ccl^;    A*.  riti«  body   <inirlc 


;i!il    i«.iUI"«  >  ti.-i-:     MK  \<>\i\-iz  lln'tuxhAyiu^t    (e»r\ 


y  Kftirrrifi.wi'; 


•  i  riiMi  liniiur  ilirr.'  im  n\nl  po'ynuriiMr  (''i-i»'>i'hil*'-.  i>H''  t'l 


l>i>lvr>i'  I.Mr-  ri'-inr-'i 


ilul**.  Mini  .<tM'  Ivini'lM<f\(t' 


-■-Mi'il'liilr.  I'ttt 


mmm^ 


PERNICIOUS  ANEMIA  93 

an<]  other  organs,  although  this  may  also  be  ascribed  to  the  unknown 
toxic  agent  causing  the  hemolysis  and  continued  blood  destruction. 

What  this  toxic  agent  is  we  still  are  in  ignorance;  obviously  it  is  of 
hemolytic  nature,  and  acts  over  lorg  periods.  One  striking  feature  of 
the  disease  is  that  it  is  already  far  advanced,  as  a  rule,  before  the  patient 
feels  himself  ill  enough  to  consult  a  physician;  another,  that  apparently, 
despite  the  varied  nature  of  the  treatment  afforded — ^save  that  the  rom- 
mon  basis  of  all  forms  of  treatment  is  rest  and  simple  diet — there  occurs 
ill  the  majority  of  cases  a  distinct  remission;  the  number  of  erythrocytes 
increases,  the  general  condition  improves,  until  the  blood  returns  prac- 
tically to  the  normal  and  the  patient  is  apparently  restored  to  heaiih. 
This  may  persist  for  but  a  month  or  two,  -r  long  as  four  years — only 
rarely  is  the  improvement  permanent.  Then,  without  obvious  cause, 
a  relapse  occurs.  Cabot,  from  an  analysis  of  several  hundred  cases, 
states  that  the  avemge  time  of  remission  is  for  one  year,  and  quotes  cases 
in  which  the  relapse  has  occurred  at  the  sam«  season  in  s'-oces  •  e  years; 
our  impression  is.that  too  great  stress  must  not  be  laid  upon  this  regular- 
ity. The  only  suggestion  that  can  be  made  to  explain  these  remissions 
is  that  the  enforced  rest  and  dieting  gives  the  system  the  opportunity 
to  counteract  the  intoxication.  More  and  more  Hunter's  conclusion 
that  we  deal  with  some  alimentary  intoxication  is  gaining  ground. 
The  frequency  of  a  septic  condition  of  the  mouth,  or  of  evidenc  ,s  of  a 
clironic  atrophic  gastritis,  the  very  frequent  absence  of  hydrochloric 
acid  from  the  gastric  juice,  the  gastric  distress,  and  the  frequent  tor- 
liition  of  diarrhaa,  all  call  attention  to  the  digestive  tract.  And  here 
tliree  possibilities  exist — either  that  we  deal  with  (J )  the  ab«f -rption  of 
lit'inolytic  products  of  abnormal  digestion,  (2)  the  absorption  of  similar 
hemolytic  products  of  abnormal  bacterial  fermentation,  or  (3)  the  pres- 
eme  an<l  growth  in  the  digestive  tract  of  organisms  of  a  low  pathi  genie 
type,  and,  as  a  consequence,  the  development  of  a  state  of  subinfection 
I  vol.  i,  p.  425),  the  increased  carriage  of  organisms  into  the  splanchnic 
1)1o(m1  stream  being  favored  by  inflammatory  states  of  the  alimentary 
mucosa. 

Certain  considerations  favor  either  of  *he  latter  two  theories,  namely, 
1 1 )  the  known  power  of  acid  reaction  of  the  stomach  contents  to  arrest 
bacterial  proliferation,  and  the  converse,  that  absence  of  hydrochloric 
at  id  from  the  upper  intestinal  tract  favors  bacterial  growth  and  abnormal 
ferinentation;  (2)  the  observed  anemia  that  accompanies  foul-smelling 
piitrrfactive  states  of  the  contents  of  the  lower  intestines. 

Here  at  the  present  time  the  study  of  pernicious  anemia  may  be  said 
ti)  rest.  We  are  coming,  that  is,  to  the  conclusion  that  pernicious  anemia 
is  not  idiopathic;  that  the  typical  forms  have  associate*!  with  thein  bac- 
ii  villi  overgrowth  in  the  alimentary  canal  of  such  an  order  that  hemo- 
1;  lie  iigents  are  developed  in  undue  quantities,  but  still  have  to  determine 
^  i':it  particular  order  of  bacteria  are  concerned,  and  how  they  act. 
i  1  ((mehision,  we  would  repeat  that  it  has  to  be  kept  in  mind  that  a 
Miiilar  syndrome  and  extreme  alteration  of  the  blood  may  be  produced 
''.    known  agencies,  by  hemolytic  substances,  sucL  as  repeated  small 


94 


THE        UKOCYTES 


I 


li 


doses  of  ricin  (Bunting),  by  the  presence  of  the  Dibothriocephalus  laliis 
in  the  intestines  (whatever  be  its  mode  of  action),  and,  rarely,  in  tlie 
latter  stages  of  malignant  disease.  In  this,  Crile  and  others  have 
determin^  the  existence  of  hemolytic  substance  in  the  blood.  We  have 
seen  the  condition  develop  also  in  a  patient  the  subject  of  repeated  small 
hemorrhages  extending  over  two  years,  from  a  villous  papilloma  of  the 
bladder.  In  that  case  the  picture  was  complete,  save  for  the  absence  of 
excess  of  iron  in  the  liver,  i.  e.,  there  had  been  no  intravascular  destruc- 
tion of  red  corpuscles,  but  a  steady  loss  of  the  same  from  the  system. 
So  also  there  was  no  recognizable  disturbance  of  the  gastro-intcstinal 
tract. 

Aplastic  Anemia. — Rare  cases  are  on  record  of  a  yet  further  staj^^e 
in  what  appears  to  be  the  same  process.  In  this  it  would  seem  that  the 
overgrowth  of  the  red  marrow  and  excessive  production  of  erythrocytes 
is  followed  by  a  stage  of  exhaustion,  so  that  upon  exan)ining  the  medulla 
of  the  sternum  or  femur,  etc.,  instead  of  finding  an  overabundance  of 
red  marrow,  that  red  marrow  is  re<luced  in  amount,  and  replacetl,  it 
may  be  wholly,  by  yellow  fat:  instead  of  hyperplasia  there  is  aplasia; 
or,  judging  from  the  rapiil  course  of  many  of  the  cases,  it  may  be  urge<l 
that  from  some  congenital  weakness  or  other  cause  the  agent  setting 
up  the  hemolysis  <loes  not  excite  an  adequate  hyperplasia  from  the  first, 
and  the  erj-throblasts  are  quickly  used  up.  As  indications  of  this 
exhau.stion  are  to  be  notetl  the  absence  of  normoblasts  and  rregaloblasts, 
and  the  low  color  index.  Poikilocytosis  and  anisocy  tosis'  are  found  largely 
wanting,  as  are  also  the  leukocytes  proper,  causing  a  relative  abundance 
of  1.  mphocytes.  Hemorrhages  are  frequent.  Cabot  has  coUeettii 
twenty-two  cases  of  this  nature  from  the  literature. 


THE  LEUKOOTTES. 

With  the  present  continued  doubt  regarding  the  relationship  of  tlie 
different  forms  of  leukocytes  in  the  circulating  blood,  it  is  essential  tiiat 
before  discussing  variations  in  the  relative  numbers  of  the  different  forms 
appearing  in  the  blood,  we  should  at  least  place  upon  record  our  opinions 
regarding  that  relationship;  not  that  we  consider  our  views  so  well 
foundal  that  they  are  unlikely  to  umlergo  change,  but  because  the  whole 
of  our  treatment  of  leukocytosis  is  influenc«l  by  these  views.  We 
have  discussed  them  elsewhere.' 

Here,  as  reganls  the  blood  as  distinct  from  the  inflamed  tissues,  we 
recognize  two  well-defined  groups:  (l)The  granular  leukocytes,  and  i2) 
the  lymphocytes,  and  these  we  hold  are  of  separate  origin.  The  ditftr- 
ent  forms  of  the  first  group  would  seem  all  to  originate  from  myelobla-is 
large,  non-granulate<l  cells,  which,  in  the  adult,  are  present  throughout 
life  as  "  mother  cells"  in  the  bone  marrow.     These  originate,  as  do  also 

■  aviaof,  unequal  (referring  U>  ftize). 

'  Inflammation.     London,  Macmillan  &  Co.,  4th  edition,  1909. 


THE  LEUKOCYTES 


95 


the  erythroblasts,  in  intimate  connection  with  the  capillary  endothelium,* 
wher«is  the  lymphocytes  are  derived  from  the  mother  cells  or  lympho- 
blasts  of  lymphoid  tissue.  The  myelocytes  give  origin  to  cells  which 
exliibit  granulations  of  different  orders — either  acidophilic,  staining  with 
tlie  acid  aniline  dyes,  or  basophilic— while  occasionally  we  may  encounter 
cells  which  morpfiologically  are  of  intermediate  type.  Despite  the  abun- 
dant studies  that  have  been  made,  we  still  lack  sure  evidence  that  the 
fullv  (ievelopetl  cell,  with,  for  example,  coarse  acidophile  granules  (eosino- 
pliiie),  undergoes  conversion  into  one  with  finely  granular  basophile 
(iieiitrophile)  granulations,  or  vice  versa.  All  the  evidence  indicates 
that  the  neutrophile  or  ordinary  polynuclear  leukocyte,  once  it  reaches 
tills  stage,  remains  a  neutrophile  and  is  incapable  of  conversion  into 
other  form.  Still  less  do  we  have  any  indifution  of  intermediate  stages 
between  the  lymphocyte  and  the  group  of  granular  leukocytes.  It  is 
true  that,  contrary  to  general  teaching,  by  special  methods  of  staining 
the  lymphocyte  can  be  seen  to  exhibit  extremely  fine  granulations,  but 
these  are  of  a  special  order,  and  are  not  demonstrable  by  the  ordinary 
metliods  whereby  the  leukocytic  granulations  are  brought  out. 

As  to  the  functions  of  these  cells  under  normal  conditions  in  the 
circulating  blood,  while  we  have  many  indications,  we  know  little  that 
is  absolute.  We  know  much  more  concerning  that  function  when  they 
liave  made  their  way  out  of  the  vessels  either  into  the  lymph  spaces  or 
on  to  tlie  surface  of' the  body.  These  latter  functions  we  have  already 
(iisciissed  in  our  chapters  upon  Inflammation  (vol.  i,  p.  375).  It  is 
qiiiif  possible  that  in  the  blood  stream  they  act  as  scavengers,  although 
normally,  judging  from  the  great  rarity  of  any  signs  of  inclusion,'  this 
property  is  little  called  into  play. 

There  are  obsen-ations  favoring  the  view  thai  in  the  intestinal  villi 
tlie  circuliiting  leuk«)cytfcs  may  actively  take  up  fatty  globules,  but  it 
may  be  ouestioned  whether  such  leukocytes  have  not  actively  taken 
np  th  "  "  ^s  outside,  and  then  migrated  into  the  veins.  Again, 
arcori  hnikoff's  views,  it  is  the  leukocytes  that  are  the  great 

man,  n  1  storehouses  both  of  immune  bodies  and  comple- 

ment .me  time  he  holds  strongly  that  where  this  is  the  case, 

the  he.  .eukwy      does  not  liberate  these  bodies  into  the  blood 

plasma.  ()n  the  wj.v  .e,  it  would  seem  more  probable  that  in  the  normal 
lilnoil  tlie  leukocytes  exert  little  functional  activity,  that  the  blood  in 
the  main  acts  as'carrier  for  those  cells,  that  their  carriage  throughout 
the  body  is  to  sub-serve  their  function  of  acting  as  patrols,  so  that,  con- 
vtycl  to  any  capillary  region,  they  may  make  their  way  out  into  the 
tissdi-s  through  chemiotactic  attraction.  Their  activity,  that  is,  would 
seem  to  be  more  extravascular  than  intravascular.  In  saying  this  we 
do  not  denv  that  circulating  toxins  have  an  influence  upon  the  number 
of  Icnkocytes  in  the  circulating  bloo<l;  this  influence,  however,  would 


'  \vk  Schridde,  Centralbl.  f.  Pathol,  19 :  1908 ;  865. 
( M)f  of  IIS  once  encountered  a  definite  bacillus  in  a  polynuclear  leukocyte  of  his 
ov  I:  Mood,  he  being  at  the  time  in  good  health. 


III 


-  ,1 


I   ^M 


96 


THE  LEUKOCYTES 


seem  to  be  exerted  primarily  upon  the  bone  marrow  aiul  lymph  glandular 
tissue,  determining  a  greater  or  less  discharge  of  the  different  orders  of 
celk.  It  is  to  this,  and  not  to  any  proliferation  of  the  leukocytes  in  the 
blood  that  any  leuko<  vtosis  or  the  reverse  condition  of  leukopenia  must 

be  ascribed.  .  i         ■       , 

Leukocytosis.— The  presence  of  any  increase  m  the  total  numl)<T  of 
white  corpuscles  in  the  peripheral  blcMxl  above  the  normal  constitutes 
leukocytosis.  I'sually  one  or  other  foim  is  in  relatively  greater  abun- 
dance; as  subgroups  we  tlistinguish  (a)  a  pnlynuclear  leukocytosis;  [b) 
eosinophilia;  and  (e)  lymphocytosis,  together  with  other  conditions  of 
the  appearance  of  aberrant  or  immature  forms  constituting  conditions 
of  (d)  leukemia.  Strictly  speaking,  we  do  not  consider  that  we  deal  w ith 
leukemia  until  the  number  of  these  aberrant  leukocytes  in  the  blood 
exceeds  15,000.  Strictly  speaking,  therefore,  we  may  have  a  myelotytic 
leukocytosis,  for  example,  that  is  not  a  leukemia. 

Using  the  term  in  its  broader  sense,  we  disiuigiiisli  next  between 
physiological  and  pathological  leukocytosis. 

Physiological  leukocytosis  shows  itself  in  a  variety  of  conditions.  In 
the  first  place,  there  is  in  the  voung  a  well-marked  relative  leukocytosis. 
During  the  first  week  r^f  life'  the  number  of  le-ikocytes  varies  between 
15,000  and  30,(KX);  during  the  first  ten  years  of  life  it  varies  between  10,000 
and  12,000.  In  the  female  toward  the  en.i  of  pregna.icy  there  is  a  well- 
marked  rise,  reaching  to  15.(KK)  to  20,000  at  the  time  of  parturition.  A 
distinct  rise  is  to  be  noted  after  violent  exercise,  massage,  cold  baths,  and 
the  application  of  electricity;  .so  also,  full  proteid  diet  favors  what  is  kiiottn 
as  alimentarv  leukocytosis.  I^astly,  a  terminal  leukocytosis  in  the  la.st 
hours  of  life'  is  so  common  that  it  may  be  reganled  as  physiological. 

Pathological  Leukocytosis.— (a)  Polynuclear  or  neutrophilic  leukocy- 
tosis. It  is  in  inflammatory  and  infectious  conditions  that  we  more 
particularlv  gain  this  form  of  leukocytosis.  We  can  produce  it  exjieri- 
mentallv  bv  the  inoculation  of  many  pathogenic  organisms,  c.  g.,  l)y 
inoculating  non-lethal  doses  of  the  Pyococcus  aureus  into  the  peritoneal 
cavitv,  when  for  the  first  few  hours  there  is  a  leukopenia,  followed 
next'dav  bv  a  pronounceil  polynuclear  leukcx-ytosis.  Thi.s  is  by  no 
means  a' universal  reaction  to  infection;  notably  it  is  wanting  in  typhoid, 
malaria,  tuberculosis  of  the  more  chronic  type,  and  when  without  second- 
ary infection,  leprosy,  measles,  mumps,  and  most  cases  of  influenza. 
But  where  there  is  'localized  or  generalized  suppuration,  it  be<oines 
most  pronounced;  in  pneumonia,  again,  there  may  be  a  leukocytosis  of 
100,0(X),  with  0.')  per  cent,  of  polynudears.  Our  contention  that  tliese, 
the  most  activelv  pliagocytic  leukocytes,  do  not  so  much  function  in  the 
bloal  as  appear  then  to  "be  utilize»l  later  in  the  tissues,  is  borne  out  by 
tlie  fact  that  in  malaria,  trypanosomiasis,  and  other  conditions  in  wtuch 
ahimal  micro|)arasites  miiitiply  in  the  bloo<l  rather  than  in  the  tisMiw, 
a  polynuclear  leukocytosis  is  characteristically  wanting;  wherciis  in 
pneumonia  and  the  sii'ppurative  diseases  in  which  the  irritants  muUii)ly 
outside  the  bloodvessels,  there  this  form  of  leukocytosis  is  most  extirme. 
There  is  another  group  of  conditions  in  which  we  encounter  this  type 


LEUKOCYTOSIS 


97 


./  leukooytosis-the  toxic.  Here  are  to  be  included  posthemoirhagic 
iXvtiu,  the  later  siages  of  hepatic  cirrhosis,  and  other  states  charac- 
«2  .y  P^ve  disturbance  of  the  liver  cells  (uremia,  etc  ),  gout,  the  later 
stoS  of  malignant  disease,  ptomaine  poisoning  coal-ffis  po|sonmg. 
aShe  effects  of  certain  drugs,  antipyretics  salicylates  P'locatyme.  ete 
C  presence,  that  is,  of  certain  products  of  abnormal  metabolism  and 
iJl  .fisintegration  on  the  one  hand,  and  of  certam  exogenous  chemical 
Sies  on  the^other,  set  up  an  increased  discharge  of  polymorphonuclear 
cells  from  the  bone  marrow  into  the  blood.  _ 

(b)  Ioiinoplim..-A  dbtinct  relative  increase  m  the  eosinophiles  of 
the  circulating  blood  is  seen  (1)  in  the  majority  of  cases  of  helmmth^asis. 
,  e  of  the  existence  of  parasitic  worms  in  the  economy  (vo  .  i,  P.  6\y). 
Win  a  group  of  irritative  skin  diseases  (pemphigus,  dermatitis  herpeti- 
hZ,  etc.)r(3)  accompanying  myeloid  leukemia;  W  >"  V;°«^^*' 
aTma,  and  to  a  slight  extent  in  a  variety  of  conditions  which  ,t  is  diffi- 

uUto  correlate:  certain  malignant  cases  of  neoplasm,  ovarmn  disease 
^where   non-malignant  and    non-suppurative).  and   postfebrile    con- 

''"ive'know  little  regarding  the  significance  of  the  eo^inrt"*^!!,"^.^ 
lareer  oxyphile  granules  recall  strikingly  the  granules  of  gland  cells,  but 
the  obsenations  rf  Kanthack  and  Hardy,  to  the  effect  that  these  may  be 
actively  excreted,  are  strongly  contested  by  most  hematologwts  although- 
il  pe'rsonally  arc  prepared  to  accept  the  statements  of  these  mos 
LSate  workers.  They  certainly  pfay  a  part  m  the  early  stages  of 
acute  inflammation,  being  the  first  celb  to  be  attr^ted;  they  accumulate 
in  the  omental  vessels  in  cases  of  peritoneal  mflammation;  and  very 
possibly  the  eosinophilia  of  diffuse  cutaneous  irritative  lesions  is  of  the 
Lme  I'cxal  type,  i.  e.,  a  determination  of  eosmophiles  mto  the  vessels 

of  the  inflamed  areas.  •    ..     i        u  -.„*^  «f 

(c)  Lymphocytosis.— Actual  or  relative  mcrease  in  the  lymphocytes  ot 

the  blood  is  seen:  .  ,      ,  »    i-       41 

1  In  many  diseases  v  lung  children,  notably  those  affectmg  the 
gastro-intestinal  tract.  I  ,1  be  recalled  that  the  infant  shows  a  marked 
rektiv,.  and  absolute  lymphocytosis.  This  is  doubtless  associated  with 
the  greater  relative  amount  of  lymphoid  tissue  in  the  young  individual 
which  ...ntinues  into  childhood,  and  is  especially  marked  m  the  intestinal 
and  nusenteric  lymph  glands,  so  that  irritation  of  this  group  of  glands 
more  .specially  is  accompanied  by  a  greater  discharge  of  lymphocytes 

into  thi-  l)lood.  .  ,      ,  •    j  u 

2.  li:  .eptic  and  other  conditions  in  the  adult,  characterized  by  exces- 
sive cilirsiement  of  more  than  one  group  of  lymph  glands. 

I  Nvhooping  cough.  Here  the  lymphocytosis  is  alm.^st  pathog- 
;.  A  lymphocytosis  of  20,000  and  more  is  very  frequent,  and 
,r.  on  record  of  counts  in  th'   neighborhood  of  100,000  (Steven, 

ilehilitating  disease— scur\7,  rickety   chlo-osis,  and  various 
.    Here  the  Ij  mphocvtosis  is  genen  ly  of  a  moderate  grade. 
ii;e  above  cases  we  deal  with  the  normal  small  lymphocj-tes, 


3.  1; 
nomi  >' 
cast- 
Cain' 

4. 
caclr 

I 


I  4 


-4'. 


itir  i 


■  il 


gg  THE  LEUKnCYTES 

(d)  L«ukeml».— We  have  in  our  first  volume  given  our  views  rejpird- 
ing  the  relationship  of  the  leukemias  to  simple  hyperplasia  on  the  one 
hand  and  neoplasia  on  the  other.  Here  we  must  briefly  indicate  the 
main  features  of  the  leukemic  state,  p  d  the  effects  upon  the  organism. 
By  leukemia,  as  distinct  from  leukocytosis,  we  signify  not  merely  the 
excess  of  leukocytes  in  the  blood,  but  the  sum  total  of  the  disturbances 
which  accompany  the  continued  presence  of  a  great  excess  of  such  leuko- 
cytes. We  do  not  employ  the  term  when  the  number  is  below  lo.OOO; 
indeed,  when  the  excess  is  below  that  figure  the  syndrome  of  disturb- 
ances is  scarcely  recognizable.  That  it  must  have  a  beginnbg  at  an 
earlier  period  is  obvious,  but  in  general  it  is  either  progressive  weakness, 
or  the  detection  by  the  patient  himself  of  a  greatly  enlarged  spleen  that 
first  leads  to  an  examination  of  the  blood  and  recognition  of  an  already 
advanced  condition.  And  then  one  of  two  orders  of  disturbance  is  to  be 
made  out;  either  a  great  excess  of  myelocytes  or  of  lymphocytes  in  the 
blood. 

Myelogenic  Leukemia.— Myelogenic  leukemia  is  a  disease  affecting 
the  male  more  often  than  the  female,  most  often  in  early  adult  life, 
and  showing  itself  especially  by  disturbances  of  the  blood-forming 
I  rans  and  the  results  of  the  same.  Those  blood-forming  organs,  to 
rtj,.  it,  are  the  bone  marrow,  and,  under  pathological  conditions,  the 
spleen,  liver,  and  lymph  glands,  and  all  these  may  be  involved,  although 
the  extent  of  involvement  varies  in  different  individuals.  The  bone 
marrow  would  seem  always  to  be  affected,  exhibiting  a  replacement  of 
the  fat  by  hyperplastic  gray  marrow,  in  which  cells  of  the  myelocyte 
type  preponderate,  with  transitional  stages  from  myeloblast  through 
myelocyte  to  the  neutrophile  leukocyte.  Eosinophile  cells  may  also 
be  encountered,  erythrocytes  and  nucleated  red  corpuscles,  along  with 
a  distinct  increase  in  the  number  of  giant  celb  (megacaryocytes).  Lym- 
phocytic elements  are  relatively  rare.  Normally  the  spleen  after  birth 
shows  little  evidence  of  myelocyte  formation,  but  now  it  is  pronounced, 
so  that  this  organ  takes  on  very  much  the  appearance  of  the  lymphoid 
Malpighian  bodico.  All  the  orders  of  celb  seen  in  the  leukemic  marrow 
are  encountered  in  this  organ,  which  undergoes  an  enormous  over- 
growth, so  that  at  times  it  may  extend  down  to  the  pubes,  still,  however, 
retaining  its  shape  and  general  proportions.  In  the  more  chronic  cases 
there  is  in  addition  an  extensive  fibrosis  of  the  organ.  Like  the  spleen, 
the  liver  is  actively  involved  in  blood  formation  during  antenatal  life, 
and  now  it  may  revert  to  its  fa'tal  activities.  Regarding  this  there  is 
still  debate;  many  autlorit''«s  hold  that  the  great  size  of  the  organ  and 
the  appearances  seen  (  l>on  are  due  entirely  to  accumulation  in  the 

capillaries  of  cells  conveye<l  from  the  spleen,  and  that  the  atrophy  of 
the  liver  cells  (which  may  be  so  extreme  that  considerable  areas  are 
encoimtered  showing  nothing  but  myelocytes)  is  due  to  the  engorfreinent 
of  and  pressure  exerted  by  the  distended  capillaries.  Others  see  an 
activity  on  the  part  of  the  vascular  endothelium,  leading,  as  in  the  enil)ryo, 
to  a  production  of  myelocytes  and  megacaryocytes  both  inward  into  the 
vessels  and  outward' to  form  {in  extravfiscular  accumulation,     io  es- 


1  !  AT!-:    !I! 


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lu'oili 

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lavtiii 

Ia 

tlle  111 


LEUKOCYTOSIS  99 

plain  this  divergence  it  must  be  recalled  that  not  all  parts  of  the  hemato- 
poietic system  are  necessarily  involved  at  the  same  time  and  to  the  same 
extent,  and  that  thus  it  happens  that  in  many  cases  the  liver  takes  no 
active  part.  This  organ  also  may  attain  great  size.  The  lymph  glands 
are,  as  a  rule,  only  moderately  involved.  Often,  save  for  some  accumu- 
lation of  myelocytes  in  their  vesseb,  they  are  normal;  but  occasionally 
some  undergo  the  changes  which  make  them  closely  resemble  the  modi- 
fied bone  marrow  and  spleen.  Accumulations  of  the  modified  leuko- 
cytes may  fill  the  capillaries  in  the  lungs,  kidneys,  myocardium,  and  other 
organs. 

The  diagnostic  feature  is,  however,  the  blood.  Here  the  average 
number  of  white  corpuscles  is  between  400,000  and  500,000  (Cabot), 
varying  from  60,000  to  as  much  as  1,500,000  per  c.mm.  The  increase 
involves  all  the  orders  of  white  corpuscles,  the  most  striking  increase 
being  in  the  myelocytes,  which  may  constitute  about  one-half  the  total, 
an<l  the  polynuclears,  constituting  almost  the  other  half.  There  is  a 
well-marked  eosinophilia  (but  this  relatively  slight  as  compared  with  the 
increases  above  noted);  an  increase  in  the  number  of  mast  cells  (coarsely 
granular  basophiles),  and  though  proportionately  they  are  greatly  dimin- 
ished, the  number  of  lymphocytes  is  actually  greater  than  that  found  in 
normal  blood. 

.\s  regards  the  red  cells,  until  the  final  stages,  there  is  usually  only  a 
slight  diminution  to  not  less  than  3,000,000.  Toward  the  end  the  dimi- 
nution becomes  much  greater,  and  with  this  there  may  be  poikilocytasis 
with  presence  of  nucleated  reds.  We  have  indications,  in  short,  of  a 
profound  hyperplasia,  affecting  especially  those  myeloblasts  which  give 
origin  to  the  polynuclears,  and  in  their  proliferation  are  discharged 
as  immature  myelocytes.  Simultaneously  the  other  elements  of  the 
marrow  tend  to  proliferate;  hence,  the  eosinophilia,  the  nucleated  reds, 
anil  somewhat  increased  discharge  of  lymphocytes. 

This  great  increase  in  the  large  myelocytes  leads  to  accumulation  of 
the  siime  in  the  organs  possessing  finer  capillaries,  and  brings  about  both 
local  malnutrition,  through  clogging  of  their  channels,  and  general  slow- 
ing of  the  circulation.  Actual  emboli  may  thus  be  formed.  The  accom- 
panying re<luction  in  the  erj-throcytes  also  favors  mahmtrition.  These 
alone  or  combined  may  explain  the  dyspna>a,  weakness,  and  moderate 
wa-iting  characteristic  of  the  disease,  as  again  the  epistaxis,  retinal  and 
other  hemorrhages,  and  the  persistent  priapism  occasionally  encountered. 
Hut  if  there  be  increased  production  of  leukocytes,  there  are  also  well- 
niaikc<l  indications  of  increased  destruction,  foremost  among  which 
we  i.MJay  place  the  excessive  discharge  of  uric  acid  through  the  kidneys 
(liic  to  the  disintegration  of  the  nuclei  of  the  destroyed  celb.  We  know 
of  h-.  uiicrohic  or  other  cause  of  the  disease,  and  to  the  liberation  of  the 
pro tincts  of  cell  disintegration  may  possibly  be  ascribed  the  fever  present 
Ml  i.tMctically  every  case.  The  course  of  the  disease  is  distinctly  chronic, 
lading  for  from  six  months  to  several  years. 

I  niiiiATic  Leukemia.— This  condition,  again,  is  more  frequent  in 
tilt  male  than  in  the  female,  and  in  young  adult  life,  though  cases  occur 


■  i 


100 


THE  LEUKOCYTES 


n 


i  4 
'  1 


'f  a 


'.i 


more  widely  distributed  from  infancy  to  old  age.  Unlike  the  myelogenic 
form,  this  may  exhibit  an  acute  onset  and  course,  and  we  may  broadly 
distinguish  the  two  types:  of  acute,  occurring  more  frequently  m  tlie 
first  thirty  years  of  life,  and  of  chronic,  in  the  latter  half.  Whereas  it 
is  the  enlarged  spleen  that  is  the  commonest  physical  sign  of  the  former 
condition,  here  enlargement  of  the  lymph  glands  is  the  marked  feature; 
weakness,  dyspnoea,  emaciation,  hemorrhages,  are  common  to  the  two 
conditions. 

The  blood  in  the  chronic  cases  shows  an  extraordmary  preponderance 
of  typical  lymphocytes— typical,  that  is,  in  form,  with  large,  deep- 
staining  nucleus  and  small  rim  of  cytoplasm,  as  again  in  size.  In  a  large 
proportion  of  the  acute  cases  we  meet  with  cells  so  atypical,  large,  with 
abundant  cytoplasm,  and  nuclei  of  irregular  shape,  and  not  so  det'ply 
stained,  that  while  in  many  cases  we  distinguish  transitional  forms 
between  these  and  the  small  lymph<Kyte,  in  others,  doubts  arise  as  to 
whether  we  deal  truly  with  cells  of  the  lymphocyte  group— whether  we 
have  not  to  deal  with  myeloblasts,  the  non-granular  forerunners  of  the 
myelocyte.  It  is  worthy  of  note  that  it  may  be  laid  down  that  the 
more  acute  the  case,  the  greater  the  tendency  for  the  lymph  glands  to 
be  but  slightly  enlarged,  and  for  the  bnmt  of  the  hyperplasia  to  be  found 
in  the  bone  marrow.  We  are  inclined  to  the  belief  that  up  to  the  present, 
adequate  means  of  distinguishing  between  the  most  immature  forms  of 
lymphoblast  and  myeloblast  have  not  been  elaborated,  and  that  m  this 
class  we  include  the  most  acute  forms  of  both  lympliMtic  and  myelo- 
genic leukemia. 

There  is  in  most  cases  both  acute  and  chrome,  some  enlargement 
of  the  spleen,  though  this  in  general  is  not  so  marked  as  in  the  myelopnic 
form;  the  same  is  true  regarding  the  liver.  A  condition  peculiar  to 
this  disease  is  overgrowth  of  the  multiple  minute  lymphoid  collections 
in  the  skin,  causing  the  appearance  of  multiple  small  nodules.  The 
number  of  circulating  leukocytes  is,  as  a  nde,  not  so  great  as  in  m.velo- 
genic  leukemia;  the  average  is  in  the  neighborhood  of  200,000.  Counts 
between  400,000  and  1 ,000,000  are  not  common.  What  is  characteristic 
is  the  infrequencv  of  fcrms  other  than  those  above  described;  the  poh- 
nuclears  are  few 'in  nunxber;  eosinophiles  and  mast  cells  may  be  wliolh 
wanting;  the  basophile  myelocytes  are  either  absent  or  not  abundant. 

Lastly,  these  cases  are  characterized  by  a  more  continuous  ami  some- 
times high  fever  (102°  to  104=  F.)  with  severe  sweats,  so  that  witliout 
blood  examination  it  is  easy  to  mistake  the  condition  for  typhoid,  acute 
tuberculosis,  hepatic  abscess,  etc.    The  condition  is  most  fata 

What  has  been  stiid  regarding  the  relationship  of  the  sympt  .ins  t)  the 
blood  changes  in  myelogenic  leukemia  applies  to  this  condition  al-o. 

Before  leaving  the  subject  it  is  necessary  to  call  to  mind  that  siinilar 
hyperplasia  of  the  lymph  glandular  system  may  present  itself  without 
excessive  discharge  of  lymphocytes  into  the  blooil  ("pseudoleukcu.ia  . 
or,  again,  that  the  blood'in  the  last  stages  of  pernicious  anemia  ma  v  emu- 
late that  of  leukemia,  while  similarly  the  last  stages  of  my.'  ,Tnic 
leukemia  may  be  accompanietl  by  so  great  a  destruction  or  !    k  of 


^ 


C\\f:   .1  III         L  III     il,l'   !■         1   .•■UI-> 


A<  ,u.il    FiiM   .     (Call'. I. 


nil..    IV  pi-:tj  -ii.dl  1\  t:i|!n,'  •.  !f>:    li  ti.  'Icl'.ii.t  .!...■•  iyii.l-l  m.\  !.■-;    \'. 


liwriiK.l.lji.^t. 


A.  III..'    L    iiipiwiti.     I'UU.iiii.'t     A.'iini    Fi.^lil,       Cii'-r.:. 


'Myiii-  I,,..  >..  ."    1  Nii.'i".  li'-  ii.\.'|..l  l.-t- ,;    I/.  i,.iii 


r-JlJ.ili.    ii.\.  l.«  >  t.-:   1'.  p,  r.    ;i,  l.-ar  n-'Ur.- 


1.  "i  .IL'.    !>  [ill'l....\  II  ,"  «il  h  "azi 


r"  --t:.!...!.-:    /i.  M.  :■■.!.. I. 111. 1  ...llrpi.-l   ;    \  ,  ;,. .ri... .1.!  , -f . 


•mm 


THE  BLOOD  PLATELETS 


101^ 


production  of  erythrocytes  as  to  bring  about  a  condition  much  resem- 
liling  pernicious  anemia.  With  Cabot,  we  regard  one  or  other  of  these 
(ortditions  as  explaining  the  condition  of  Uvkanetnia  of  Leube'  and 
other  recent  writers. 

Regarding  pseudoleukemia,  Hod^b's  disease,  chloroma,  and  lympho- 
sarcomatosis,  the  reader  is  referred  to  our  first  volume  (pp.  675-686). 


TBI  BLOOD  PLATXUTS. 

If  only  because  they  play  so  important  a  part  in  the  process  of  thr  .m- 
bosis,  it  is  necessary  to  have  a  clear  understanding  regarding  the  blood 
platelets,  or,  more  accurately,  regarding  what  b  knowii  concerning  their 
origin.  Apart  from  this,  with  the  advent  of  the  Romanowsky  stain  and 
its  modifications,  they  have  of  late  years  come  m  for  increasing  recogni- 
tion. There  is  no  longer  any  disposition  to  regard  them  as  artefacts, 
but  there  is  still  dispute  as  to  their  exa- 1  signScance  and  as  to  their 
unity  or  duality. 

They  are  small  bodies  of  varying  size,  in  i^'eneral  about  2  (i '  liameter, 
oval  or  pear-shaped,  evidently  labile,  and  varying  in  shape  i*h  slight 
compression  by  neighboring  cells  or  platelets,  tending  to  be  present  in 
smears  in  small  groups  (possibly  as  the  result  of  .apid  agglutination  in 
the  shed  blood).  They  are  non-nucleated,  although  containing  often 
fine,  central  granules,  which  assume  a  redder  tint  with  the  Romanow- 
sky stain  in  contrast  to  the  bluer  groundwork.  Pratt's  careful  studies 
siiow  th»t  they  are  present  in  the  normal  blood  in  greater  numbers  than 
the  leukocytes,  although  the  number  shows  wider  variation— from 
200,000  to  700,000  per  c.mm.  Since  their  discovery  and  the  early  papers 
by  Hayem,  Bizzozero,  and  Mrs.  Ernest  Hart,  there  have  been  very 
various  views  regarding  their  nature  and  mode  of  origin:  (1)  That 
they  are  precipitated  r'obulin  (Lowit,  Wooldridge);  (2)  that  they  are 
products  of  disintegration  of  white  corpuscles  (Lilienfeld,  Zenker,  and 
others);  (3)  that  they  are  given  off  from  liiainlegratmg  red  corpuscles 
(Mosso,  Klebs,  .\mold,  etc.).  The  exquisite  preprations  made  by 
J.  H.  Wright,  of  Boston,'  demonstrate  without  possibility  of  doubt  that 
some  at  least  of  the  platelets,  and  those  most  typical,  are  normally  derived 
from  a  particular  order  of  cell,  namely,  from  the  giant  cells  (megacaryo- 
lytes)  of  the  bone  marrow.  These  cells  give  off  processes  projecting 
into  the  lumma  of  the  capillaries,  and  it  is  the  distal  portions  of  these 
wliiih  become  liberated  into  the  blood  as  platelets.  As  such  they  mav, 
as  Schimmelb'jsch  was  the  first  to  demonstrate,  retain  some  power  of 
iiiiuuhoid  movtment,  but  the  mode  of  their  devMopment  sets  at  rest  the 
<ltl):ite  as  to  the  nature  of  the  central  staining  ^nules;  thev  in  no  sen^e 
ii'[)ri'sent  a  nucleus. 

Tiie  important  question  still  to  be  determined  is  whether  all  the 

■  Deutsche  Klinik,  1902,  No.  42. 
I  nfortunately,  the  photographs  which  illustrate  his  paper  are  not  worthy  of  the 
!  •  '.irationij,  and  do  not  carry  conviction. 


108 


DUST  BODaES—HEMOCONIA 


■I    ! 


I 


1 

!<■ 
i 


El 


I     I 


f 


blood  platelets  have  this  one  mode  of  origin;  and  this  is  far  from  settled. 
That  the  leukocytes  play  any  part  in  their  production  must,  ve  think, 
be  put  on  one  side,  although  certain  of  the  smaller  "dust  bodi;  s"  to  be 
presently  referred  to  would  seem  to  have  this  origin.  Their  origin  from 
erythrocytes  cannot  be  so  easily  dismissed.  Some  would  urge  that  there 
exist  bloo.1  platelets  proper,  and  other  botlies,  derived,  it  may  be,  f nun 
red  conuscles  which  are  not  platelets.  But  t lib  cannot  be  seri'-isly 
defended.  The  blood  platelets,  it  has  to  be  admitted,  are  very  variable 
—variable  in  size  from  1  /i  up  to  half  the  diameter  of  a  leukocyte;  some 
have  the  central  granules  above  describetl,  others  show  more,  and  where 
granules  are  present  they  vary  in  amount  and  in  position;  most  contain 
no  hemoglobb,  others  have  a  hemoglobin  tint.  Now,  it  has  been  shown, 
more  particularly  by  Am  >ld,  that  under  conditions  of  intravascular  and 
extravascular  clotting  the  ilisintegration  of  the  erythrocytes  leads  to 
the  appearance  of  bodies  which  by  no  criterion  can  be  dis*=  guishr ! 
from  the  platelets  of  ordinary  blood.  They  may  originate  us  discharged 
endoglobular  bodies,  which  by  diffusion  soon  lose  their  hemoglobin, 
by  plasmorrhexis  (detachment  of  peripheral  nodu'ar  projections),  or  bv 
plasmoschisis  (whereby  the  whole  body  of  the  corpuscle  br'^ks  up 
into  oval  bodies  which  become  separate  platelets).  Appearanc-es 
which  in  our  opinion  can  only  be  attributable  to  this  breaking  down  of 
the  erythrocytes  are  frequently  to  be  noted  in  connection  with  thrombi 
of  the  smaller  vessels  {e.g.,  of  the  liver),  and  if  we  do  not  accept  these 
products  of  e;ythrocytic  disintegnition  as  platelets,  then  we  are  placed 
in  the  dilemma  of  regarding  the  process  of  thrombosis  as  due  in  a 
notable  proportion  ot  cases  not  to  blood  platelets  proper,  but  to  a  eon- 
glutination  of  bodies  which  are  not  blood  platelets,  but  simulate  tlieni 
in  shape  and  properties.  In  short,  we  come  perilously  near  occupying 
the  position  of  the  student  who  held  that  the  Iliad  was  not  written  bv 
Homer,  but  by  another  man  of  the  same  name.  It  is  simpler  to  admit 
that  the  products  of  disintegration  en  masse  c^  more  than  one  order  of 
cell  afford  bodies  having  the  nature  of  blood  platelets. 

We  must  admit  that  in  pernicious  anemia  the  platelets  are  frequently 
(though  not  always)  diminished  in  number,  and  that  here  there  has 
been  observed  a  lack  of  giant  cells  in  the  bone  marrow.  In  purpura 
they  have  at  times  been  found  completely  absent.  We  know  of  no 
observations  o"  the  marrow  giant  cells  in  these  cases.  They  are  dimin- 
ished also  in  typl  oid— but  increased  in  myelogenic  leukemia,  and  in 
pneumonia. 

DUST  BODIES— HEMOCONIA. 

Still  smaller  bodies  or  particles  are  to  be  recognizer!  in  the  normal  Mood 
—1  /I  and  less  in  diameter.  To  these  H.  F.  Miiller  has  given  the  name 
of  dust  bodies,  or  henioconiu.  The  observations  of  Nicholls'  and  t.tlier? 
indicate  that  these  also  are  the  products  of  disintegration,  more  jar- 
ticularly  of  the  erythrocytes. 

>  Trans.  Royal  Sec.  of  Canada,  2d  series,  11,  1905,  sec.  4:1. 


CHAPTER   V. 


THE  LYMPHATIC  SYSTEM— (EDEMA. 

Recent  observations  have  very  ma''  rially  altered  our  cor'eption  o' 
the  finer  anatomy  of  the  lymphatic  system,  and,  with  this,  havr,  of 
necessity,  modified  the  conditions  which  have  to  be  taken  i'lto  considera- 
'ion  in  formulating  our  views  regarding  both  lymph  foririation  and  the 
disturbances  in  the  amount  of  lymph  present  in  the  tissuas  and  parts  of 
the  body.  So  recent  are  these  observations  that  time  hiis  not  yet  been 
afforded  for  experimental  review  of  the  older  hypothese-  in  the  light  of 
this  newer  knowledge.  It  is  impossible,  therefore,  to  write  m  other  than 
a  very  tentative  manner  about  what,  from  a  pathological  point  of  view, 
is  the  most  important  morbid  state  directly  dependent  upon  alteration  in 
lymph  production  and  lymph  discharge,  the  state,  namely,  of  oedema. 

The  older,  long-accepted  view  was  that  the  lymphatic  system  had 
its  origin  in  the  intercellular  spaces  of  the  various  tissu^jj,  and  that 
these  "lymph  spaces"  ope-.ie<l  freely  into  an  arborization  of  lymph 
channels,  which  differed  from  the  spaces  in  being  of  a  definitely  tubular 
nature,  and,  like  the  bloo<l  cani'.laries,  lined  by  an  endothelium.  The 
careful  studies  of,  more  par'  ularly,  W.  G.  M-'-Callum  and  P'lorence 
Sabin  seem  to  demonstrate  conclusively  that  he  system  of  lymp'i 
vessels  has  arisen  by  a  proces-  of  budding  from  the  veins,  and  that 
it  remains  distinct  from  the  system  of  intercellular  lymph  spaces — as 
distinct,  that  is,  as  are  the  blood  capillaries.  It  follows,  therefore,  that 
in  discussing  lymph  formation  in,  and  lymph  discharge  from,  any  region, 
we  have  constantly  to  keep  in  mbd  not  merely  the  mechanisms  whereby 
fluid  passes  out  of  the  bloodvessels  into  the  tissues,  but,  in  addition,  those 
controlling  the  passage  of  fluid  from  the  intercellular  lymph  spaces  into 
the  lymph  vessels.  We  have  to  recognize  thus  (1)  blootl  plasma,  (2) 
intenellular  lymph,  (3)  lymphatic  lymph. 

Doing  this,  we  immediately  find  ourselves  in  an  impasse  so  far  as 
rejrards  the  establishment  of  hypotheses  on  the  basis  of  exact  data;  the 
ultiniiite  lymphatic  vessels  and  the  lymph  spaces  are  of  microscopic 
diimiisions;  in  other  words,  no  sure  method  has  as  yet  been  devised 
wh(T(l)y  to  collect  intercellular  lymph;  we  cannot  introduce  the  finest 
cammlii  into  the  tissues  without  breaking  into  lymphatic  vessels;  and 
so  ciiinot  compare  lymphatic  lymph  and  unmixed  intercell"'rr  lymph 
foniiid  at  the  same  time.  This  has  been  abundantly  determined,  that 
tlic  fluid  obtained  from  a  larger  lymph  vessel,  frof^  the  thoracic  duct, 
or  one  of  the  vessels  of  the  extremity  of  the  neck,  differs  materially  in  the 
rehuivf  amounts  of  its  com  lent  constituents  from  the  blood  plasma. 
is  variation,  even  if  slight,  in  the  percentage  amount  of  the  most 


Thf 


It     V 


104 


THE  LYMPHATIC  SYSTEM-<EDEMA 


soluble  inorganic  salts.  We  have  not,  therefore,  to  deal  with  the  simple 
leakage  of  fluitl  from  one  set  of  vessels  into  the  other.  But  what  is 
the  nature  of  the  process  or  processes  of  lymph  formation  i.-  itill  a  niiittei 
of  keen  debate.  On  the  one  hanil,  we  have  the  upholders  ot  the  jmreh 
mechanical  theory,  first  clearly  formulateil  by  Ludwig;  those  who  holi 
that  the  laws  of  filtration,  diffusion,  and  osiuosLs  are  adequate  to  explain 
the  variation  in  the  amount  an«l  conijiosition  of  the  lymph  discliargeii 
from  a  part  under  varj'ing  conditions;  on  the  other,  those  who,  with 
Heidenhain,  urge  that  while  the  known  physical  laws  in  part  iletiTinint 
the  production  and  constitution  of  lymph,  there  are  alterations  in  aiiuNint 
and  constitution  which  cannot  lie  brought  into  harmony  with  the  working 
of  those  laws.  ITiese  workers  demand  a  certain  selective  oipacity  ami 
activity  on  the  part  of  the  capillary  endothelium,  determining  to  .some 
extent  the  amount  of  at  least  some  of  the  constituents  of  the  blood  plasma 
which  is  allowed  to  escape  from  the  capillaries.  The  most  prominent 
supporters  of  the  mechanical  theory  at  the  present  time  are  Starling" 
and  Cohnstein;  of  the  opposed  view,  are  Asher,  Hamburger,  I^izarus 
Barlow,  Meltzer,  and  Carlson.  These  observers,  it  is  true,  differ  among 
themselves  as  to  cells  mainly  involve«l  in  the  process  of  lymph  formation, 
but  are  members  of  the  "  vitalistic"  school  to  this  exteiit,  that  they  are 
unable  to  explain  lymph  formation  by  simpie  physical  principles,  aiul  are 
compelled  to  fall  back  upon  more  elaborate  processes  occurring  within 
the  cell  as  intro<lucing  modification  in  the  fluid  during  its  passage 
from  the  interior  of  the  blood  capillaries  to  the  interior  of  the  lymphatic.', 
Here  a  wonl  is  necessary  regarding  the  meaning  of  "vitalism." 
There  are  those  who,  with  Haldane  and  B.  Moore,  see  evidence  .  f  the 
existence  of  "biotic  energj',"  of  energy  associated  with  and  determining 
the  activities  of  living  matter,  distinct  from  other  forms  of  energ}. 
This  view  necessitates  the  fatalistic  attitu<le  that  vital  phenomena  are, 
beyond  a  certain  point,  incapable  of  explanation  by  the  onliiiary  law- 
governing  matter  in  general.  With  this  view  we  have  ab.soliitely  no 
sympathy.  All  that  Heidenhain  meant,  and  laid  down  with  preiision in 
his  opposition  to  Ludwig,  was  that  processes  are  undergone  in  tlie  livim 
cell  which,  while  govemwl  by  the  ordinary  laws  of  physics  and  cheinistn, 
are  nevertheless  so  complicated  that  hitherto  we  have  been  unable 
to  follow  the  successive  forces  acting  upon  the  assimilated  inolfcule  in 
iu  passage  through  the  cell;  that  the  simpler  processes  of  (litfii.«ion, 
osmosis,  and  filtration  are  at  work  l.ut  are  not  everything.  According 
to  this  view,  it  is  quite  {Mj.ssible  that  further  research  will  throw  li;:lit  upon 
the  nature  of  the  intracellular  forces.  To  this  extent,  and  thi-  extent 
only,  with  Heidenhain  and  Meltzer,  we  class  ourselves  with  the  \itali>y. 

'  The  dearest  statement  of  the  mt-chanical  thaory  is  afforded  by  .Starlim;  (.^rris 
and  Gale  Lectures,  Lancet,  London:  May  9,  16,  and  2.3,  1906);  a  tluirigh  ani 
impartial  criticism  of  .ill  the  theories  up  to  date  is  eiven  by  Meltzer  in  thr  Kumnr- 
ton  Lectures  on  (Edema,  .\merican  Medicine,  8:1904:Nos.  1,  2,  4,  and  ■  Th:! 
latter  is  the  fullest  recent  study  on  the  subject,  and  is  provided  with  a  riilj  bibliog- 
raphy. 


THE  LYMPHATIC  SYSTEM— <E  DEM  A 


ia5 


I'm- ourselves  we  tuiinot  an-ept  the  simpler  inechank-al  theory,  an<)  this 
fur  llie  following  broad,  hut  we  think  ohvious,  reasons,  namely,  that  this 
view  presupposes  that  lymph  Is  merely  the  outcome  of  the  discharge 
tliroiigh  a  suigle  endothelial  membrane,  the  bl(MMl  capillary,  into  the 
Ivinph  channels,  takes  no  adecjuate  account  of  the  influence  of  the  tissue 
('('lis  in  its  composition,  and,  lastly,  fails  to  explain  how  the  interstitial 
lymph  makes  its  way  into  the  lymph  vessels.  The  problem  of  lymph 
formation  in  reality  consists  of  three  parts:  (1)  What  is  the  mechanism 
by  which  certain  constituents  of  the  blood  plasma  pass  through  the  capil- 
lar}- wall?  (2)  How  and  to  what  extent  is  the  interstitial  lyniph  tnus 
produced  acted  upon  by  the  tissue  cells  which  it  Irathes?  (3)  By  what 
incchanism  does  the  interstitial  lymph  gain  entrance  into  the  lymphatic 
vewels?  If  for  the  moment  we  admit,  with  Starling,  that  the  first  of 
thtrse  step  is  purely  a  mechanical  process  deterniine«i  by  the  interaction 
of  two  factors,  the  intracapillary  blood  pressure  and  the  permeability 
of  the  capillary  wall,  we  still  have  the  other  two  problems  to  answer. 
Now,  as  regards  the  one  of  these,  we  are  altogether  too  apt  to  repeat, 
parrot-like,  that  the  tissues  are  nourished  by  the  blood  As  a  matter 
of  fact,  save  for  the  vascular  endothelial  celk,  and  one  or  two  rare  excep- 
tions, like  the  Kupfer  cells  in  the  liver,  in  which  tissue  cells  impinge 
directly  upon  the  blcxxl  stream,  the  tissue  cells  are  not  nourished  directly 
by  the  blcKxl,  but  by  the  interstitial  lymph;  the  nutritive  fluid  has  to  pass 
out  of  the  capillaries  into  the  lymph  spaces  surrounding  the  individual 
tissue  cells  before  those  cells  can  abstract  from  it  the  particular  f(x»d- 
stuffs  needed  by  them.  This  demands  that  the  different  orders  of 
cells  abstract  from  the  interstitial  lymph  different  orders  of  substances, 
as  also  that  they  excrete  or  discharge  into  it  very  varying  products 
of  metabolism;  in  short,  demands  conditions  of  give  and  take  of  so  com- 
plex a  nature  that  even  if  broadly,  under  certain  conditions  of  experiment, 
tliorucic  duct  lymph  has  the  character  of  a  filtrate  through  a  semi- 
permeable membrane,  it  cannot,  in  its  finer  analysis,  tonform  to  a  fluid 
of  that  nature,  and  under  normal  conditi(}ns  of  moderate  flow,  mist 
inevitably  depart  widely  from  this  type  of  fluid. 

.\nd  as  regards  the  last  of  these  problems,  there  are  again,  it  seems 
to  us,  insuperable  difficulties  in  regarding  the  eventual  lymph  of  the 
K  iii|)ii  vessels  as  a  filtrate  or  product  of  diffusion.  The  ultimate  lymph 
vessels  are  so  delicate  that  we  fail  to  recognize  their  existence  in  ordinary 
sections,  even  under  high  powers.  We  utterly  fail  to  conceive  how  the 
result  of  increased  accumulation  of  lymph  in  the  tissue  spaces  can  result 
in  iiii  increased  filtration  of  that  lymph  into  these  delicate  vessels,  (^n 
tlie  coiitrarv-,  the  greater  the  interstitial  pressure,  the  greater  the  tendency 
fill-  these  delicate  channels  to  become  collapsed  and  obliteratetl.  AihI, 
ii^  :i  matter  of  fact,  the  extreme  tension  of  the  tissues  in  cases  of  advanced 
aii.isiirca  of  the  lower  limbs,  for  example — a  tension  so  great  that  the 
IviKjili  is  apt  to  ooze  through  the  deeper  layers  of  the  cutis  and  form 
•l)lil)s" — indicates  that  this  actually  hap[)ens.  But  in  other  cases,  as, 
ti  !  example,  in  inflammatory'  nedema,  we  obtain  a  marked  increase 
r:  ilie  discharge  of  lymph  through  the  lymph  vessels  coming  from  the 


■1 

!i  ■ 

M  i 

.1    ! 

1 

i  i 

:,    S 

106 


i4Ar^5^ACi4 


inflamed  area.  The  sunplest  and  moat  rational  conclusion  to  reach 
is,  that  ordinarily  the  lymphatic  endothelium  actively  absorbs  and 
secretes  the  interstitial  lymph  into  the  vessels,  and  that  under  certain 
conditions  this  secretion  is  increased.  Only  in  this  way  can  we  ima^^ine 
an  active  flow  l>ecoming  set  up  within  them.  And  if  we  are  forced  to 
pr«licate  such  powers  for  the  lymphatic  endothelium,  then,  by  analog-, 
we  must  suppose  that  the  capillary  endotheliirn  has  powers  of  a  like  onler, 
and,  with  Heidenhain,  must  endow  this  with  a  certain  grade  of  selective 
secretory  activity.  Indeed,  the  conception  of  the  tissue  cells  as  nourislieil 
not  directly  by  the  blood,  but  by  the  lymph,  would  seem  to  demund 
that  the  capillary  endothelium  of  the  various  tissues  abstracts  particular 
substances  from  the  circulating  blood  necessary  for  the  specific  metalio- 
lism  of  these  tissues,  and  passes  these  into  the  interstitial  lymph.  We 
cannot,  for  -xamp'^,  comprehend  the  extraordinaiy  pas.sage  of  fats  into 
the  milk,  unless  the  capillaries  of  the  mammary  gland  in  the  first  pliue 
possess  a  selective  power. 

Under  the  term  oedema  we  include  all  abnormal  .\ccumulation.s  of 
fluid  approximating  in  its  constitution  to  that  of  lymph,  and  occurring 
in  the  tissue  spaces  and  serous  cavities  of  the  body.  To  these  accuiniiia- 
tions  in  different  regions  special  names  have  been  given,  and  with  this 
newer  knowledge  we  can  divide  them  into  distinct  classes: 

1.  Anaurea,  or  interstitial  oedema,  as  of  the  limbs  and  body  wall. 
Ohamoiit  is  the  name  given  to  serous  infiltration  of  the  sulK-onjunctival 
tissue.     (Idema  glottidis,  to  anasarca  of  the  up|)er  portion  of  the  larvnx. 

2.  Accumulations  in  serous  cavities,  including  aacitat,  involving  the 
peritoneal  cavity;  hydrothorax  (the  pleural);  hydrocele  (the  tunica 
vaginalis);  hydroeephalai,  internal  and  external,  involving  the  ventricles 
of  the  brain  and  the  pia-arachnoid  spaces. 

3.  Accumulations  of  albuminous  fluids  which,  strictly  speaking;,  are 
outside  the  body,  i.  e.,  affect  surfaces  in  direct  communication  with  the 
exterior.    The  important  example  of  this  form  is  pulmonary  oedcnia. 

A  little  consideration  shows  that  in  these  three  classes  we  have  three 
different  orders  of  rccumulations: 


3       !' 


ANASARCA. 

The  essential  feature  of  the  anasarcous  state  is  the  excessive 
accumuktion  of  intercellular  lymph.  In  other  words,  the  discliarge 
of  this  lymph  into  the  lymphatic  vessels  has  not  kept  pace  with  the 
formation  of  lymph  by  passage  of  fluid  through  the  capillary  walls. 
Examination  of  dropsical  tissues  under  the  microscope  shows  the  indi- 
vidual cells  composing  the  tissue  widely  separated,  in  con.sequeii<  «•  of 
the  intercellular  accumulation.  What  is  characteristic  is  that  the  lym- 
phatic vessels  are  not  obvious.  On  the  contrar}*,  the  absence  of  distt  .ided 
lymph  vessels  suggests  that  the  interstitial  pressure  due  to  fluid  accunmla- 
tion  has  brought  about  a  relative,  or,  it  may  be,  a  complete  occlusidii  of 
the  delicate  lymphatic  channels,  and  that  one  of  the  factors  in  the  ron- 


ASCITES  AND  ALLIED  CONDITIONS 


107 


tinii()u»  and  progressive  intensity  of  anasai  >  is  this  local  obliteration 
of  (hrse  vesseb.  A  comparison  between  :iectiuns  from  simple  ana- 
san-u  anil  those  from  elephantiasis  or  macroglassia,  due  to  acquired  or 
inli*'ri(e<l  obstruction  of  the  lymph  vessels  of  u  part,  shows  that  we  have 
to  lirul  with  two  dlttinct  conditions,  namely,  of  (1)  interstitial  tissue 
ai'ciiinulation  of  lymph,  and  (2)  lymphangiectasis,  or  distension  of  the 
Ivmuh  vesseb.  Even  prior  to  a  knowledge  of  the  barrier  separating  the 
Ivtnpii  spaces  from  the  lymph  vesseb,  it  had  become  recognized  that 
this  latter  condition  was  a  separate  entity,  although  it  had  been  in  gen- 
eral neglected  in  the  discussion  of  nedema.  In  the  exbtence  of  these 
two  pathological  states  we  possess  the  confirmation  of  the  conclust  n 
reaclit'd  by  MacCallum  and  the  anatomists. 


AIOITIS  AHD  ALLIED  OOHDITIOITB. 

Tlie  serous  cavities  are  lined  throughout  by  an  endothelium.  It 
follows  thus  that  serous  fluid  accumulations  within  them  have  passed 
through  not  one  but  two  endothelial  layers  in  the  process  of  production. 
To  this  extent  they  correspond  with  lymph-vascular  lymph.  Here 
again  wo  note  that  there  may  be  pronounced  (interstitial)  oedema  of 
the  intestines,  with  little  or  no  ascites,  and  vice  versa.  As  to  how  the 
ascitic  and  pleural  fluid  gain  entrance  into  the  efferent  lymph  vesseb 
pro|)er  is  still  a  matter  of  debate.  ITie  more  recent  teaching  is,  that 
under  normal  conditions  the  peritoneal  cavity  is  closed  off  from  the 
underlying  efferent  lymphatic  channeb,  and  that  an  endothelial  layer 
covers  over  the  apparent  ostia.  We  find  it  difficult  to  harmonize  this 
teachinj;  with  the  abundant  injection  of  the  diaphragmatic  lymph 
channels  with  retl  blood  corpuscles  which  rapidly  follows  the  introduction 
of  l)lo(xl  into  the  peritoneal  cavity.  Such  abundant  passage  can  only, 
we  hold,  he  due  to  the  existence  of  actual  stomata,  or  channels  of  direct 
coniinunication,  and  we  have  explained  the  curious  minute  hemispherical 
pits  (Mcasionally  observable  in  plastic  exudates  covering  the  dome  of 
the  hver  as  caused  by  eddies  opposite  to  those  stomata  in  the  diaphragm. 
While  saying  this,  we  cannot  pass  over  the  evidence  adduced  by  Mac- 
CidhKu  and  others  that  sections  through  the  diaphragm  demonstrate 
tlie  p;  -scnce  of  I  distinct  membrane  separating  the  diaphragmatic 
lyni|(!iatics  from  tnt  peritoneal  cavity.  The  only  satisfactory  com- 
promise would  seem  to  consist  either  in  concluding  that  under  certain 
coiidiiions,  by  retraction  or  contraction  of  the  endothelial  cells  constitut- 
inj;  (II  affording  the  membrane,  what  had  been  an  intact  membrane 
l>e(  (iims  ])rovided  with  a  central  stoma  or  passage  of  direct  communica- 
tion (ir  that  there  exbts  normally  a  combination  of  intact  membranes 
ami  iK.asional  scattered  stomata.  We  confess  that  the  latter  view 
ill-  -  iii)t  appeal  to  us;  the  existence  of  lining  membranes  would  seem  to 
prniir;ite  a  certain  selective  function  and  control  of  the  composition  of 
til  •  'icrent  lymph;  that  of  coarse  pores  or  stomata  would  be  diametri- 
i  ii  1 !  \  .  I  >posed  to  any  such  selective  action.    On  the  other  hand,  the  exist- 


108 


PULMOSARY  (EDEMA 


enre  of  potmtial  .ntomata,  which  at-t  ait  wein,  closed  timirr  normal 
toiHiitioiiM,  hut  |)ermitting  the  fret*  )itt.iia|{«  cif  fluid  and  fn-i!  partuin 
whm  the  intraperitcnieal  preswure  l>ec-omeH  exrewive,  would  Mem  not 
irrational.  We  bring  thew  matters  forward  at  this  point  in  onlir  to 
indicate  that,  acconling  to  the  (Hie  view,  accumulations  in  serou.t  cuvitin 
are  distinct  from  lymph-va.<<oukir  lymph;  acronling  to  the  other,  the 
normal  existence  of  a  dividing  membrane  would  indicate  that  ii-nlrr 
more  natural  conditions  there  may  Ite  essential  differences  in  the  (Dm. 
position  of  the  two  fluids,  although,  under  abnormal  conditions,  the 
contents  of  the  serous  cavities  may  pass  unchanged  into  the  etftTnt 
lymphatics.  \Ye  regret  that  in  the  present  state  of  our  knowlnlge 
it  is  impossible  to  atford  dogmatic  teaching  on  thU  point.  The  fart 
t^at  in  a  hydrocele,  or  in  a  case  of  ascites,  the  fluid  may  accumulate 
until  there  Is  verj'  high  pressure  Is  not  to  l)e  brought  forward  on  one  niile 
or  the  other;  there  might  be  abundant  stomata,  and  nevertheless  the 
pressure  be  such  as  to  oliliterate  the  underlying  network  of  delicate  lymph 
channels,  and  thereby  arrest  the  outflow.  'ITiere  is,  however,  one 
striking  feature  in  connection  with  simple  transudates  (as  distinct  from 
inflammatory  exudates)  into  the  serous  cavities,  namely,  th^t  they  con- 
tain much  less  soli<ls  than  either  serum  or  ordinary  lymph  i  >  reduction 
being  specially  marked  in  uUiuminous  matter.  This  in  itse  may  justifv 
us  in  considering  them  as  constituting  a  class  apart. 


rUIMOHART  (IDmA. 

There  can,  however,  be  no  doubt  as  to  the  necessity  of  rejfiirding 
pulmonary  (rdema  as  belonging  to  a  distinct  class.  That  fluid  is  ulways 
pouring  from  the  pulmonary  capillaries  into  the  alveoli  is  clearly  shown 
by  the  abundant  niui.^uire  contumed  in  the  expired  air;  the  accumulation 
of  serous  fluid  in  the  alveoli  is,  therefore,  only  to  be  regarded  as  an  exag- 
geration of  a  normal  process.  What  is  distinctive  is  that  here  the  aceu- 
mulation  of  fluid  is  not  interstitial,  but  is,  strictly  speaking,  external 
to  the  body;  the  discharge  is  on  to  surfaces  communicating  with  the  ex- 
terior. It  is  not,  therefore,  determined  by  any  force  acting  t»u  the 
capillaries  from  without;  neither  diffusion  nor  osmosis  can  be  cullcil  into 
play  to  determine  the  «li.scharge.  What  is  more,  the  delicate  alveolar 
epithelium  is  so  «lire<"tly  applied  over  the  capilhiry  network  that  we 
appear  to  have  a  relationship  similar  to  that  seen  in  the  glomenili  of  the 
kidneys,  with  a  practical  absence  of  intervening  lymph  space  lifiween 
vessel  and  epithelium.  Here,  then,  again,  we  have  a  different  order  of 
conditions. 

Briefly,  while  it  is  impossible  not  to  be  impresse<l  by  Professor  Star- 
ling's valiant  support  of  Liidwig's  mechanical  hypothesis,  a  studv .  more 
particularly,  of  actual  clinical  cases  of  (edema  cannot  but  couMiaeUi 
that  this  hypothesis  does  not  satisfy.  Pressure  plus  variation  in  per- 
meability alone  will  not  explain  the  great  varieties  of  cases  in  which  we 
encounter  the  cedematous  state,  nor  the  variations  in  the  constitution  of 


kttL 


COSOgSTIVK  (KDEMA 


109 


thr  ii'dfiiui  fluid.  It  will  not,  for  rxamplp,  rxplain  \jAtn'»  experim«it,' 
in  wliich  hr  showed  that  the  t-oniea  with  intact  epithelium  of  the  mem- 
hraiio  iif  IHwetnet  will  .ttand  a  preiMure  of  2()U  mm.  o>*  mercury,  whereas, 
oii(<'  iliHt  qiithelium  is  removed,  solutions  readily  filter  throuf^h;  or 
the  oliservatiotis  of  Tifferstetit  and  Sante<i<«on  that  the  freshly  removed 
lnn);i)f  a  frof(  filial  withU.fi  per(*ent.  NaCI  solution  will  .stand  a  pressure 
of  14  mm.  of  mercury  for  .several  hours  without  any  escajH"  of  the  con- 
tainnl  flui<l,  whereas  the  same  lung  kille«l  by  .slight  heat,  or  by  pouring 
in  iii.Htilleil  water  or  (frog's)  bile,  at  once  allows  filtration. 

Something  is  neceivwry  to  explain  the  sudden  change  in  the  porosity 
of  thj-se  membranes  over  and  alwve  the  onlinary  physical  laws  deter- 
mining the  rate  of  filtrati«m  thrnugh  dead  membrane's. 

Wc  are  apt  to  reganl  the  endotiielial  cells  of  the  vessels  and  i  pitlaries 
a.s  i)f  an  extraonlinarily  l.)W  tyjie,  as  flattened  plates  of  cytoplasm  and 
little  more;  on  the  other  hand,  we  admit  freely  that  Iwcteria,  organiama 
much  more  minute,  and  of  a  much  lower  type  of  .stnicture,  pos.sess  selec- 
live  ussimilstive  powers.  The  position  is  irrational.  These  endothelial 
cells  arc  nucleated;  they  are  actively  phagocytic;  can  proliferate  actively; 
and,  as  obsened  in  inflammatory  states,  are  acutely  sensitive  to  changes 
in  their  environment.  While  admitting  that,  other  things  l>eing  equal, 
they  |HTniit  a  more  active  passage  of  plasma  under  a  higher  pressure, 
ami  conform  in  many  respects  to  the  laws  governing  filtration,  diffusion, 
anil  o.>.nasis,  it  mu.st,  we  think,  be  concluded  that  certain  .substances 
are  taken  up  by  them  selectively,  while  at  times  other  substances  -  f  equal 
solubility  are  not  taken  up.  We  feel  some  compunction  in  dealing 
thus  so  largely  in  generalities.  The  subject  is  most  complicated,  and 
to  analyze  conscientiously  the  data  at  our  disposal  would  consume 
more  space  than  we  can  afford.  At  most,  keeping  these  views  in  mind, 
we  believe  that  the  different  forms  of  oedema,  and  the  variations  seen  in 
these,  become  more  comprehensible.    These  forms  are: 

1.  OongSStive  (Edema. — This  is  the  commonest  clinical  type,  and 
is  seen  in  cases  of  obstruction  to  the  venous  onflow,  either  local  c  ■■: 
gen  nil.  The  most  extensive  cases  are  .seen  in  obstructive  heart  diseas;.. 
in  such  cases  there  is  (a)  increased  venous  pressure,  (6)  increa.se  in  the 
total  amount  of  blood  within  the  ves.sels,  (c)  dilatation  of  the  capi"aries 
and  iiicrease<l  capillary  pressure,  (rf)  .slowing  of  the  blood  stream,  {e) 
incrciists!  venosity  of  the  capillary  bloo«l.  The  increased  capillary 
pressure  is  here  not  the  sole  factor.  Thus,  nvlema  does  .lot  ensue  if 
the  main  vein  of  a  limb  be  ligatured  in  a  healtliy  animal.  Again,  the 
variitijoii  in  albuminous  contents  is  too  great  to  be  ascribe«l  to  mere 
diircrciicc  in  the  permeability  of  the  cppillary  wall.  As  shown  by  Reuss, 
plciirnl  fransudi..ions  on  the  average  contaui  four  times  as  much  albumin 
a^  do  liiose  from  the  sul)cutaneous  tissues,  and  twice  as  much  as  does 
av;ii(  fluid.  We  are  forced  to  the  conclusion  that  the  cells  in  these 
dip-  I  nt  regions  have  a  varying  sensibility,  ond  are  affected  differently 


1 1  r,  Archiv  f.  Ophthalm.,  19: 1873: 125.    TigcrsteJt  and  Santesson,  Bijhang 
..  Sv.nsk.  vet.  Akad.  Stockholm,  11: 1886:  No.  2. 


; 


iji 

:    i; 

110 


o:dema 


\ 


by  the  increaseil  veiiosity  of  the  blood.  It  may  further  be  noted  that 
there  are  pronounce«l  individual  differences  in  the  reaction  to  one  and 
the  same  lesion.  Thus,  long-continued  mitral  stenosis  commonly 
results  in  ptdmonary  oedema;  we  have,  nevertheless,  encountered  two 
cases  of  this  disease  in  which,  with  extreme  anasarca  and  ascites,  tliere 
has  been  inconsiderable  hydrothorax,  and  the  lungs  have  been  <i«'void 
of  serous  effusion.  Cases  of  advanced  anasarca  with  little  or  no  ascites, 
and  of  the  converse  condition,  are  far  from  infrequent. 

2.  Lymphatic  Obstruction. — ^The  accumulation  of  fluid  in  the  spaces 
of  the  body  is  dependent  on  the  interaction  of  two  factors — the  rate 
of  discharge  of  fluid  from  the  bloodvesseb  and  the  rate  of  removal. 
If  the  latter  be  less  than  the  former,  then  an  redematous  condition  must 
develop.  We  should  then  expect  a  priori  to  find  that  lymphatic  obstnic- 
tion  is  a  potent  cause  of  oedema.  But  this  is  not  the  case.  The  main 
lymphatics  of  a  part  may  be  ligatured  or  compressed,  and  yet,  as  ii  nile, 
no  tt'dema  occurs.  Even  when  the  thoracic  duct  is  ligatured,  ascites 
may  develop,  though  slowly,  yet,  as  Cohnheim  rhowetl,  oedema  does 
not  result.  Two  factors  are  responsible,  namely,  the  existence,  in  many 
cases,  of  abundant  collateral  channels,  and  the  reabsorption  of  the 
tissue  lymph  into  the  bloodvessels.  And  the  latter  would  seem  the  more 
important— so  important,  i  fact,  that  we  seem  justified  in  regiiniinj; 
the  lymph  channels  not  as  the  prime,  but  as  an  accessory-  factor  in  tissue 
drainage,  with  the  ad<litional  function  of  removing  selectively  certain 
products  of  metabolism.  Even  during  the  process  of  bleeding  an  animal 
to  death,  the  last  portions  of  blood  are  much  more  waterj'  than  the  first, 
a  fact  which  can  only  be  explaineii  by  the  passage  of  tissue  fluid  into  the 
circulation  through  the  capillary  walls.  And  as  shown  by  Roy  and  Lloyd 
Jones,  after  less  extreme  hemorrhage,  the  specific  gravity  of  tin  tissues 
becomes  rapidly  raised,  that  of  the  blood  diminished.  The  exc  liange 
of  fluid  between  the  surrounding  tissues  and  the  blood  may,  nay,  must, 
be  mast  considerable.  This,  first  demonstrated  by  Magendie,  has  been 
convincingly  shown  by  Starling  and  Tubby.' 

Methylene  blue  or  indigo  carmine  injected  into  the  pleural  cavity 
appeared  in  the  urine  within  five  minutes,  whereas  the  lymph  presented 
no  trace  of  coloration  for  another  twenty  minutes,  or  it  might  lie  two 
hours.  Lymphatic  obstniction  alone  is  thus  little  likely  to  cause  (iilcnia. 
It  is  true  that  occasionally  we  meet  with  this  condition  following olvsiruc- 
tion ;  'hus,  secondare'  cancer  of  the  axillary  glands,  with  the  not  inf  n  (pient 
extension  of  the  malignant  growth  along  the  lymph  channels,  or  extensive 
removal  of  the  axillary  lymphatic  chain,  may  be  followed  by  u'dcnia  of 
the  arm.  But  this  is  not  a  necessary  outcome,  and  where  it  occurs  we 
must  conclude  that  hydremia,  or  a  toxic  con<lition  of  the  bl«nl,  with 
altered  state  of  the  capillary  endothelium,  is  superadded. 

As  already  noted,  where  there  is  lymphatic  obstruction  there  the 
vessels  Iwhind  the  obstniction  are  apt  to  be<omr  dilated;  and  fnn!!  these 
dilated  vessels  it  is  evident  that  fluid  may  escape  into  the  tis.sue-  and 


'  Jour,  of  Physiol.,  1(5: 1894: 140. 


INFLAMMATORY  (EDEMA 


111 


spacrs  of  the  body.  This  b  often  to  be  determined  where  there  has  b<^en 
cancerous  or  tuberculous  growth  involving  the  region  of  the  receptaculum 
rliyli.  Radiating  from  the  affected  area  are  distended  lymph  vessels, 
or  wliite  strenks,  filled  with  semisolid  inspissated  lymph,  consisting  of 
fat  droplets  and  cell  debris.  This,  it  may  be  noted,  only  in  the  upper 
alxlominal  area;  to  our  knowledge,  this  inspissation  is  never  encountered 
in  cases  of  lymphangiectasis  of  the  limbs  or  face — a  further  evidence  of 
the  selec-tive  activity  of  the  lymph- vascular  endothelium. 

Chylous  Ascites. — Did  the  lymph  vessels  communicate  freely  with 
the  tissue  spaces,  we  should  expect  as<-itic  fluid  to  approximate  in 
com[K)sition  to  the  chyle  in  the  alxlominal  lymphatics;  but  this  is 
notoriously  not  the  case  under  onlinary  circumstances.  Under  abnormal 
conditions  we  obtain  this  approximation.  A  condition  of  true  chylous 
ascites  is  found  in  cases  of  rupture  of  the  receptaculum  chyli,  the  fluid 
affording,  upon  analysis,  a  relatively  high  percentage  of  proteins  and 
fat,  tlie  latter,  though  small  in  amount,  giving  it  a  mill.y  appearance. 
llii|)ture  of  the  thoracic  duct  may  similarly  lead  to  chylous  hydro- 
tboraz  (of  the  renal  or  bladder  lymphatics  in  filariasis  and  other  states, 
to  chyluris).  The  thoracic  and  pleural  accumulations  may  occur  not 
only  tlirough  trauma,  but  through  inflammatory  erosion,  or  sometimes 
as  the  result  of  obstruction  and  dilatation. 

Ghyliform  Ascites. — The  above  condition  is  with  some  difficulty  to 
he  distinguished  from  one  seen  occasionally  in  low  forms  of  serous 
peritonitis,  most  frequently  due  to  alxlomiiml  carcinoma  or  tuberculosis, 
in  wiiich  the  fluid  becomes  milky  from  fat  liberatetl  by  the  breaking  down 
of  leukocytes  and  endothelial  cells  which  have  undergone  fatty  degenera- 
tion. Tl>e  percentage  of  fat  is  in  general  high  (as  high  as  6  per  cent, 
in  some  cases,  compared  with  Q.H  per  cent,  and  less  in  true  chylous 
ascites).  Sugar  and  diastatic  enzymes,  frequently  to  be  detected  in 
tiie  former  condition,  aie  absent  in  this. 

Pseudochylous  Ascites. — More  frequent  than  either  of  these  states 
is  tliat  termed  pseudochylous  ascites,  in  which  the  milky  fluid  simulating 
diylc  is  found  to  be  free  from  fats.  There  has  l)een  much  obscurity 
as  to  the  cause  of  the  turbidity;  in  some  cases  it  is  apparently  due  to 
the  [ireseiice  of  mucoid  suKstances;'  in  others,  it  would  seem,  to  partly 
dissolved  proteins.'  Joachim  aseriljes  it  to  a  combination  of  lecithin  and 
pseiiiiofrjobulin.' 

.{.  Inflammatory  (Edema. — In  this  group  of  ocdcmas  either  we  can 
recdfrnize  under  the  microscope  changes  in  the  endothelial  lining  of  the 
capilhiries,  to  which  we  ascrilie  largely  the  increased  transudate  (exudate), 
or  l.y  analogy  we  hold  that  changes  of  like  onler  must  obtain.  The  type 
ewiinpie  is  to  be  seen  in  acute  inflammation.  In  this,  in  addition  to 
aridiid  and  capillary  dilatation,  the  capillary  endothelium  is  swollen 
and  more  prominent,  and  there  arc  other  indications  of  alteration  in  the 


'  Gourami  and  Corset,  Compt.  Kend.  Soc.  Biol.,  (iO;  19()(i:23. 
'  PoljakolT,  Fortschr.  d.  Med.,  21: 100.}:  1081. 
•Joachim,  Uiochcm.  Centralbl.,  1:1903:437, 


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112 


ffiDBMA 


state  of  these  cells,  such  as  adhesion  of  the  leukocytes  (suggestiii};, 
as  Wells  has  pointed  out,  an  altered  surface  tension),  and  nuclear 
enlargement  and  proliferation.  Associated  with  these  various  changes 
we  find  increased  pouring  of  fluid  from  the  tissues  along  the  lymphatics, 
higher  proteid  content  of  the  discharged  lymph,  and  increased  cell 
contents,  both  leukocytes  and,  it  may  Ix-,  red  corpuscles.  Such  modified 
transudate  is  termed  an  exmlate.  In  constitution  it  approaches  more 
nearly  to  the  blood  plasma  than  does  congestive  oedema  fluid.  It  lias, 
however,  to  be  admitted  that  in  different  inflammations  we  find  every 
transition  from  fluid  of  the  one  type  to  the  other,  and  that  in  practice 
it  is  at  times  practically  impossible  to  state  with  precision  whether  we 
deal  with  a  hydrothorax,  for  example,  or  a  mild  form  of  serous  pleurisy. 

There  can  be  little  doubt  regarding  physical  changes  in  the  capillaries 
being  responsible,  to  a  very  large  e:  ■  -nt,  for  the  increa.sed  transudate :  the 
increased  intracapillary  pressure,  the  dilatation  and  thinning  of  the 
capillary  walls,  the  dilatation  of  the  stigmata  of  the  vessels,  or  formation 
of  stomata  or  passages  where  the  leukocytes  and  re<l  corpuscles  pass  out. 
Such  gross  openings  in  the  ca,.iilary  wall,  when  present,  must  necessarily 
cause  the  exudate  to  approximate  in  composition  to  the  blood  plasma. 
At  the  same  time,  the  indications  of  reactive  change  in  the  entlothelial 
cells  at  least  suggest  the  co-existence  of  some  amount  of  .selective  activity 
on  the  part  of  the  endothelial  membrane,  while,  at  the  same  time,  the 
enlargement,  nuclear  and  cytoplasmic  changes  in  the  tissue  cells  of 
the  inflamed  area  suggest  an  altered  interchange  lietween  them  and  the 
tissue  lymph,  and  that  the  resultant  lymph-vascular  lymph  is  much  more 
than  the  result  of  mere  filtration,  diffusion,  and  osmosis. 

4.  Toxic  (Edema. — Intimately  allied  to  this  last  is  the  group  of 
toxic  oedemas.  As  Heidenhain  demonstrated,  there  is  a  cla.ss  of  sulj- 
stances  which  act  as  lymphagogues,  i.  e.,  circulating  in  the  bloo<i,  set 
up  incrcascil  lymph  formation  in  sundry  areas.  Some  of  these  set  up 
alterations  in  blood  pressure  which  may  be  an  important  factor,  hut 
others  (curare,  extract  of  mussels,  crab,  etc.)  induce  lymph  flow  in  the 
absence  of  noticeable  change  in  the  circulation.  The  logical  conclusion 
is  that  they  act  directly  on  the  vascular  endothelium  of  certain  arca-s, 
moclifying  -'ts  properties.  It  is  the  custom  to  describe  these  IkxIIcs  as 
having  a  toxic  action;  the  difficulty  is  where  to  draw  the  line  Ixtwcen 
stimulation  and  irritation.  Thus,  it  may  l)e  laid  down  as  a  rule  tliat 
increaseil  glandular  activity  is  accompanied  by  marked  increase  in  lyinpli 
flow.  This  is  notably  the  case  in  the  liver.  It  is  scarcely  to  l)e  iniaiiiiKii 
that  when  in  the  course  of  its  normal  function  the  liver  removes  ilile- 
terious  agents  from  the  portal  bliHxl,  we  are  dealing  with  a  diseased,  toxic 
state  of  the  capillary  endothelimn.  Rather  we  nmst  conclude  that  that 
possesses  a  selective  capa<'ity;  that  certain  substances  containe<l  in  the 
portal  blood  stimulate  it,  and  that  only  when  these  are  in  e.\(<s.s  is 
there  an  overstimulation  and  toxic  state  of  the  ceils  induced,  \\hile 
saying  this,  we  have  also  to  n-cognize  that  lowered  vitality  of  the  i  lulo- 
thelium  is  accompanietl  by  increased  passage  out  of  fluid.  We  neeii  only 
recall  the  difference  in  transudation  U-tween  living  and  dead  meml"  nies, 


NEUROPATHIC  (EDEMA 


113 


A  well-marked  example  of  this  order  of  toxic  oedema  is  seen  in  the 
so-cuIKhI  iscliemic  uedema  supervening  after  prolonged  lowering  of 
the  l)i()od  supply  of  a  part  after  ligature,  compression  (as  by  Esmarch's 
barxlajif).  or  frostbite.  In  these  cases,  clearly,  the  inadequate  blood 
supply  has  deleteriously  affected  the  endothelium,  and  now,  upon  the 
lirciilation  being  resumed,  the  escape  of  fluid  into  the  tissues  is  extreme. 
Hut,  iulmittedly,  it  is  difficu'*  to  determine  in  every  case  which  of  these 
two  conditions  we  have  to  deal  with.  Thus,  we  are  still  undetermined 
wluTt-  t(i  place  one  of  the  most  common  examples  of  widespread  oedema 
and  anasan-a,  namely,  the  oedema  of  acute  parenchymatous  nephritis. 
This  differs  from  the  oedema  of  heart  disease  in  its  relatively  rapid  onset 
and  in  its  primary  distribution.  Thus,  a  favorite  seat  for  its  early  appear- 
and is  in  the  loose  tissue  of  the  orbit,  resulting  in  a  puffini'  s  around  the 
eyes.  Congestion  and  alteration  in  blood  pressure  cannot  explain  its 
development,  and  the  experiments  of  Cohnheim  and  others  prove 
definitely  that  mere  hydremia  will  not  reproduce  the  condition.  We 
ran  only  conclude  that  in  consequence  of  the  renal  incompetence  certain 
toxic  substance  circulating  in  the  bloo<l  have  a  more  or  less  specific 
action  upon  tht  vascular  endothelium  of  certain  areas.  But  what  is 
the  nature  of  this  action  we  do  not  know — whether  depressant,  lowering 
the  vitality,  or,  on  the  contrary,  stimulant,  leading  to  the  active  altsorption 
and  removal  of  fluid  plus  toxic  substances  from  the  blood  stream. 
The  matter  has  to  be  left  sub  judice. 

.').  Neuropathic  (Edema. — Here,  in  connection  with  «i>dema,  as 
with  inflammation  and  so  many  other  processes,  we  find  that  nervous 
influences  alone  can  set  up  disturbances  of  the  same  type  as  those  due 
to  local  irritation.  We  may  encounter  ( 1 ),  as  we  have  already  pointed 
out  (vol.  i,  p.  410),  a  collateral  or  sympathetic  (edema  in  the  areas  inner- 
vated from  the  same  region  of  the  brain  or  cord  as  that  controlling  a 
focus  of  acute  inflammation,  or  (2),  in  association  with  definite  nerve 
lesions,  may  find  onlema  of  particular  fields  of  ner\e  supplv,  as  in 
herpes  zoster.  But  in  additicm  to  these,  and  unassociated  with  Mriv 
api)arcnt  inflammatory  disturbance,  we  meet  with  a  remarkable  se.i<', 
of  angioneurotic  asdemas  exhibiting  sudden  and  acute  pouring  out  of 
fluid  nito  particular  areas,  for  which  we  can  ascril)e  no  cause  other  than 
nervous  influence  upon  the  vessels  of  the  part.  It  is  true  that  the  line 
distuijjuisliing  these  from  the  urticarias  of  cases  of  idiosviicrasv  is  not 
alwiiys  easy  to  draw.  In  the  latter  the  exhibition  of  certain  foods,  even 
ui  iniMute  an  ounts,  leads  to  local  vascular  disturbances  with  infiltration 
and  siilxiitaneous  or  submucous  swelling.  Underlving  this  there 
woiiM  siym  to  lie  a  neurotic  influence,  though  the  suggestion  has  of 
late  t.clved  crt-dence  that,  as  in  .serum  sickness,  some  substance 
prcMiii  III  the  circulating  blood  in  minute  quantities  has  a  specific 
l,viui.li,ijr„g„e  action  upon  the  endothelium  of  the  ves.sels  of  particular 
rcL'!.!:  lint  as  in  hay  fever,  and  in  lliosc  severely  affected  by  the  mere 
pn><  im.  of  ,1  eat  in  their  neighborhood,  acute  local  cwlematous  condi- 
tiois  iiwy  be  inducetl  by  influences  acting  through  the  respiratory 
sv  '    1,  which  It  is  difiicult  to  attribute  to  any  but  pure  reflex  nervous 


:l  l 


!|        I 


(      il 


114 


(EDEMA 


influence,  with  vascular  instability  of  particular  regions.  An  important 
group  of  spasmodic  asthmas  would  seem  to  come  mto  this  catcRon-, 
at  least  in  part,  due  not  merely  to  constriction  of  the  bronchial  muscula- 
ture, but  also  to  sudden  congestion  and  <Edenm  of  the  bronchial  iniicous 
membrane.  It  would  thus  seem  necessary  to  distinguish  a  class  ..f  pure 
angioneurotic  (edemas  from  that  of  the  idiosyncratic  cedemas  of  what, 
failing  a  l)etter  term,  we  must  still  refer  to  as  toxic  in  origin. 


I-Kl.    14 


Urticaria  factitia  (angioneuro»i!.).      (Hyde  and  Ormsby.) 


().  Hydrops  ex  Vacuo.  -Lastly,  reference  must  be  made  to  the 
condition  in  whicii,  with  atrophy 'of  tisiues,  there  is  rcpiiucnunt  by 
lymphatic  fluid.  Practically  the  only  region  in  which  this  is  rcco^jnizalilf 
is  in  the  brain  case  and  yertchral  canal  following  upon  shrinka>:i'  of  the 
brain  and  cord.  Here  clearly  the  lack  of  pressure  must  be  ll..'  main 
reason  why  the  extravasated  cerebrospinal  fluid  fails  to  Ik.-  (liMliar(:ed 
into  t  -e  Ivmph  ycssels,  and  as  a  consequence  accumulates.  Mhvd  u> 
this  is  what  we  may  term  tiie  rrplarcmnit  ///yr/rop^ seen  in  the  d.'vtlop- 
ment  of  necrotic  and  iiemorrliagie  cvsts  (yoi.  i,  p.  7!).'>). 

From  the  above  recital  it  is  obvious  that  0)  the  time  lia.  not  yet 
arrived  to  lav  down  any  broadly  simple  laws  regarding  tlu'  i.  .tiirc  o 
cedema,  and  thft  (2)  we'niust  reeogni/.e  a  varying  interaction  «i  s.veral 
factors— blofxl  pressure  and  filtration,  ditfusioti.  osmosis,  llic  xlretive 
activity  of  the  vascular  endothelium,  the  tissue  cells,  and,  it  imy  well  be, 
the  endothelium  of  the  Ivinph  vessels.  .Much  has  still  to  be  <t"n.'  W* 
we  can  speak  with  precision  of  the  relative  value  of  thes.'  ditterent 
agencies. 


CHAPTER    VI. 

THE  CARDIO-VASCULAR  SYSTEM. 

OABDIAG  FXTNGTION  AND  ITS  DISTUBBANGZS. 

\\r.  must  take  for  grantetl  a  knowlp(lj,'e  of  the  gross  anatomy  of  the 
heart,  here  merely  recalling  (1)  that  the  weak  muscular  tissue  of  the 
auricles  is  independent  of  the  stroi  _'  musculature  of  the  ventricles  save 
for  a  small  connecting  bundle  first  noted  by  Stanley  Kent,  and  later  by 
the  younger  His.  As  we  shall  see,  this  bundle  plays  an  important  part 
in  the  regulation  of  the  heart  Ijeat;  (2)  that  the  musculature  of  the 
ventricles  is  not  entirely  independent,  there  l)eing  an  extensive  crossing 
of,  more  [)iirticularly,  the  outer  bundles  from  the  one  ventricle  to  the 
other,  will  ichy  it  comes  to  pass  that  the  work  of  the  two  ventricles  must 

e  largely  synchronous,  and  (.i)  that  we  have  evidence  of  the  existence 
of  both  motor  and  sensory  nerves  in  association  with  this  organ.  Fillers 
pass  to  tiie  root  of  the  heart  from  both  vagi,  others  again  from  the  upper 
dorsal  sympathetic  ganglia;  and  by  physiological  methods  we  have 
determined  the  existence  and  some  of  the  functions  of  nerve  bundles  of 
different  orders. 

.\s  Inuring  upon  disturbed  function,  certain  coasiderations  regarding 
the  pliysiology  of  the  heart  demand  .somewhat  fuller  treatment.  As 
a  meclianism  for  the  propulsion  of  the  blood,  we  observe  in  that  mechan- 
ism ( 1 1  chambers  for  the  collection  of  the  blood;  (2)  the  motor  apparatus 
proper  for  the  propulsion  of  the  blood;  (3)  valves  to  determine  that  the 
blood  i  ischarged  in  a  particular  direction,  so  that  the  heart  being  inter- 
polate 1 1  111  a  .system  of  closed  vessels,  a  circulation,  and  not  merely  a  flow 
and  el>l)  of  the  blood,  is  assuretl. 


1.  THE  CARDIAC  CHAMBERS. 


Till'  lit' 
or  morr  ; 
trinilur  ( 
the  niii^c 
more,  \\i 
orii,'iiiiiii- 
vcntvi: !:  . 
anrc  uf 
Fiirtlvr. 
wave  ;- 


art  is  a  double  pump,  each  moiety  consisting  of  twi  uambers, 
iccurately,  of  an  auricular  antechaml)er  lending  into  the  ven- 
liaml)er,  or  pump  proper.  Undoubtedly,  the  auricles,  through 
Ic  in  their  walls,  do  act  as  pumps  propelling  the  hlootl;  nay, 

possess  ample  evidence  that  the  normal  cardiac  contraction 
-  at  the  venous  ostia,  where  the  vena;  cavic  open  into  the  right 
and  that  the  aiiricnliir  muscle  is  essentia!  for  the  due  convey- 
ilie  wave  of  contraction   from  this  region  to  the  ventricles. 

(hire  is  evidence  that  in  certain  siates  the  auricular  pulse 
kinonstrable  in  the  arterial  pulse,  or,  otherwise,  the  eflfect  of 


Wi 

■  E           ! 
:             :: 

I 


116 


THE  CARDIAC  CHAMBERS 


the  contraction  of  the  auricnlur  muscle  Is  then  sufficiently  i-  /w.rtul 
to  lie  fonveveil  through  the  ventricular  hUxxl  into  the  column  of  a<.rtic 
bl«Kl.  But  admitting  this,  it  ha.s  also  to  l)c  admitteil  that  the  inus- 
cular  contraction  of  the  auricular  walls  is  not  the  dominant  force  Icad- 
iuK  to  the  fillinc  of  the  ventricles.  It  is  but  necessary  to  observe  the 
auricles  of  the  ex{Kxse«l  mammalian  heart  to  note  that  their  contnirtion 
is  inc-omplete;  that  it  does  not  empty  the  auricles  at  each  beat.  U  hat 
is  more,  we  have  accuuiulatetl  increasing  evidence     te  p.  U.i)  that 

Fia.  15 


Thrombus  completely  fillii.K  the  left  ounele  exrepl  f..r  two  passanes;   1  and  3  re|.r,-ent 
the  ihannel"  from  the  right  and  left  pulmonary  vein.i. 

the  ventricular  expansion  is  active,  and  that  a  large  proportion  of  the 
blo<Kl  filling  the  ventricles  enters  it  U-forc  the  auricular  systole  <<m\rs\ 
in  other  words,  that  svstole  is  not  absolutely  essential  for  the  -mward 
passage  of  the  bl(Mxl;  at  most,  when  thn)ugh  the  progmssive  filluijr  and 
expansion  of  the  ventricle  the  active  diastole  is  U-coming  w.iik,  the 
auricular  contraction  acts  as  a  final  but  auxiliary  force  whereby  ih.  intra- 
ventricular blood  pressure  is  raised,  and  thereby  (we  would  hold )  ''"»"•*>• 
matic  or  idiomuscular  contraction  of  the  ventricular  muscle  is  stimiihited, 
or  perhaps,  more  accuratelv,  the  muscle  fibers  are  placed  in  tli.sl  tense 


M 


ABNORMALITIES 


117 


state  which  favors  contraction  following  upon  a  minimal  stimulus. 
Thorc  arc,  indeed,  cases  in  which  obviously  the  auricles  are  incapable  of 
extitiii),'  any  propulsive  action,  and,  nevertheless,  the  circulation  continues. 
Thus  wc  have  seen  the  left  auricle  completely  filled  and  distended  with 
blood  dot  save  for  two  passages  leading  from  the  right  and  left  pul- 
raonarv  veins  respectively  to  the  ventral  orifice.  In  this  case,  judging 
from  the  appearance  of  the  thn»mbus,  the  auricle  mast  have  been  out 
of  action  for  days  rather  than  hours;  nevertheless,  the  circulation  was 
not  noticeably  impetletl.  An<l,  as  Ho«jver  points  out,  there  are  not  a  few 
ca-ses  rworded  by  veterinarians  in  which  the  auricles  in  the  horse  have 
k-eii  found  completely  rigid  from  universal  calcification.  Thus  we  are 
imliiifd  to  regard  the  auricles  as  essentially  antechambers  for  the 
gradiial  collection  of  blood  from  the  veins  prior  to  the  active  diastole  of 
the  ventricles.  Did  these  antwhamliers  not  exist;  did  the  thin-walled 
and  collapsible  veins  open  directly  into  the  actively  expanding  ventricles, 
then  the  suction  force  exerted  by  the  ventricles  would  tend  to  approxi- 
mate the  venous  walls  and  arrest  the  circulation  into  the  ventricles. 
These  collecting  chambers  prevent  any  such  catastrophe. 

Use  of  the  Ventricles. — These  are  essentially  the  pumping  apparatus 
of  the  circulating  system,  and  as  such  their  functions  are  best  coasidered 
umler  the  next  heading.  Here  we  would  only  note  that  their  walls  are 
far  from  rigid,  but  elastic,  and  that,  just  as  if  we  attach  a  weight  to  a 
n'stin>;  IkuuI  of  muscle,  such  as  the  gastrocnemius  of  a  frog,  we  find  that 
tlie  luind  undergoes  progressive  elongation,  so,  similarly,  if  through  posi- 
tive pressure  increasing  volumes  of  fluid  seek  to  gain  unimpeded  entrance 
into  the  ventricles,  or,  to  express  it  otherwise,  if  a  column  of  blood  of 
increasing  lengtli  l)ecomes  conntx-tinl  with  the  ventricular  cavity,  this  has 
thesauie  result — the  resting  muscle  expands  and  the  chamlK-r  undergoes 
<listeiision.  We  shall  have  more  to  say  reganling  this  when  we  come 
to  consiihT  the  subjects  of  hyjDertrophy  and  dilatation. 

Abnormalities. — The  most  serious  <listurbances  of  the  heart,  con- 
siiicrcii  us  a  series  of  chamlwrs,  occur  in  connection  with  certain  congenital 
vieis  of  development.  Although  the  heart  develops  into  the  two  distinct 
pumping  systems,  right  and  left,  already  note<l,  it  must  l)c  recalled  that 
at  an  early  stage  it  exists  in  the  embryo  as  a  two-chamliered  organ  with 
a  sitii;h-  auricle  and  a  single  ventricle.  By  a  very  complicated  series  of 
out^Towths  there  develop  septa  dividing  each  of  those  primary  chamliers 
into  two;  so  that  the  normal  state  after  birth  is  that  the  right  heart 
is  cimiijletely  cIosihI  off  from  the  left.  I'p  to  the  time  of  birth  the  sepa- 
nitinii  littween  the  two  auricles  is  wanting  to  this  extent,  that  there 
exi^l^  ,1  passage  or  foramen  (the  foramen  ovale)  whereby  the  bl(X)d  from 
the  iiitrrior  vena  cava  (more  particularly)  crosses  the  right  auricle 
ami  I  liters  t\\v  left.  In  quite  a  large  proportion  of  cases  this  undergoes 
imoiiiplete  postnatal  closure;  in  a  few  cases  it  remains  widely  open; 
or  ih, '  may  l)e  yet  more  incomplete  formation  of  the  interauricular 
sepiiii  .  In  all  these  cases  there  is  the  possibility  of  mingling  of  the  venous 
bliii!,!  iiteriiig  the  right  heart,  with  the  oxygenattnl  blood  entering  the 
left.     J  l.e  same  is  liable  to  happen  when  the  inter\entricular  septum 


118 


THE  MOTOR  APPARATUS 


is  imperfect.  Yet  grnver  dbturbances  ensue  when,  through  abnormal- 
ities in  the  division  of  the  originally  single  vessel  of  discharge,  wo  am 
a  long  series  of  anomalies,  from  mere  narrowing — congenital  stenosis— 
of  either  pulmonary  arterj'  or  aorta  to  conditions  of  complete  "Hechts- 
lage,"  in  which  the  systemic  arteries  are  supplied  with  blood  fmm 
the  right  heart,  the  pulmonary  arteries  with  blcixi  from  the  left.  Thesf 
abnormalities  in  the  growth  of  the  arterial  septum  dr)wnward  an-  vtrv 
frequently  associated  with  incomplete  development  of  the  interventricular 
septum  upward,  so  that  there  is  combinwl  free  communication  lx>t\veen 
the  two  ventricles,  with  consequent  admixture  of  venous  and  arterial 
blood. 

2.  THI  MOTOR  APPARATUS. 

Here  we  deal  essentially  with  the  ventricles,  and  of  these,  the  left 
ventricle  more  particularly  concerns  as. 

Arrangement  of  the  Muscle  Fibers. — In  the  first  place,  it  must  he 
noted  that  the  ventricle  does  not  contract  as  a  sphere  and  thus  IxTome 
narrowed  in  every  direction.  The  successive  layers  of  muscle  fillers 
are  so  arranged  that,  with  contraction,  the  length  of  the  left  vcntritle 
is  practically  unaltered.  The  form  of  this  ventricle  and  motle  of  con- 
traction are  such  that  in  systole  singularly  little  internal  pressure  is 
exerted  upon  the  apex.  It  is  a  fact  which  we  think  is  not  generally 
known  that  the  total  thickness  of  the  ventricular  wall  at  the  ajnx  of 
the  heart  is  little  more  than  one-eighth  of  an  inch.  The  arrangement 
of  the  fibers  and  the  motle  of  their  contraction  is  such  that  the  walls 
of  the  apical  half  are  brought  together  and  the  blood  propelled  upwanl. 
i.  e.,  toward  the  aorta.  Another  fact  not  generally  recognized  is  that 
the  left  ventricle  never  becomes  completely  emptied;  there  is  always 
left  some  of  what  Roy  antl  Adami  have  termed  residual  hltMKl.  As 
may  be  determined  by  inserting  the  little  finger  through  a  small  slit 
in  the  ajK>x  of  a  large  animal  that  has  l)een  cura»ized,  the  lower  half  of 
the  ventricle  contracts  tightly  round  it  in  systole,  but  alx)ve  the  level  of 
the  apices  of  the  papillary  muscles  there  is  a  persistent  chamlier. 

Two  accessory  muscle  systems  are  to  Ik-  noted,  the  papillary  (Albreelit). 
whose  function*  is  to  keep  taut  the  mitral  valve  and  prevent  this  from 
becoming  everteil  into  the  auricle;  the  fillers  from  this  pass  downward, 
then  laterally  and  forwanl  and  to  the  surface  of  the  septum;  iiiul  the 
ring  musculature  (Krehl),  wntrolling  the  upper  orifice  of  the  vcntrieie. 

The  contraction  of  the  right  ventricle  is  not  so  complete;  the  shape 
on  transverse  section  is  that  of  a  crescent  applitnl  to  the  more  ( inular 
left  ventricle.  The  result  of  contraction  is  that  the  outer  wall  iMtonies 
approximated  to  the  inner,  a  process  aide<l  by  the  bands  of  imiscle  which 
pass  across  the  cavity. 

Nature  of  the  Cardiac  Contraction:  Systole.— Our  «>!!*( ption 
of  muscular  contraction  is  naturally  based  upon  what  we  know  re<.';ir(linf: 
the  contraction  of  the  skeletal  muscles.  In  them  we  know  ihat  a 
nervous  stimulus  is,  under  ordinary  conditions,  the  originator  of  the 


THE  MYOOEStC  THEORY 


119 


conlriiction,  and  we  are  apt  to  neglect  Sherrington's  observation  on  the 
nature  of  the  patellar  and  other  reflexes,  that  these  occur  so  rapidly 
after  the  blow  that  induces  them  that  they  can  only  be  explained  as  the 
dirtH't  response  of  the  muscle  fibers  to  a  sudden  strain,  and  cannot  be 
of  mrvous  origin.  Thus  it  is  that  the  early  view  of  the  cardiac  contrac- 
tion W11.S  that  each  svstole  was  the  result  of  a  nervoiu  impulse. 

The  Myogenic  teeory. — We  owe  more  particularly  to  Gaskell 
(IHs;})'  the  v*e  which  prevails  to-day— that  the  cardiac  contraction  is 
automatic,  or,  more  accurately,  is  myogenic  rather  than  neurogenic, 
the  muscle  directly  responding  to  stimuli,  the  contraction  stimulus 
travi'lliug  not  by  the  nerves,  but  along  the  muscle  cells.  Thus,  in  the 
erahrvo,  the  primitive  heart  is  the  earliest  organ  to  present  active  function, 
and  tiiat  long  before  there  is  any  sign  of  the  development  of  the  peripheral 
nervi's.  We  see  it  there  iis  a  tul)e  In-nt  upon  itself,  and  undergoing  rhyth- 
mical contraction,  ?ontractions  which  begin  at  the  one  end,  and  continue 
as  a  jK-ristaltic  wave  to  the  other.  Anil  still,  in  the  fully  developed  higher 
animal,  it  is  seen  that  the  wave  of  contraction  l)egins  at  the  region  corre- 
sponding with  the  sinus  venosus,  or  first  portion  of  the  more  tubular 
heart  of  tlie  embrvi)  and  of  lower  forms  of  life.  The  earlier  difficulty 
in  understanding  the  conveyance  of  the  wave  from  one  chamber  to  the 
other  in  the  apparent  absenw  of  any  muscular  band  of  connection  be- 
tween auri<Ies  ami  vi-iitricles  has  Ix-en  solved  by  the  important  discoveries 
of  late  years  with  which  one  associates  the  names  of  Stanley  Kent,' 
the  younger  His,'  Aschoff  and  Tawara,*  Erlanger,^  and  Keith  and  Flack.' 
Such  liaml  of  connection  dcx's  exist,  and  is  of  a  very  remarkable  character. 
Thus,  ill  1893  the  first  two  of  these  observers  demonstrated  the  exist- 
ence of  a  peculiar  band  of  fil)ers  of  muscular  tj-pe,  which,  beginning 
apparently  in  a  small  no<le  in  the  wall  of  the  right  auricle  near  the  coro- 
narv  sinus,  continues  downwan)  "vto  the  ventricles.  The  course  of  these 
fiUrs  has  l)cen  very  thoroughly  studic<l  by  Tawara,  working  under  Aschoff, 
who  lias  found  that  forming  a  no<le  alnive  the  auriculoventricular  junction, 
the  hand  divides  into  two  main  branches,  one  for  each  ventricle,  and  each, 
iK-coniinj;  superficial,  branches  in  the  suliendothelial  tissue,  important 
branches  pissing  to  each  papillary  muscle.  The  cells  forming  these  sub- 
eiulothclial  filK-rs  had  hitherto  Imhmi  known  as  Purkinje  cells,  and  had 
been  r(c;aiiled  as  a  layer  of  vegetative  muscle  cells  (Fig.  1.')).  Whether 
there  exist  two  onlers  of  cells  in  this  position,  those  of  the  conducting 
systtni,  and  myoblasts,  has  still  to  be  determinecl.  The  cells  of  this 
system,  it  may  be  added,  are  not  ordinary  muscle  cells — they  are  rela- 

'  (Itriiiaii  writers  are  apt  to  gi\e  the  credit  to  Engelmanii,  whose  work  was  later, 
as.iKo  il  iriay  lipre  be  noted,  they  credit  His,  Jr.,  rather  than  the  earlier  English 
oliMiMi  Kent,  with  the  discovery  of  the  auriculoventricular  bundle. 

-  .luiiriial  of  rhysioli>g\-,  14:  1803:  220. 

'  Ari .  ileii  a.  <1.  med.  Klinik  zii  Leipzie,  18S.3:21. 

•  i'.-  i;<'izleltung  Kystoin  der  Siiugethiere,  Jena,  Fischer,  1906. 

■•  I  il.  i>f  Kxp.  Med.,  7:1905;  see  also  Erlangcr  and  Blackman,  .\iner.  Jour,  of 
I'liy  ■  !   lM;l;i07. 

'  '    ir...  Anat.  and  Physiol.  (Proc.  Anat.  Soc.  Great  Britain),  37: 1903. 


'I 

w 

120 


THK  MOTOR  APPARATUS 


tively  larjp;  and  rli-ar,  with  «>»Iy  iN-cnsional  .sun-tnw  eli'ini'iiL'*;  tht'V  n<nl|, 
in  fact,  c-ells  of  a  nioiv  i-nibn'oni*-  tyjM'.  Mon-  n'<fntlv  Koith  aiwl  Hack 
have  ilcmoattratwl  a  .sinii-atirifiilar  rin^  or  iunIc  of  vvm  of  .niniilar  onlcr 
situated  at  the  o|M>itin);  of  the  .sii|N>rior  vena  cava  into  the  ri^ht  anriclc. 
The  eonntvtion  »>f  tliejw  with  tiie  aiiri<'nloventrieiilar  iMxh*  Ims  still 
to  \te  worked  out. 

The  signifiranit'  of  the.s«'  oli.ser\-atioii.s  is  shown  by  ex|M'rinH>nts  in 
which  (a)  th  •  sinas  n>^on  is  by  jm-ssim'  eut  off  from  the  auri-jc, 
or  (b)  the  aurieh-s  se|>arated  from  the  ventrieles.  The  result  in  citlitr 
ease  is,  at  first,  arn-st  of  the  In-art  wave  In-ytmil  the  jxiint  of  stritiiirc. 
After  a  wrtain  |H'ri«»d,  in  the  first  ex|>t'rimeiit  the  aurieles  In-ffin  to  Inat 
af^in,  hut  at  a  rate  slower  than  tiiat  of  the  simis,  and  in  the  seeoml.  ilir 
ventricles  l)ej{in  contmeting,  hut  at  a  rate  slower  than  that  of  the  auriclps, 
or  otherwis«>  the  individual  jmrts  of  the  heart  an-  <-a|>al>le  of  exhiMiinj; 
automatic  contraction,  hut  ordinarily  the  stimulus  to  contraction,  orip- 


Fi<^  1*1 


Purkiiije*!*  fiber»  fnim  a  s*'!****!!*!*  Iiparl:    n.  iiurlfi;   r.  pn>tiiplar<m;   f,  (*triatp«i  inuwular  !*ii!'-tanr* 
(After  Uaiivier,  I^v'*""  ii'Ana!i>uiie  tU^nerale  fur  !?  S>>ri'inc  Miwuluin*.  Pari.*,  I8N0,  i-    u^"** 


natin^  in  the  sino-auricular  ntxie,  is  conducted  to  the  auricular  walls 
thence  to  the  auriculo-veiitricular  ncxle,  and  thence  to  the  vcniricuh'r 
muscles. 

Before  consiilering  the  sij;nificance  of  these  observations,  other  cliardc- 
teristics  of  the  canliac  contraction  have  to  1h-  briefly  refcrn-d  to.  I  ii  ihe 
first  place  the  heart  muscle  differs  from  the  skeletal  in  this,  that  wlurca* 
the  latter  can  l)e  tet^inizt-*!,  the  fomier  cannot.  That  is  to  say.  with 
ordinary  muscle  the  state  of  contraction  docs  not  prevent  a  lunim- 
electric  stimulus  still  influencing;  the  filK-rs,  so  that  if  stimuli  Ik-  n  |m  atai 
with  sufficient  fre<|uency,  the  muscle  passes  into  a  state  of  }K'r-i>ti'iit 
contraction.  The  heart  muscle,  on  the  other  hand,  exhibits  a  refractory 
stage  (Marey),  whereby  we  mean  that  when  once  in  the  state  n!  i-on- 
traction  it  is  refractory  to,  or  uniiifluencetl  by,  stimuli,  and  tin-  >ia!r 
persists  for  a  certain  period.  Ass(K'iated  evidently  with  this  is  the  t  irther 
characteristic  known  as  the  law  of  maximal  contraction,  that  the  '  'jhft 
stimulus  adequate  to  produce  a  contraction  evokes  as  powerful   ;  ''on- 


Tlin  SEVWWKNIC  TIIKORY 


m 


Irtvtion  an  the  ttrongrd  (Itowdilch).  Thi-H,  wr  would  i>mpha.<ti»>,  ia 
not  ili«'  same  a.s  .sHviiig  that  ovi-ry  contruction  of,  .say,  the  left  ventricle, 
i.4  of  (iiuul  fon>e.  There  ure,  ax  we  shall  point  out,  ronditions  umler 
which  the  r«>frH(t«iry  period  may  Ik-  pn>lon((e<l  in  whi<-h,  then-fon-,  the 
nioiiiit  of  "eontraetile  material"  lM><tmie.s  in<-n*u.se<l,  and  the  .suh.se(|uent 
conlnu-tion  in  therefore  more  (lowerful.  It  only  Hif^nifies  that  thin  .<(ul>- 
s<-<|ii<-iil  contraction  >  etjually  p«>werful,  whether  incite«i  hy  a  minimal 

or  II  intiximal  stin  u.u.Km;  that  the  expliMion  of  the  ke^  of  ){unp4iwder 
will  In-  (ijually  forceful,  whether  cau-siil  hy  the  .M-aree  f^lowiti);  stump  of 
n  nititch  or  a  2(NNI  v«>lt  eltvtrie  current;  the  amount  of  f^unpowder  in 
the  kcj{  will,  however,  imnlify  mattt-rs.  Aceonlin);,  therefore,  to  the 
rnyop-nic  th(H>r}',  the  "explosi«>n"  of  the  cells  of  the  sirio-auricular  niMle 
— Hiid  iif  the  heart  miLscle  fil)ers  in  succession— is  followed  by  a  periiMl 
nf  n>suscitation  of  the  contractile  matter,  ami  with  this  accumulation 
the  cells  IxH-ome  more  an<l  more  excitable  until  some  stimulus,  not 
iit>r\ou.s-  it  may  Ite  the  strain  put  upon  the  cells  hy  the  acc-umulati(m 
niitl  pn'sjMK-e  "f  the  hlcMxl  in  the  auri<'le— induces  another  explosion. 
Or.  aj,'ain,  it  may  Ik*  that  the  very  excitahilit/  of  the  elements  which  >{o  to 
f(inii  the  contractile  material,  I'-ads,  as  they  iKt-ome  store<i  up,  to  an 
active  rcarranjfement  of  th,  se  elements.     This  is  still  undetermined. 

The  Neurogenic  Theory.— What  part,  then,  is  played  by  the  nervoas 
niccliiiiii.sin  of  the  heart,  for  this,  as  we  have  pointe<l  out,  definitely  exists, 
lH)th  nerves  coming  fn)m  without,  and  intrinsic  ganglion  cells  in  the 
auri<iilar  septum  and  elsewhere.  The  vagas  fil)ers,  we  know,  can  com- 
pletely arrest  the  heart,  but  with  more  miMlerate  power  of  stimulation 
they  slow  the  heart  beat,  increase  the  refractory  peri<xl,  .so  that  the 
indiviiliiitl  contractions  are  fewer  in  numU-r,  but  each  individual  l>eat 
more  |Mi\verful,  although  in  a  given  pericxl  the  main  result  is  that  the  work 
(lone  by  the  heart  is  lessened.  The  aj-celerator  fiU'rs,  on  the  other 
hand,  re<lnce  the  refractory  |)eriod,  so  that  the  lx>ats  succeed  each  other 
with  ^jreater  rapidity.  At  the  same  time  they  appear  to  stimulate  the 
iiHTeased  formation  of  the  contractile  material,  as  shown  by  the  fact  that 
the  work  accomplished  by  the  heart  in  a  given  time  is  increased.  For 
tiiis  reason  they  have  also  l)een  descril)e<l  as  augmentor  fi!)ers.' 

The  more  recent  work  of  Engelmaiui'  indicates  that  those  nerves  may 
eontrol  the  heart  work  by  various  tneans.  Thus,  he  distinguishes  be- 
tween liiofmpe  influences  (causing  change  in  the  force  of  the  heart  U-ats), 
chriiiiiitmpf  (causing  change  in  the  rate),  drninoirope  (causing  changes 
m  till'  rate  with  which  the  wave  of  contraction  is  conveyetl  frf)m  one 
sepiiint  of  the  heart  to  the  other),  and  bathmotrope  (causing  modifications 
III  e\(  itnbility).  We  wouhl  add  that  changes  other  than  ner\ous  may 
also  iitlei  t  the  hei  rt  in  one  or  other  of  these  directions. 

As  already  imlicattHl,  the  myogi-nic  theon.-  here  put  forwanl  is  still 
stroii-ly    opjKwed    by    not    a     few    physiologists;    more    particularly 


i;      Mini  Adami.  Phil.  Trans.  Roy.  Soc.,  I.ond.,  183  B;  1892:199. 

An  li.  1.  .\nat.  Physiol  (Physiol.  .Abth.),  1900:  315,  and  Deutsche  Klinik,  4:  1903: 


122 


THK  MOTOH  APPARATUS 


Kroneckrr  ami  his  si-liool  liavc  hroii^iit  forwuni  «iata  wliicli  are  tliffi- 
cuit  to  iwuntili'  tt)m|tl«t«ly  witli  tlu*  (iH-ory  of  iniucular  roincy. 
ance  of  iIm'  caniiur  wuv«.  'I'liiw.  KrornxkiT  ami  Imriianitzk^  Imve 
sijown  tliat  tiie  Itumllr  of  His  nui  U-  lijtiitumi  williout  (ILiturliinK  (■<). 
oniiiiatioii  iK'twwn  tin-  auricles  ami  vi'ntricl«-!i,  ami  Paiikui  iiaa  liniion- 
strated  the  exuttrm*  of  iutvi«  |)1»'mi.sch  a«'<'«mtjwnviiijt  the  liiimile,'  ami 
has  found  that  if  tluvs«'  Iw  injumi,  inoMtnliimtion  Is  imiuciil.  it  Is  tnit, 
therefoif,  acconiiii^f  to  this  .stiiool,  tin-  luiwc-lc  IniiMile  itself,  i>ur  the 
f     ttnpatiyiiig  nerves  that  ftiiLstitutt   tlie  ciHtniinatinK  n»e<'hanLsn>. 

ere  is  a  r»'juurkul>le  ci>niliti«>n  of  im-j^ular,  iiMlejK'mient  etjntniclion 
of  tl  ;  heart  nuisc-le  HU-rs  wliieli  may  Ih-  brought  iilMiut  in  varioas  ways 
in  animals  of  the  lalM»rutory.  'I'liis  is  known  us  flbftlUttOB.  If.  for 
example,  the  anterior  eoronury  artery  of  the  lioj^'s  heart  lie  ligatunsi,  or 
puncture  made  into  a  |mrti<'iilur  s"|M>t  in  tin-  inter\entrieuiar  s«'|>tuni 
(Kronetker),  tlie  lieurt  |Missfs  into  this  state,  uml  from  n-guiarcontracliom 
takes  on  the  ap|H'animr  «>f  a  thin  hip  KIUhI  w  itii  actively  wrireling  w<.rtns. 
In  ({I'lieral  this  state  is  not  n-toverisl  from,  and  fr«)tn  arrest  of  ein-nlalion, 
death  ensues.  If.  n«>w.  the  heart  Ite  treaftsi  by  a  strong  fixative  aj.tm 
when  in  this  state  of  fii>rillali(>n,  iinehanitzkv'  hus  shown  that  the  state 
of  striation  in  ud joining;  wlls  may  1m<  sharply  eontra.sted;  at  one  side 
of  the  dividinj;  line  In-twiH-n  two'eells  the  striie  may  lie  widely  iiiwrt, 
at  the  other  eK)se  toj;ether;  the  «>ne  cell  in  a  state  of  exmnsioii,  the 
other  of  tense  it)ntnution.  The  up|K'aninees  are  eertainly  not  those 
we  would  exiM-et  to  find  wen-  there  tiie  eon<luetion  of  the  contrartile 
wave  from  one  e»'ll  to  the  next  in  series.  This  argument,  however,  does 
not  strike  us  as  absolutely  convineinj;.  for  she  admits  that  there  may  he 
the  same  sudden  than>{i'  of  striation  in  the  course  of  a  sii)>;If  cell.' 
On  the  other  hand,  the  earlier  oliservations  |)oint  strongly  in  the  dirtttion 
of  the  fine  plexus  of  nerves  iiiters|HTsed  throujjh  the  heart  musculature 
serving  as  the  main  eoonlinating  mechanism. 

To  n>eoncil<'  these  divergent  views,  wv  would  again  have  reeoiirse  to 
the  parable  of  the  coach  and  its  horses  aial  the  driver  (vol.  i.  p.  44fli. 
We  cannot  but  think  that  under  normal  coiuiitions  the  filn-rs  contract 
umler  the  influence  of  the  " strain  "  to  which  they  are  subjec-ted,  altli(mj:h 
constantly  under  the  controlling  influence  of  the  nerve  ple.xus,  whit  li  are 
'  >  the  cells  what  tiie  reins  and  bit  are  to  the  horses. 

•er*  |H)ints  out  a  jwssible  means  of  nconciling  the  myogciiit  ai-tl 

'"  theories.      Tawani   has   descrilH-<l   in   tlie  atriovenii    ular 

xistence  of  a  jH'culiar  mass  of  net-like  structure  eotitaiiun). 

Iwt..  cells  and  nerve  IiIhts  (Tawara's   node),  while  Keith  and 

'  It  desiTVOs  iiiite  tli.it  Tiiwar.i  had  dcscrilx-tl  tlio  co-cxixtence  of  nervo  lilnrsin 
the  bundles. 

'  Arch.  IiittTiiat.  de  I'hy.'-iid.,  4:  l!HHi:  1.  Thi.s  article  gives  a  rtsunii  of  il  i-  liter- 
atUft;  utl  thi.-i  rul'jeot. 

'  The  same  phenomenon  haa  l)ecn  oliserv ed  in  human  heartH  e.\hibitin);  fruiiiinta- 
tion;  it  may  !«  the  indication  tliat  in  the.se  ca.ses  death  haa  bct.n  due  to  !'••  hfart 
assuming  the  .state  of  (ibriUalion. 

*  Medical  Hecotd,  75:  IIKK):  873.     An  excellent  resume  of  recent  studie.-^. 


DIASTOLE 


m 


Hark  lmvc«  «li.Hrovrml  a  .liiiiilttr  body  ut  thf  junction  of  tlie  superior 
Venn  cavil  tirol  Burith-  (Koith'M  mxlr).  W««  may  MuppuM*  that  thf  normal 
wuv)  of  riinliuc  i-ontriictions  oriKtnatefi  in  Ki'ith'.t  nu(li>,  aiwl  that  un<li>r 
cxciiitiimiil  rircunistaiKt'M  Tuwuru's  no«li'  can  autnmutirully  9«'t  up  the 
vtntrii  iiliir«'ontrttfti<>nH  in<l(>|N>n(li>nt  of  the  m«>rr  proximal .sino-auncular 
tHNJi',  or  othfrwis*'  the  cijntrttrtion.i  ori/nimte  usually  in  the  heart  itJK'if, 
hilt  lliroii>{h  the  ajp-nev  of  these  ner\-e-<f)ntainin){  e«-ntres. 

I'arciitlietieuliy,  ill  t^tis  eonniftion,  it  must  In*  re<iille<l  that  the  heart 
possesses  u\m)  efferent  ner\e.s.  These  are  ni>t  scasory  nerves  proper, 
ill  ilic  .s«'ii.s«'  that  we  nonnally  prrreii'e  the  effects  of  their  stimulation. 
Normally,  that  is,  like  other  vLstx-ral  ner\«'s,  stimuli  «lo  not  extern!  bevond 
the  roni,  or  at  most  the  niealulla,  there  setting;  up  rt-flexes.  Only  in 
(•as<'s  <if  more  seven-  stimulation  of  certain  onlers  do  we  in  lower  <legree 
<)l>'iiiii  a  viijfiK-  senw  of  dLseomfott  that  cannot  be  accurately  localized, 
in  tlir  hi>;lnT  ilejiree  acute  pain,  which,  af{ain,  is  not  shaqily  localized, 
hilt  i^  ncojjnizjsl  more  definitely  to  l)e  in  the  «  'lac  region.  Wliat  is 
iiiorf  iimrkcfl  in  these  ruses— in  unpnu  pecto  for  example — is  the 
'nfcrnii  pain;"  pain  referred  to  th*'  areas  inm-rvated  by  the  first  and 
sccoml  (IdMul  nerves,  to  the  skin  ov«t  the  \ipper  part  of  the  thorax, 
ilowii  the  inner  si«le  of  the  left  arm  as  far  as  the  elliow,  more  rarely  down 
lN)t]i  arms,  i»r  to  the  little  finjjer  or  finders.  As  pointe<l  out  by  Sir  Lauder 
Hriiiitim,  Harvey  knew  that  the  outer  wall  of  the  heart  is  insensitive 
to  toiicli.  It  is  either  anemia  of  the  ventricular  mascle,  or  disteasion 
from  within  that  indm-es  cartliac  pain.  The  referre«l  pain  is  an  irradia- 
tion rtrcct.  .Stimulation  of  the  specific  ((anfjiion  cells  in  the  first  dorsal 
n);ion,  if  extreme,  ciiuses  an  overflow  to  neif»hlx)rin(j  cells,  those  associ- 
atcii  with  tactile  and  other  cutaneous  sensations  of  the  first  dorsal  area; 
and  as  tliese  have  cen-bral  connections,  stimuli  proceeding  along  them 
to  the  brain  are  referre«l  to  the  regions  they  innervate.  At  most,  efferent 
oaiiliai'  sti'iiuli  reach  normally  the  mtHliillii  It  may  Ik;  questioned 
whcthiT  in  cases  of  severe  stimulation  \vc  iicrc  iipiiii  c'eal  wi*h  irradiation 
(■tTtds,  or  wiietlier  then;  is  thence  a  normal  dinit  path  to  the  cerebrum, 
wlii(  h.  ix'ing  little  used,  does  not,  when  stimuli  pass  along  it,  convey  to 
us  all  a((urut(  -ensr  of  the  locality  of  the  primar.  stimulation.  The 
iniijiirity  of  pat  nts,  for  example,  can.  ot  siin'ly  determine  whether  they 
('\|)(Tit'iicc  cardiac  or  gastric  pain.  These  considerations  apply  not  only 
til  iMiiliac  pain,  but  to  visceral  pain  in  general. 

Diastole,  -.\lthoiigh.  as  we  have  pointe«l  out,  the  properties  of  the 
( anliiic  muscle  fil)ers  difft  r  in  important  particulars  from  those  of  onlinary 
sttiiitiil  imiscie,  it  is,  nevertheless,  natural  that  our  conceptions  of  their 
iiinilr  of  action  are  based  upon  our  knowle«lge  of  that  of  voluntarv*  muscle. 
lliiii I ,  as  it  is  firmly  fixed  in  our  minds  that  muscular  contracti<»n  .i!o»  c 
is  ;iii  :ii  tivc  process,  relaxation  iK'ing  passive,  for  long  the  tendency  i ;.- j 
liccii  til  rc;;ard  diastole  as  passive,  as  a  mere  act  of  n>la.\ation.  I'or 
iiiii;;  iliirc  have  Ix-en  observations  known  opposing  this  view,  suci  •  the 
tviilnitly  forcible  n)unding  of  the  ventricles  in  diastole,  when  the  living 
aiiil  liiaiiiifr  heart  of  an  animal  is  held  l»etween  finger  and  thumb,  an 
cN|iiiiiiiii  tw)  forcible  to  be  explained  by  the  internal  blood  pressure 


f 


■;  t 


124 


THE  MOTOR  APPARATUS 


or  by  elastic  recoil.  So  long  ago  as  1885  Pawlow  demonstrated  that 
in  the  fresh  water  mussel  there  exists  a  muse'e  which  expands  on  stiiiiu- 
lation,  contracting  when  that  stimulation  is  removtHl.  It  has,  however, 
l>een  difficult  if  not  impossible  to  demonstrate  the  active  niitiire  of 
muscular  expansion  in  warm-blotxltnl  animals.  And  so  it  follows  that 
the  negative  pressure  which  can  often  l)e  detennine«l  in  the  ventrii  iilar 
cavities  of  the  mammalian  heart  under  experimental  conditions  has  Iki'ii 
ascribed  to  the  elasticity  of  the  heart  wall,  the  general  negative  prtssurc 
of  the  thoracic  cavity  during  inspiration  acting  as  an  adjuvant. 

Under  ordinary  conditions  of  experiment— <•.  </.,  in  Uolleston's  valiiahle 
studies  upon  the' intraventricular  pressure — it  is  difficult  to  demonstrate 
this  negative  pre.ssure  as  constantly  existing  during  the  diastolic  phase, 
and  that  liec-au.se,  coincident  with  the  expansion  of  the  ventricles,  the 
blmxl  pours  into  the  ventricles  under  definite  jM)sitive  pressure;  it  is 
only  when  this  flow  becomes  slowetl  that,  prior  to  .systole,  a  brief  pericKl 
of  negative  pressure  shows  itself  on  the  curves.  Recently,  Stefaiii,' 
working  under  Luciani,  has  placi-d  the  existence  of  active  diastole  1m  yonil 
rea.sonable  doubt.  Enclosing  the  dog's  heart  in  a  canliometer  or  (x«, 
such  as  that  employed  by  lloy  and  Adami,  he  found  that  the  licart 
•!>s  still  able  to  propel  the  bk)o<l  into  the  aorta  when  the  {HTJciirdiHl 
■.ssurc  (i.  p.,  the  pressure  of  the  fluid  within  the  l)ox  enclosing  the  lunrt) 
is  25  cm.  HjO  higher  than  within  the  cava,  /.  e.,  within  the  right  ven- 
tricle. Further,  when  the  pressure  acting  upon  the  heart  from  without 
wa."  so  increa.se<l  that  no  blmxl  enterwl  the  heart,  and  none,  tiierefore. 
pa-sswl  into  the  aorta,  stimulation  of  the  peripheral  end  of  the  cut  vapiis 
letl  to  the  appearance  of  an  aortic  wave.  Evidently,  therefore,  ya);iis 
stimulation  increa.sed  the  active  expansion  of  the  ventricles,  peniiitiiiij; 
bloo<l  to  enter  their  cavities,  which  bUxKl  liecame  expelled  in  svstoie. 
The  heart,  there>fore,  is  not  merely  a  foree  pump,  but  is  al.so  a  suction 
pump,  and  in  lM>th  ways  brings  al)out  the  cireulation  of  tiie  hlood. 
From  a  pathological  jMiint  of  view  these  ol«ervations  are  of  iini>()rtan(f 
as  throwing  light  upon  its  action  in  cases  of  circulatory  obstruction. 
The  hypertrophy  that  occurs  in  these  cases,  it  is  suggested,  is  not  only  due 
to  increased  work  in  propulsion,  but  also  to  increase<l  suction  in  diastole. 
We  thus  gain  an  explanation,  hitherto  wanting,  for  the  not  infre(|iien'. 
cases  in  which  uncomplicated  stenosis  of  the  mitral  valve  is  accoinpaiiiwl 
by  hypertrophy  of  the  left  ventricle.  If  .systolic  effort  alone  iuduced 
overgrowth,  then,  less  bUxxl  reaching  it  through  the  narrow  vaKe,  tliat 
chaml)er  .should  remain  small,  but  as  above  note<l,  that  frcipu  iitly  is 
not  the  case. 

Here  must  Ik*  calletl  to  mind  the  similar  indication  of  active  dilatation 
of  the  mascles  of  the  arterial  wall.  The  well  ascertaininl  t-xisti  iiee  of 
vasodilator  nerves,  which  on  stimulation  cause  enlargement  of  tlie 
arterial  lumen,  in  contrast  to  the  va.scx-onstrictor  fibers,  can  onix  mean 
that  dilatation  of  the  muscle  fillers  is  an  active  prix-ess.  Ilei.',  ii  i^  true, 
we  deal  with  non-striate<l  muscle  filx^rs,  but  in  their  relatiollslli|l^  these 

'  Luciuni,  Physiologie  der  Menschcn,  1 :  1905. 


ARRHYTHMIA 


125 


are  strictlv  homologous  with  the  cardiac  muscle,  which  we  must  regard 
as  a  lii);hiy  differentiated  development  of  the  masclu  layer  of  one  part 
of  till-  liemal  tube.  With  Sir  Lauder  Brunton'  we  may  assume  the 
existiMKr  of  two  onlers  of  contraction  on  the  part  of  these  muscles,  (a) 
|()ii);ituiliiial  contraction,  leading  to  a  shortening  of  the  long  diameter, 
and  (li)  transverse  leading  to  a  lengthenin<r  of  the  same. 
Arrhythmia. — For  us  the  main  s'.-.ii  : 'aur"  of  these  recent  develop- 


irow  upon  vanous 


mints  of  the  myogenic  theory  i:L  iio  lif^ht  thty 
oniirs  of  cardiac  irregularity.  It  aniiot  he  said  t'.at  we  as  yet  have 
fullv  solvi'd  by  any  means  all  the  p  )1>1.  rns  viliicK  t!i  -se  cardiac  irregular- 
itifs  present.  There  are  still  thttsi'  n,l  "u-d  to  u(  iiold  the  pure  neuro- 
gi'iiic  or  the  pure  myogenic  theory  of  origm  of  many  of  these  states. 
But  if  what  has  been  laid  down  in  the  previous  volume  be  kept  steadily 
in  mind,  namely,  that  analogous  series  of  reactive  phenomena  may 
present  themselves  set  up  by  the  direct  action  of  no.xce  upon  the  tissues 
ami  1)}  nervous  influences  respectively,  as  demonstrated  by  the  existence 
of  neurogenic  and  "referred"  inflammatory  disturl)ances,  and  of  neuro- 
genic liyp<'rpyre.\ia,  then,  applying  the  same  consideration  to  the  heart 
action,  we  can  harmonize  what  appear  to  be  absolutely  contradictory 
findings.     Of  these  arrhythmias  six  types  are  to  l)e  recognized : 

( 1 )  Respiratory. — It  is  a  very  old  obser\ation  that  the  rate  of  the 
pulse  is  accelerated  with  inspiration,  slowed  with  expiration.  At  times, 
ill  neurasthenia,  those  recovering  from  acute  infections,  etc.,  this  differ- 
ence in  rate  is  greatly  exaggerated,  the  pulse  during  inspiration  l)ecoming 
so  rapid  and  the  heart  lK*ats  so  small  as  to  lx>  scarcely  n'cognizable. 
Mackenzie'  ascrilH-s  this  to  pressure  influences  acting  upon  the  sinus,  or 
as  we  may  express  it,  to  excitability  of  Keith's  no<le. 

( 2)  "Extrasystolic." — Exjvrimentally  upon  the  hearts  of  animals  of  the 
lalM)ratory,  working  regularly,  it  is  possible  to  interpolate  extra  contrac- 
tioiisorsystoles.aiid  where  this  is  done  by  ventriculurstimulation  itis  found 
that  ( I )  this  interpolated  beat  is  smaller  than  normal;  (2)  that  it  is  followed 
In-  a  longer  diastole,  and  this  (.3)  by  a  systole  more  powerful  than  usual 
in  siicli  a  way  that  the  diastole  In'fore  the  extra  l)eat  and  the  compara- 
tivelv  lengthened  post-systolic  period  together  ecpial  in  length  two  dias- 
toles, while  it  may  be  suggested  that  the  small  extra  systole  and  the 
following  delayed  systole  together  in  effectiveness  correspond  to  two  ortli- 
iiarv  i)cats.  In  the  conditions  of  pulsus  bigeminus,  pulsus  trigeminus, 
etc.,  wc  have  indications  in  man  of  the  existence  of  this  extra  systole, 
and  this  is  the  most  common  type  of  cardiac  irregularity.  What  is  the 
mciiiiiiii;  or  the  cause  of  this  extra  systole  is  still  an  open  question.  For 
oiirvi  Ives,  studying  a  large  series  of  tracings,  we  cannot  but  l)e  impressed 
with  their  resemblance  to  interference  curves,  namely,  to  the  interfer- 
emc  I"  t ween  two  .series  of  waves  of  different  length  and  rate. 

'I  li''  character  of  the  pulse  tracings  in  this  series  of  cases  is,  we  would 


'  i  I'  r  ipeutics  of  the  Circulation,  I.Andon,  J.  Murray,  1008:  4.3. 
■  I  i-  i^>'.s  of  the  Heart,   London,  1908:  the  fullest  study  upon  this  and  allied 
phiii  ...iria  that  has  yet  been  published. 


'H 


1 

V 

li 

1      r 

! 
'     i     i 

P 

J. 

126 


THE  MOTOR  APPARATUS 


emphasize,  that  of  "iiittrference  ciines;"  it  com-sponds,  that  is,  with  the 
orders  of  tracings  that  can  l)e  obtained  by  the  interference  of  two  s.tsof 
periodic  waves  of  differing  wave  lengths,  with  these  distinctions  (1  j  that 
owing  to  the  law  of  maximal  coiitniction.  where  the  waves  au<;mcm 
each  other,  i.e.,  when  the  upstrokes  of  the  two  coincide  then-  is  no 
summation;  and  (2)  that  the  existence  of  a  refractory  period  folh)\\iii;; 
the  wave  of  the  one  order  prt-vents  tiie  ajipearancc  of  waves  of  tluotlicr 
order  timed  tosiiow  themselves  during  that  refractory  period.  \V.  have 
in  the  previous  paragraphs  suggested  that  these  twoonlersof  waves  are 
the  nervous  stinmli  and  the  atitomatie  eont  ructions  respectively.  I'herc 
are,  however,  difl!  i  '.ies  in  accepting  this  view.  If  the  assuuiptioii  (if 
tlic'physiologists  Ik- correct,  that  the  law  of  maximal  contraction  dtinainl> 
that  each  contraction  of  the  heart  muscle  necessitates  the  ex|)losi()n  or 
using  up  of  all  the  contractile  material  accumulated  during  the  previous 
refractory  pericnl,  it  must  follow  tiiat  wiicr(>  stimuli  of  two  rates  of  peri- 
odic incidence  act  on  the  ventricular  muscle,  the  waves  of  gri-ater  fn- 
(piency  alone  will  be  effcctiv*-.  the  other  onler  of  waves  will  make  no 
imprt'ssion  upon  tiie  curves.  The  very  existence,  however,  of  these 
irregular  curves  of  heart  beat,  in  which  it  by  no  means  neeosariiy 
follows  tiiat  the  longer  the  interval  In'tween  the  In-ats  the  greait  r  the 
size  of  the  subs(H|Uent  wave,  shows  that  our  ordinary  conception  of  the 
significance  of  the  refractory  phase  is  not  wliolly  satisfactory.  It  i^  ;ii 
least  wortliv  of  suggestion  that  the  refractory  phase  corresi«)ii.ls  with 
tiie  stage  of  active  expansion  of  the  heart  filH-rs.  already  noted  i|>.  12:i 
If  we  assume  that  active  contraction  and  active  expansion  are  imdir 
the  contr()l  of  different  nerves  ic.  j/.,  the  accelerators  and  the  va;-!. 
respectivclv).  then  were  the  stimuli  to  pass  down  these  nerves  to  the 
ventricular  muscle  at  diff<Teiii  rates,  we  would,  it  may  be  siij;;'est.-i!. 
obtain  interference  curves  of  the  nature  of  tiiose  observed  in  thi^  onler 
of  cases. 

(3)  Due  to  Disturbance  in  Conduction.— Great  interest  has  of  late  i)een 
manifested  in  cases  of  what  is  termed  the  Stokes-Adams  syntlroine,  or 
"heart-block."  In  this  there  is  a  striking  bradycardia,  or  slowiiit;  of  the 
pulse.  By  fluoroscopic  examination,  or  by  simultaneous  register  of  arterial 
and  venous  (jugular)  pulses,  it  is  found  that  the  ventricular  heat  iKrur* 
only  with  everv  other  auricular  contraction,  or,  it  may  be,  wiiii  even 
third  or  fotirth".  Along  with  this  there  may  lie  Cheyne-Stokes  breaihini:, 
attacks  of  syncopi-  or  of  epilepsy,  or  even  apoplectiforiii  seizures.  ,>iin(r 
the  publication  of  Tawara's  paper  autopsies  upon  quite  a  series  of  suf- 
ferers from  this  syndrome  have  reconiiMl  the  existence  of  disease  atlVctms 
the  region  of  the'atrioventricular  node,  degeneration  of  the  myoraniium 
and  necrosis  involving  the  region,  fibrosis  and  gummas,  i.!ulin>:  to 
partial  or  complete  destruction  of  the  same:  conditions,  that  is.  which 
evidently  have  obstructed  or  completely  destroyed  the  banil  of  (oinmuiii- 
cation  between  auricle  ami  ventricle.  They  amply  explain  t!:e  lack 
of  coordination  between  the  two  sets  of  chamliers. 

(4)  Of  Oentral  Origin.— But  there  are  other  cases  on  record  m  which 
anemia  of  the  medulla  or  vagus  irritation  can  alone  be  invoked.    Brady- 


A 


ARRHYTHMIA 


127 


canlia,  or  abnormal  slowing  of  the  heart  beat,  jnd  tachycanlia,  or  abnor- 
mal rapidity,  may  both  exju-rimentally  be  pro<iuce<l  by  nervous  influences 
aloiip.  It  is  possible  th:  •  efferent  impulses  alone  may  so  depress  the 
excitability  of  ventricular  muscle  that,  instead  of  there  lieing  (as  in 
sonic  cases)  simple  bradytanlia,  auricle  and  ventricle  becoming  equally 
si()wc<l,  arrhythmia  may  l)e  producwl  of  such  a  nature  that  only  every 
other,  or  it  may  lie  only  every  third  or  fourth,  auricular  contraction  may 
lie  followetl  by  a  ventricular  systole.  With  Krlanger*  we  may  explain 
tills  as  due  not  to  alxsence  of  stimulus  conveyed  (mm  auricle  to  ventricle, 
aioii^  the  "bundle  of  His,"  i)ut  as  due  to  the  fact  that,  following  a  ven- 
tricular In-at,  the  contractile  nixtcrial  is  so  slowly  accumulati-d  (or  the 
muscular  excitaliility  so  de;viess<'<l)  that  tlie  next  stimulus  passing  from 
the  auricles  fails  to  arouse  a  contraction.  Only  with  further  accumula- 
tion of  the  contractile  material  will  a  second  or  later  stimulus,  of  like 
strength,  Ix-eome  effwtive. 

Here,  the  opposite  condition  must  also  be  noted.  Of  this  we  only 
know  one  instance,  observed  in  our  lalMiratory  at  the  Royal  Victoria 
Hospital  by  Dr.  Klotz  in  the  Ik  art  ol"  a  late  |)aticiit  of  Dr.  (".  F.  Martin 

—  the  condition  of  ctmiplete  iiiterru|ition  of  the  bundle  of  His  or  con- 
ducting system,  with,  nevertheless,  no  sign  of  cardiac  irregularitv  or  heart- 
l)l(Mk.  In  this  case  there  was  coniiilefe  rcplaccnient  of  all  the  tissues 
ill  the  region  of  the  aiiricuio-ventriciilar  node  liy  a  very  <'xteiisive  sarco- 
matous infiltration.  .\t  most,  some  scattereil  and  greativ  (legeneratwl 
fillers  were  to  be  det<'cte<l,  wiiich  might  [>ossil)ly  represent  isolated  cells 
of  the  system.  The  patit'iit  had  for  long  been  be<lridden,  and  as  the 
.Stokcs-.\(ianis  syndrome  is  peculiarly  apt  to  manifest  itself  after  .some 
act  of  exertion,  it  may  we'll  Ik-  that  in  this  case  tiic  ventricles  were  lieating 
autoniatically,  /.  p.,  had  assuuHHl  their  own  in(lc|>eiident  rhythm  of  con- 
traction -just  as  happens  exp  ifally  and  eventually  after  compres- 
sion or  destruction  of  the  bi>  .  His,  and,  doing  this,  were  able  to 
fulfil  all  the  needs  of  the  orgai.. 

Wiiile  everything  indicates  t;  at  the  heart  automatically  may  take  up 
an  independent  rhythm  which  results  in  irregular  action,  i.  e.,  that 
dircit  stimuli  acting  on  the  ventricular  muscle  may  stimulate  the 
prmiiiction  of  independent  contractions,  nevertheless,  the  indications 
arc  that  \er\-  often  vagus  action  is  responsible  for  cardiac  arrhythmia. 
Tlic  many  years  of  study  of  the  mammalian  heart  l>y  Roy  and  one  of  us' 
led  to  the  conclusion  that  the  main  function  of  the  vagus  is  to  protect  the 
heart,  even,  if  nee<l  lie,  at  the  expense  of  the  IkxIv  in  general.  Moderate 
vajru^  stimulation  slows  the  heart  beat,  the  inilividual  lieats  liecoming 
strtMt;:cr,  fmt  undoubtedly  the  work  accomplished  by  the  heart  is  lessened 

-  tlic  output  of  the  ventricles  in  a  given  time  is  reduced.  Stronger  vagus 
stiiniil.ilion  actually  stops  the  auricles,  and  experimentally  we  can  pro- 

'  '    i.!i.  "f  Exp.  Mctiicinr,   7:190.'),  i.iul  Itiill.  uf  lUe  .Ji.lms  Hopkins  Hosp.,  16: 

l!HI.',J,i|.  ^ 

'  1!  '^  and  .\dami.  Contributions  to  the  Phy.siolojty  and  Palhologj-  of  the  Mcm- 
nu,!iiiii  Heart,  Phil.  Trans.  Roy.  .Soc,  London,  1S3  B:  1892:  199  to  298. 


I    il 

M        ) 


l.r 


128 


THE  MOTOR  APPARATUS 


3i|     f 


•lutf  the  various  grades  of  (1)  ti>iii|M)mrv  complote  st(>ppn>?p  of  the 
vfiitricles,  and  so  of  tlie  (Milsf,  (2)  assumption  by  tin-  ventric-K-s  of  an 
indepenilent  rhythm,  the  aiiriclfs  still  iK'inft  arn'stwl;  ami  {'.i)  varioiu 
grades  of  arrhythmia.  It  is  not  that  the  vajjus  dir««<-tly  stimulattN  the 
ventricle  or  auriel"  t<>  .•ontract;  on  the  eeiitrary,  we  have  evi<lencc  that 
this  wave  lowers  the  exeitahility  of  Intth  »'.i<'  auricular  and  tlie  ventridilar 
muscle.  Rather  along  the  lines  suggi-stcd  ahovt-,  we  may  regard  the 
vagus  as  the  analwlic-  nerve,  or,  at  h-ast.  .-s  the  nerve  favorinj;  the 
active  expansion  of  the  heart  nui.s<le.  'J'hus,  if  stimuli  conveywi  down 
this  nerve  Ik-  sufficiently  powerful  they  may  neutralize  ami  ovircoiue 
th(xse  passing  down  the  atrioventricular  Inindle  and  favoring  contrac- 
tion. And  now,  when  through  the  -iction  of  vagus  stimuli  there  has 
l)een  increa-swl  accumulation  of  the  contractile  or  expansive  material 
either  a  minimal  nervous  stinnilus  to  contraction  may  n'sult  in  a 
maximal  contraction,  or  other  stimuli,  not  of  nervous  origin,  may  1h' 
directiv  effective  in  causing  contraction.  In  other  words,  accordin);  to 
the  conditions  acting  h\mu  the  heart,  so  may  there  Ik-  eithc  ner\  ons  or 
automatic  contraction  of  the  ventricles  manifesting  itself.  We  may  thus 
lay  down  that  when  the  vei:tricles  are  ov«-rv- rkwl,  us  is  the  (ase  in 
l)eginning  failure  of  coin|H'nsution,  then  foi  self-pn>tection,  atfcrem 
impulses  fp  a  tiie  heart  call  the  vagus  heart  centres  into  activity.  It  is 
under  ♦'  ■  .e  conditions  that  arrhytiimia  shyws  itself.  Or  otiurwiM', 
arrhythmia  is  friMpiently  an  indication  that  the  ventricles  iirv  workini; 
at  the  limit  of  their  reserve  force,  and  nci>d  vagus  assistance  in  order  to 
prevent  coi  ^,lete  cardiac  exhaustion.  Further,  otlur  n-flex  arcs  niav 
stimulate  the  vagus  centres.  These  tentrcs  may  l>e  acted  upon  In 
emotional  and  psychic  inHuences,  or  iiiHucnces  reaching  them  from  the 
gastric  or  splanchnic  areas  anil  from  sensory  surfaces.  The  anaiysi- 
and  determination  of  the  cause  in  any  particular  ca.se  of  cardiac 
arrhythmia  demands,  therefore,  a  wide  survey  of  conditions  throu|:h- 
oiit  the  organism. 

(o)  Pulsus  Altsman..— Of  this  and  the  next  form  of  irregularity  of 
heart  heat  less  lias  been  determined.  In  the  pulsus  alternans  a  stron; 
ventricular  heat  alternates  with  a  weak,  with  ftptal  inter rals  Inturfn 
the  beats.  It  oc-ciirs  with  indications  of  great  cardiac  weakness.  ^'.. 
have  alreadv  indicated  that  in  "extra  systole"  the  lengthene<l  di:.-tole  i« 
associate*!  with  ventricular  disturhance.  The  want  of  .such  lenj.'thenini; 
in  these  ca.ses  suggests  that  the  disturlnince  originates  in  the  aiirideur 
at  Keith's  mxle. 

((»)  Aperiodic  Irregularity  (puhm  irregulari.i  prrpf/Hu.i).— Al:irke<liv 
irr»-gular  irregularity  is  encountered  in  cases  of  advanced  mitral  and 
tricuspid  stenosis  and  incompetence.  Mackenzie  assun<es  that  there 
is  some  break  in  contiiu:ity  of  the  conducting  paths  between  tlo>  sM),> 
auricular  and  the  atrioveiitricular  mode.  It  cannot,  however,  ly  said 
that  we  have  adequate  anatomical  or  other  data  upon  whiili  t'   'awa 

conclusion.  ^.      ,,     u 

The  Filling  of  the  Ventricles,  and  its  Meet  on  the  Muscle 

Fibers.— Distension,  Hyperixophy,  and   Dilatation.— The  work    acom- 


THE  FILLINC 


THE  VENTRICLES 


129 


plisliol  l)y  the  heart  in  a  given  time  is  determined  by  the  amount  of  hloorl 
propolliHl  in  that  time,  and  the  external  (arterial)  pressure  against  which 
it  is  (iisc-harged.  And  the  amount  propelled — or  exp«'lled — is  the  pnxluct 
of  tlic  amount  discharged  per  heart  beat  into  the  numlier  of  heart 
1k\iIs.  The  pressure  remaining  the  same,  the  like  amount  of  work  is 
iiccoinpiished  by  a  rapidly  beating  heart  discharging  a  small  quantity 
of  hlfMKi  at  each  systole,  as  by  a  heart  heating  at  half  the  rate,  discharging 
cacli  time  twice  the  quantity.  It  will  be  realized  that  in  those  two  cases 
the  conditions  within  the  ventricles  may  lie  very  different,  to  the  extent 
that  tlic  (litestolic  expansion  in  the  latter  case  will,  in  the  normally  act"  ig 
heart ,  \x  roughly  twice  that  seen  in  the  former,  or  otherwise,  the  muscle 
fibers  in  the  latter  case  have  to  contract  against  twice  the  \c\d,  and,  in 
diastole,  expand  to  a  greater  extent  under  this  increased  load. 

Tlie  physics  connecte<l  with  this  aspect  of  cardiac  work  are  not  a 
little  interesting,  inasmuch  as  they  give  a  clearer  understanding  of  what 
lia[)peiis  in  the  not  infrequent  cases  of  obstruction  to  the  outflow  of  blood 
from  file  heart.  Here  we  may,  we  think,  employ  safely  our  knowledge 
of  the  laws  of  contraction  of  voluntarj-  muscle.  The  ventricle,  that  is, 
under  its  load  of  I)I(kk1  to  Ik*  ex|X'lle<l,  may  \te  compare<l  with  the  familiar 
f;astr(Hiieiniiis  muscle  of  the  frog.  If  r  series  of  weights  be  attachi-d  to 
such  a  muscle  hanging  at  rest,  it  is  to  l)e  noted  that  sonu;  weights  are 
so  small  that  the  length  of  the  muscle  is  not  altered ;  the  natural  tonus  of 
the  muscle  is  greater  than  the  expanding  force  exerted  by  those  weights. 
With  progressively  increasing  weights,  however,  the  resting  muscle 
l)ecomcs  more  and  more  stretched,  at  first  with  relatively  rapid  increases 
in  lcnj,'lli,  later  as  the  limit  of  elasticity  is  reached,  with  lessened  increment 
in  len^'tii.  The  application  of  these  facts  to  the  ventricle  is  that,  with 
increase  in  load,  even  within  normal  limits,  the  ventricles  show  distension, 
and  timt  increase  in  work  per  individual  systole  is  "ecompanied  by  a 
natural  distension  of  the  ventricle.  In  other  words,  within  normal 
limits  increased  work  of  the  heart  is  followed  by  increased  size  of  the 
orpiM  in  diastole.  There  is  a  natural  distension  as  distinguishable  from 
a  |)alliological  dilatation. 

On  the  other  hand,  still  considering  the  gastn)cnemius,  if  we  record 
.he  excursion  of  this  muscle  when  stimulate<l  with  the  like  strength  of 
electric  current,  but  when  l>earing  a  succession  of  increasing  loads, 
we  find  that  the  work  accomplished  by  the  muscle,  i.  e.,  the  weight  raisecl 
multiplied  by  the  distance  to  which  it  is  raised,  is  far  from  being  at  its 
tnaximiuii  with  the  smallest  weight.  The  work  done  when  progressively 
mi riiiMii^'  weights  are  attached  undergoes  increase  up  to  a  certain  point, 
or,  mhcrwise,  there  is  an  optimum  load  which  with  a  given  muscle  and 
pvcii  -^trcngth  of  stimulus  leads  to  the  accomplishment  of  the  greatest 
aiiioiuit  of  work.  Here  the  application  is  that  the  heprt  accomplishes 
most  work  not  when  the  arterial  pressure  is  lowest,  but  under  a  certain 
mean  arterial  pressure,  which  of  necessity  varies  with  different  in- 
divi.liils  and  difTerent  states  of  nutrition  of  the  ventricular  muscle. 
So  M-i,  it  would  seem  that  a  certain  amount  of  diastolic  stretch  of  the 
mu  ;  ;i  fillers,  or  distension  of  the  vent.icles,  results  in  more  effective 


i'  1 


I 


130 


TIIK  MOTOR  APPARATUS 


contractions,  /.  r.,  in  the  expulsion  of  the  j^n-ater  amount  of  blood  a>  the 
result  of  individual  eontraction. 

Or  we  can  approach  this  sui)j«H't  fn»ni  another  point  of  view.     If,  us 
shown  h\  Roy  and  Adanii,'  two  points  1h>  laken  u|M)n  the  surface  of  tlie 
left  ventricle  of  a  doj?,  and  l>y  a  profx-r  instrument  the  distance  iHtwcen 
tlu'se  points  under  various  conditions  Ik-  reconliM),  it  is  foumi  that  upon 
increasing  the  intraventricular  pressure,  as  by   narn)win>;  the  aortir 
arch  by  means  of  a  lipitun-,  the  heart  Ix-comes  more  fille»l  in  diastole, 
ami  the  two  jxiints  liocome  farther  apart,  while  in  systole,  the  iK)ints  do 
not  approximate  to  nearly  the  same  extent  as  when  there  is  less  nsist- 
ance.     Similar  results  art-  «)b!ainable  if,  instead  of  primarily  incnasini; 
the  pressure  in  the  arterial  systi-m,  the  heart  is  jjiven  more  work  to  (!» 
by  increasing  the  amount  of  l)lood  supplietl  to  it.     This  can  Ik-  accimi- 
plished,  temporarily,  by  prj-ssurt>  upon  the  alxlomen,  or  over  loiifpr 
perio<ls,  by  injecting  into  the  venous  circulation  .some  few  hiimlnil 
cubic   centimeters   of   defibrinated    bl<HMl.     Again,  there   is   the   >amf 
filling  in  diastole,  an<l   n-latively  slighter  approximation  ot   the  points 
in  systole.     With  increase<l  work  of  the  heart  accompanying  the  (ii>- 
tension  in  «liastole,  there  is  a  dilatation  in  systole  also;  the  fiU-rs  «lo  iidt 
shorten  to  the  same  extent.     'I'hen-  is  (»f  necessity  rrxidml  bUxxl  in  the 
ventricular  chamWrs.     The  significance  of  this  is  grasped  if  we  consider 
the  ventricular  chamln-rs    as  a  sphere.^    Tln-n-  is  this  to  Ik-  noted  con- 
cerning the  relationship  between  the  circumference  of  a  sphere  ami  it> 
contents,  namely,  that  as  a  splier»>  expands,  its  cubic  contents  inereiw 
out  of  all  proportion  to  its  increase  in  circinnfereiu-e,  or,  more  accurately, 
the  ratio  of  incrca.se  is  not  an  arithmetical  ratio,  but  is  such  that  if  the 
circumference   Ir>   taken   as   ab-:ci,s,sn>,    the  corresponding   voliitiics  a> 
onlinates,  the  curve  of  successive  values  is  what  is  known  as  a  » iilmal 
parabola  ( Fig.  li))-     From  this  it  follows  that  a  degree  of  sliorteniin; 
of  the  fillers  of  the  lu-art  wall  sufficient,  let  us  say,  to  reiluce  the  circum- 
ference of  the  ventricle  an  inch,  will   cause  a  gn-ater  dimiiiiition  in 
volume  (or  greater  output)  the  niore  <listended  or  dilated  the  ventricle 
is  at  the  Ix-ginning  of  its  contraction.     For  example,  a  diminutioM  of  the 
circumference  l)y  an  inch  of  a  sphen-  of  ten  inches'  circ  uinfereiu  c  ( aii.v- 
a  dimiinition  of  vohune,  or  an  output,  wjual  to  4.5  cubic  incht;,  when  a 
diminution  by  one  inch  in  the  circumference  of  a  sphere  five  iiiche< 
round  causes  "an  output  of  only  1.027  cubic  inches,  although  in  tl>"  fiN 
case  the  cin-umference  was  reduce<l  only  one-tenth,  in  the  secomi  one- 
fifth.     That  is  to  say,  with  nKMlerate  distension  or  dilatation  of  tlic  hean, 
the  filx-rs  will  nted'to  contract  a  very  small  amount  in  order  to  cxp!  a 
given  amount  of  bloo<l  compared  with  the  amount  of  their  eoniraction 
in  a  normal  undilate<l  heart.     It  is  thas  very  po,ssible  that,  in  ^  lianl- 
working  heart,  a  certain  grade  of  distension  is  economical,  and  that  the 
presence  of  residual  bUxxl  by  diminishing  the  extent  to  which  each  tilier 

'  Practitioner,  52- 1894:  SI. 

»  This  is  the  nearest  geometrical  figure  that  we  can  employ  here  for  |    -jk.*?  o: 
illustration. 


THE  FILLING  OF  THE  VENTRICLhS 


131 


is  called  upon  to  contract,  may  \ye  a  saving  to  the  heart  and  to  the 
orpatiistn  as  a  whole. 

Kmni  these  considerations  and  oKservations  it  follows  that  kyper- 
trophi/  in  never  primary;  distension  (or,  as  it  is  usually  termed,  dilatation) 
always  precedes  hypertrophy.  The  only  <listinc'tion — and  p-rhaps  it 
is  a  iiit-e-s-sary  distinction  —that  we  can  recognize  l)etween  these  two 


Fm.  17 


; 

IS 

/ 

/ 

/ 

i*,. 

' 

/ 

/ 

/ 

2t 

; 

/ 

/ 

/ 

/ 

/ 

' 

2 

/ 

/ 

^ 

y 

C 

4 

e 

a 

8 

10 

Circumferencea  in  $neAe.s. 


('iir\i>  riprewnting  ihe  relationship  between  the  cirrumferenre  of  a  sphere  and  its  volume,  with 
suc(T«si\i-  unit  inirementii  of  circumference.  Ordinate— volume  in  cubic  inches.  Abwissa'^ 
cin'Uinf.-r.-ii.-i.  in  inches. 


terms  di.sten.sion  and  dilatation— is  that  the  former  is  a  temporary 
state  wliiih  disappears  as  soon  as  the  heart  Ls  relieved,  the  latter  is  a 
niitrc  iKiaianent  condition,  brought  alx)ut  by  disease,  and  still  persist- 
ing «ii(  II  the  cause  cea.ses  to  be  effective.  Possibly,  we  may  add  that 
dilat.iiioii  proper  should  only  be  regarded  as  present  when  there  is  actual 
iui)in|Ki  lice  of  the  heart  muscle  and   incapacity  to  contract  to  an 


p 


132 


THK  HEART  V  \LYKS 


extent  cominensurato  with  the  Imd  lK>riM'  liv  tlie  iniiwle.  If  we  deal 
simply  with  distiMision,  tiiul  tlie  hi-iirt  iiiiisrie  Im-  well  ni>tirtslu><l,  we  Imvf 
the  inevitable  seipiel  that  eontiiiiianit-  of  iiicn-ased  work  within  n>as«iiial.lf 
limits  leatls  to  hypertn)phy  eitiier  hy|MTtniphy  pn>|KT,  or  hy|Hr|.l;iMa, 
or  often  a  eombinatioii  of  (he  two  (\^^.  i,  p.  '•JO).  Sneh  hy|Hrir..pliv 
or  hyperplasia  will  either  n-lalively  or  alwohitely  Uvssen  the  KmuI  (if  vm\. 
individual  musele  filn'r.  .Vs  a  result,  with  lessenitl  load,  each  fil«  r  will 
contraet  more  completely,  and  the  dilatadon  will  lend  to  disii|.|),ar 
In  such  eases  we  deal  with  simple  hypertrophy. 

There  can  Ix-  no  doubt  that  where  then'  is  ample  n-serve  force  and  pxxi 
eompnsation,  thi.s  .simple  liy|M'rtro]>hy  exists  and  may  jn-rsist  for  yt•a^. 
though  it  is  the  exception  rather  than  tln>  rule  n|)oii  (he  jH»s(iii..ntnj 
table.  >N'here  there  is  persistent  eau.se  for  inen-astsl  heart  work  a-  ir. 
aortic  stenosis  or  incom|H'(enee~),  then  more  ofti'ii  we  fin«l  tliat  ilr 
reser^'e  force  of  the  ventrieujar  musele  Imh-oum's  diminished  or  exliau-ini  ■ 
and  eeeentrie  hypertrophy  su|HT\enes ;  (ha(  is  (o  .say,  we  have  cDinhiwi 
a  pathological  dilatation  with  hypTtrophy.  Not  a  few  authoriiiis  ju: 
describe  a  concentric  hypertrophy.  In  our  opinion  (his  is  non-exi>ir!:! 
It  is  true  that  now  and  again  we  eneiamter  an  appan-nt,  a  false  eoiut  i;i-: 
hypertmphy  upon  the  j)ostmortem  (able,  in  whit-h  what  is  striking  > 
the  teasely  knit  ventricular  nnisile,  gr«-a(ly  inereasi'd  in  amouni.  w;:r 
practically  no  lumen  to  the  ventricle.  All  the  ea.ses  we  have  seen  <'f  v.:.- 
condition  have  Ixhmi  from  cuses  cxamintMl  widiin  the  first  six  iiour«  : 
so  after  death.  They  represent  rigor  mor(is,  the  heart  musele  jxis-i  : 
into  this  state  in  one  hour  after  tleath.  Si-cn  next  day,  suili  hearj 
present  well-marke<l  liyjHTtrophy  with  dilatation.  There  is  no  >j  : 
thing  as  true  concentrii-  hyjH'rtrophy;  it  implies  that  the  ventri.le.  ;: 
contracting,  expends  a  largi'  part  of  its  energy  in  compressing  ili<  m  r« 
internal  fil)ers,  a  mast  uniiatund  lack  of  economy  in  the  work  if  lirf 
organ.  The  cau.ses  of  hy{MTtropliy  and  tlilatation  will  be  dealt  «t.: 
seriatim  on  pp.  1")")  and  l.Vl. 

3.  THE  HEABT  VALVES. 

The  mec-hanisni  of  the  action  of  the  heart  valves  is,  or  .shoul.l  !>e.  >. 
well  known  that  little  nce<l  lie  said  reganling  their  physiology,  ahhour- 
in  di.scu.ssing  their  pathology  certain  less  known  asp«-cts  of  their  do-eu,. 
mode  of  function  will  have  to  be  dwelt  u{M)n.  We  have  to  et>i:-ider  -^ 
results  of  their  imperfect  closure  and  imperfect  opening:  of  im-r  i^r^^t 
and  stenosis.  Practically  all  the  disturlwinces  we  have  to  iv.^ya^ 
whether  congenital  or  of  postnatal  origin,  come  under  these  two  r  -.'scliiir 

Incompetence. — This  may  lie  relative,  due  to  no  dist>a-t  .f  ui; 
valves  themselves,  but  to  a  giving  way  and  expansion  of  the  rin^-  f  !L«>Jt 
to  which  the  valves  are  attached,  so  that  their  casps  do  not  i:  *t  uc 
close  the  aperture;  or  actual,  due  to  di.sea.se  or  injury  to  the  (  ■;-  :i-:- 
ducing  the  like  result.  As  a  con.sefjuence,  at  the  periwi  of  t!.'  -^Tont' 
cycle,  when  the  valves  should  lie  closed,  there  is  reffurgitatioii  • :'  ^i»- 
and  passage  back  of  the  .same  into  chambers  from  which  it  had  ;  :  ^  io'Js:' 


INCOMPETENCE 


133 


I)ccii  ili^lmrjrwl.  The  blood  thus  n-^urgituted  coaititutes  an  additional 
load  f'lr  these  chambers  to  propel  at  their  next  systole  in  addition  to  the 
normal  load  reachinj?  them  from  the  normal  source  or  sources.  To 
actoinmiKlate  this  additional  bloal  the  affected  chambers  undergo  dis- 
tension (or  physiological  dilatation);  to  cope  with  the  increased  work 
thev  are  called  upon  to  perform,  they  exhibit  hypertrophy. 

'i"l'<'  stmly  of  the  heart  past  mortem  suggests  that  incompetence  is 
a  more  frequent  com'.ition  than  is  recognized  clinically;  or  otherwise, 
that  fre(|uently  regurgitation  exLsts  without  the  existence  of  murmurs 
•allin);  attention  to  its  presence.  Notably  b  this  the  case  in  connection 
with  the  tricuspid;  the  shape  and  the  relative  weakness  of  the  right  ven- 
tricle may  almost  be  said  to  favor  incompetence  and  regurgitation  with 
even  u  infHierate  grade  of  distension  of  the  ventricle.  Such  distension 
is  tiie  outcome  of  either  (1)  iiiconipetence  or  stenosis  of  the  pulmonary 
valve,  (2)  obstructive  disease  of  the  lungs  and  pulmonary  circulation, 
or  (.1)  obstruction  to  outflow  of  the  blood  through  the  left  heart.  The 
result  is  distension  of  the  right  auricle,  and,  as  there  are  no  adequate 
valves  at  the  entrance  of  the  venie  cavie,  with  contraction  of  the  ventricle 
a  reverse  wave  of  blood  is  propelled  into  the  larger  systemic  veins,  and 
these  Ixwme  distended  at  a  period  when  normally"  the  blood  should 
Ik-  pouring  from  them  into  the  right  auricle.  The'  result  Ls  a  marked 
obstruction  to  the  venous  circulation.  The  greatly  distended  right 
auricle  undergoes  some  hypertrophy,  but  verj-  soon  the  compensation 
is  incomplete,  with  the  result  that  the  blood  accumulates  or  is  dammed 
back  on  the  venous  side  of  the  heart,  passive  congestion  showing  itself 
in  the  liver  and  other  organs,  and  with  the  :>ther  consequences  already 
discussed  on  p.  10*)  et  seq. 

A  similar  relative  incompetence  is  not  infrequent  at  the  mitral  valve, 
whether  as  the  result  of  high  blood  pressure  or  obstructive  aortic  valve 
disease,  or  again  through  acute  or  tenninal  dilatation  of  the  left  ventricle; 
acute  dilatation  being  brought  on  by  the  action  of  toxemia,  alcohol  and 
other  drug's;  terminal,  being  due  to  failure  of  compensation  after  long- 
continuid  hypertrophy  or  progressive  malnutrition.  Nor  is  this  relative 
incoinpttencc  unknown  in  coiiiuction  with  the  pulmonary  and  aortic 
orifices;  the  fact  that  in  the  la-i  thr'e  years  we  have  en'countered  at 
autoI)^v  no  less  than  three  cases  of  the  last  condition,  makes  us  think 
that  it  is  more  common  than  is  generally  suspected.  Ii»  one  of  these 
three  tlic  regurgitation  had  eviilently  l)een  of  long  continuance,  for  the 
corpora  .Vrantii  and  free  edge  of  those  portions  of  the  cusps  which  did 
not  ni. .  t  at  the  centre  had  been  thickem><l  and  rounded.  Such  relative 
mcouipct.ncc  of  the  pulinonarj-  and  aortic  valves  wouhl  seem  to  be 
bron^'lii  about  in  part  by  dilatation  of  the  origins  of  the  pulmonary 
artery  and  of  the  aorta;  in  part  bv  a  giving  wav  of  the  muscular  ring 
unni.ihat.ly  beneath  the  valves.  ' 

A '!■;•!  or  organic  incompetence  of  the  heart  valves  will  be  discussed  in 
the  (1  ,a  I  Iters  devoted  to  the  morbid  anatomy  of  the  heart.  Here,  it  is  only 
nec^^-.,l\  to  call  attention  to  the  fact  that  incompetence  most  frequently 

I  vMs  when  there  is  stenosis.    The  narrowing  of  the  cardiac  orifices  is 


CO- 


134 


THE  HEART  VALVES 


rarely  of  such  a  nature  as  to  pcnnit  complrte  apposition  of  thi-  iliscas^l 
components  of  the  valve. 

'ITie  results  of  incompetence,  whether  relative  or  actual,  are  of  thf 
same  onler,  whichever  valve  Ls  iiivolve<l,  namely:  re>furRitation,  over- 
loading  of  the  -hamlKTs  into  which  the  Moot!  re);ur)(itutates,  distension 
of  the  same,  lollowetl  by  <H»nipensat«)ry  hy|M'rtrophy.  The  overtillinu 
of  the  chamber  lH>hintl  the  incompetent  valve  sooner  or  later  Wmp 
about  further  damminfj  Imck  of  the  blo<xl  towuni  the  venous  si«le  of  the 
heart,  until  eventually,  in  H«)rtic  inconi|H'tence,  f«)r  example,  we  ()l)tain 
mitral  incompetence,  pulmonary  congestion,  tricuspid  incomi)eteiKr,  and 
general  passive,  venous  i-ongestitin  of  the  organs. 


J I 


CHAPTER    VII. 

IIIK  UKAin  ;  l'.\TH()I,(X!I(At,  ANATOMY  AXI)  HlSTOI.OOY. 

KiiK  piiqxtse.s  of  doscriptioii  it  Is  convenient  to  regani  the  heart  as 
n)iisistiii^  of  three  t>ortion.>4:  the  [M>ricanlinin,  the  myoraniiiim,  ami  the 
fiidcKiinniini.  It  should  lie  borne  in  mind,  however,  that  no  serioua 
affcitii)!!  of  any  one  of  these  stnu-tiires  can  exist  without  involving  the 
(iiIhts  to  a  fjn-ater  or  less  extent. 

iii'iii^  a  hollow  viscas  that  contains  a  constantly  moving  fluid  tissue, 
the  liiilk  of  which  is  constantly  altering,  and,  n.oreover,  lieing  subject 
t(i  various  |M'ripheral  impressions,  the  heart  is  in  a  i  nte  of  physiological 
unrest  and  is  con.se<|uently  proportionately  liable  to  l»e .  fTecte<l  by  disease 
processes. 

'I'lie  average  weight  of  the  heart  in  the  adult  male  is  .300  grams;  in 
the  female,  2')0  gnims. 


THE  PERICARDnTM. 

The  |HTicunlium  if  a  serous  sac  compised  of  a  "onneotive-tissue 
nieiiiUrane  iiiiwl  with  endothelium.  Unlike  the  other  large  lymph 
spaces  of  tlic  InmIv,  it  usually  contaiiLs  a  relatively  large  amount  of  fluid, 
viz.,  from  .'50  to  .j<)  to  100  c.cni.,  even  in  the  ab,stncc  of  any  pathological 
(•oiKhiioii.  No  doubt,  the  presence  of  the  larger  quantities  is  to  Ik"  re- 
pirihil  as  an  i.goiial  manifestation.  From  the  fact  that  the  pericardial 
ttiiiil  !•>  ricii  in  ali>iimin,  we  must  conclude  that  the  ves.sels  of  the  peri- 
eanliiim  liave  a  physiologically  greater  permeabilitv  to  their  fluid  con- 
tents tliaii  have  tho.se  of  the  other  .serous  cavities.  This  will  explain 
the  frreater  su.sceptibility  of  the  pericartlium  to  exudative  processes  and 
the  formation  of  considerable  amounts  of  fibrin. 

Tlie  close  relation.ship  of  the  pericardium  to  the  heart,  lungs,  and 
ph'iiral  cavity  renders  it  also  especially  liable  to  secondary  invasions, 
and  the  free  movement  of  its  two  layers,  one  upon  the  other,  explains 
tlie  ra[)id  |)ropagation  of  the  varioiLs  inflammatory'  proces.ses  to  which 
it  i>  subject. 

DEVELOFMErrU.  ANOMALIES. 


ill  :i<ardiae  monsters  the  pericanlium  is  more  or  less  imperfectly 
<h-vi  Injied. 
roiiiphte  or  partial  defects  occur  in  rare  c"ses,  generally  a.s.sooiated  with 
The  sac  may  be  quite  absent  or  represented  by 


oilii  i  iiiaiformations. 


130 


THE  PERICARDIUM 


a  few  fringes  at  the  base  .  f  th<<  heart.     Mure  commonly  there  is  a  partial 
loss  of  substance  over  the  left  ventricle,  through  which  the  heart  may 
protnide  into  the  pleural  cavity. 
Hemiie  of  the  serosa  through  the  outer  fibrous  layer  are  very  rare. 


11 


1 


OIBOULATOKT  DIITUUAMOU. 

AnemU. — ^This  may  aiTcct  the  pericardium  in  common  with  the  rest 
of  the  body. 

QyparMnift. — .\ctivf>  hyperemia  is  met  with  in  cases  of  death  from 
pressure  on  the  base  of  the  brain,  and  in  commencing  inflammation. 
Passive  hyperemia  occurs  from  the  same  causes  as  it  does  eUewhrrr, 
and  in  death  from  suffocation.  It  may  lead  to  rupture  of  the  vt^seU 
and  the  formation  in  their  neighborhood  of  small  rcchymwes  or  sub- 
serous hemorrhages,  which  arc  nu»st  commonly  present  almui.  the  imsf 
of  the  heart.  Petechial  tpots  are  so  common  at  autopsy  that  it  is  prob- 
able that  they  are  frequently  produced  during  the  death  agony. 

Similar  extravasations  are  the  effect  of  poisons  (e.  g.,  phosphurus), 
septicemia,  morbus  Werlhofii,  pernicious  anemia,  leukemia,  and  the 
various  infections. 

Hematopericardiom. — Hemntnpcricanlium  is  the  condition  in  which 
blood  is  found  in  the  pericardium,  'i'his  is  due  to  wounds  of  the 
heart,  rupture  of  the  heart  wall,  of  an  aortic  aneurism,  or  of  the  aorta, 
pulmonary  artery,  or  coronary  vessels. 

Hydropericardium.— Hydropericardium,  or  hydrops  perirardii,  may 
be  part  of  a  general  anasarca.  The  amount  of  fluid  sometimes  naches 
as  high  as  one  liter.  The  fluid  is  pale  amber  in  color,  clear,  without 
flocculi,  and  pour  in  albumin.  The  condition  is  important,  as  it  leads  to 
stretching  of  the  pericardium,  pressure  upon  and  even  atrophy  of  the 
heart,  and  pressure  upon  neighboring  structures. 


PNIUMAT08I8. 

Pnenmopericardiom. — Air  in  the  pericardium  may  be  due  to  fistulous 
communication  Ix'tween  the  hollow  viscera,  such  as  the  oesopha^ii-  and 
stomach,  and  the  pericanlial  sac;  to  sulxliaphragmatic  abscess,  or  to 
fracture  of  the  ribs  and  traumatic  perforation;  or,  again,  to  the  pir^cnce 
of  certain  bacteria  like  the  Bacillus  Welchii  and  the  B.  eoli.  In  tlic  last 
contingency  the  sac  is  often  empty  and  the  surface  of  the  heart  resembles 
meat  dried  in  the  sun.  A  very  striking  example  is  recordetl  by  (nie  of 
us,'  where,  in  a  case  of  perforative  appendicitis,  pneumopericardium 
developed  during  life  with  a  distiiut  musical  sound  over  the  preconlium, 
which  could  he  heard  at  a  considerable  distance.  At  the  autopsy 
there  was  a  subdiaphragmatic  pus  collection,  but  the  continuity  »f  the 
pericardium  was  intact.    The  B.  Welchii  was  found  in  all  the  drgans. 

'  A.  G.  Nicholls,  Brit.  Med.  Jour.,  ii:  1907:1844. 


m^kki 


PEKlCARDlTtS 


137 


onpumuTioMi. 

PeriCftrditil.— 'llie  most  important  disease  of  the  pericardium  is 
iiiflimiiMtion,  whith  may  prt-sent  a  variety  of  characteristics. 

Primary  idiopathic  pcriearditli,  so  railed,  proluibly  does  not  exist,  except 
in  Ihosf  cases  due  to  wounds  of  llie  perVurdium.  The  cases  recorded 
in  children,  while  they  may  be  "iiliopti  "  clinically,  almost  certainly 
arc  due  to  some  ine<liastinal  lesion. 

iMondary  parleaniitii  Is  a  term  anplietl  to  those  forms  due  to  extension 
of  disease  from  other  parts.  It  is  less  misleading,  however,  to  divide  the 
cas«s  into  (1)  hematogenic,  in  which  the  irritants  reach  the  pericardium 
bv  way  of  the  blood,  as,  for  instance,  miliary  tul>erculosis  ami  those 
f()nns  that  complicate  acute  rheumatism,  smallpox,  influenza,  nephritis, 
diulx'tcs,  septicemia,  and  cer«'l>rospinal  meningitis,  and  (2)  thase  arising 
per  txiftmonem.  In  the  latter  class  the  disease  may  arise  from  a  great 
varipty  of  causes,  among  which  may  be  mentioned  pneu.nonia,  chronic 
pnlmonarj^  tubercuUxsis,  acute  p  curisy,  empyema,  aortic  aneurisms, 
inflanunation  of  mediastina  •  R-ribronchial  glamis,  acute  and  chronic 
rmkxanlitis, and  many  abc  .  conditions, such  as  peritonitis, app«.n- 
liicitis,  alxstes.s  of  the  live  pancreas,  and  ulcer  of  the  stomach.  In 
!•!  (uses  of  which  we  have  notes,  tx-curring  in  the  postmortem  practice  of 
tlie  Uoyal  \ictoria  Hospitals,  ")8  fx-r  cent,  arose  by  extension,  of  which 
tlimMjiiHrtt-rs  were  due  to  pret-xisting  disease  of  the  lungs  or  pleura. 

Willie  it  is  true  that  in  some  cases  cultures  have  failed  to  show  the 
prt'stmc  of  micriHirganisms,  it  is  almost  certain  that  all  exudative,  as 
distinguished  from  transudative  processes,  are  due  to  their  action.  The 
organisms  which  arc  usually  fourul  are  the  Diplococcus  lanceolatus, 
B.  coii,  Staphylococcus  pyo>;t>nes,  streptcK-occiis,  B.  tuberculosis.  Fried- 
lander's  pneumobacillus,  M.  meningitidis  intracellularis,  and  B.  Welchii. 
One  case  has  come  under  our  notice  where  the  B.  pyocyaneus  was  present. 
Mixed  infections  are  not  uncommon,  -ind  the  B. 'tuberculosis  is  at  fault 
in  niorc  cases  than  are  usually  suspected. 

The  relative  frequency  with  which  pericarditis  complicates  endocarditis, 
partii  iilurly  of  the  aortic  valves,  is  readily  explained  when  we  remember 
the  (lose  anatomical  relationship  of  the  pericardial  reflexion  to  the 
aortie  ririi;.  That  the  inflammation  can  extend  through  the  vessel  wall 
at  this  |«,int  is  lj«-yond  a  doubt,  and  not  only  acute,  but  chronic  endo- 
(•anjiiis  may  provide  a  starting  point. 

Ulirn  pleurisy  exists,  it  is  verj'  common  for  the  outside  of  the  peri- 
cardii,,! sae  (o  Xre  affecte<l  (perirardltin  erferna).  Often  in  such  cases 
the  |),  II. aniial  fluid  is  increased  in  amount,  but  without  flakes  (inflam- 
vmluni  In/drupi,),  while  the  superficial  ves.sels  of  the  pericardium  are 
wmg.  ,t.  ,|  and  the  surface  of  the  heart  mav  show  a  rosv  flush.  Though 
the  ei  .iniliejium  may,  in  general,  be  quite  smooth,  even  at  this  early 
.sta);e  l.,,.t,.ria  may  lie  present.  The  condition  is  sometimes  called 
pi-nr.,r.hii.^  serosa.  This  form  rapidly  passes  over  into  a  serofibrinous 
tion,  m  which  the  sac  becomes  distended  with  a  fluid  exudate  of 


iiifl 


'  \  I 


13g  THE  PERICARDIUM 

a  vellowLsli  turbid  appearanc-e,  .sometimes  stained  with  blood,  in  which 
float  flakes  of  fibrin.  The  amount  of  the  exu<late  may  be  small  or  may 
reach  a  liter  or  more.  The  eiiarac-ter  of  the  exudate  varies  considerably, 
depending  on  the  natun'  of  the  infection. 

The  fibrin  may  take  the  form  of  a  granular  deposit,  renderiiij;  the 
fluid  turbid,  or  it  may  exist  in  large  flakes,  or  again  may  lie  gelatinous. 
If  pus-producing  organisms  l)e  pre.sent,  such  as  the  staphylococc-us  and, 
in  certain  ca.ses,  the  pneuraocwcus,  the  exudate  is  purulent  {pyoperi- 
cardium).  The  amount  of  fluid  may  lie  .so  small  that  the  floriiious 
deposit  is  quite  thick  and  dry  (pericarditis  Jibriitosa  sicca).  This  comlition 
may  alternate  with  the  serous  outptjuring,  or  may  be  due  to  absorption 
of   the  fluid  during  the  later  stages  of  the  affection.     The  deposit 


Kibrinmi!"  iK-ritarilii is.      (l-'rnin  the  i'atliulugirsi  Muneum  of  McUill  l'nivrr>iiy  ) 

does  not  form  a  layer  of  even  thickness  upon  the  epicardiiiin,  l>ut, 
owing  to  the  movements  of  tlu-  heart,  tends  to  collect  in  little  dumps. 
The  condition  is  aptly  dcscriln-d  by  Laennec,  who  compan-d  it  to  the 
appearance  producinl  by  the  rapid  sepanition  of  two  slices  of  l)rea(l  and 
butter.  In  .some  cases' the  fibrin  over  the  left  ventricle  is  arraiiH  "^ 
a  raised  network,  wiiilc  over  the  right  it  takes  the  form  of  tniiisvcrsc 
parallel  l>ands.  When  tiic  dejK)sit  is  thick  and  in  the  form  of  Inii);  tags, 
the  condition  is  known  as  tlie  cor  i<illo.ium.  The  serous  tiuiil  mav 
contain  .so  much  blixxl  thiif  a  chiirjicteristic  .ippannce  Ls  pre-iented, 
known  as  pericardifis  linnorrliayica.  In  such  <'a.ses  there  may  be  ivhitively 
little  fibrin.  This  form  (Hcurs  in  debilitatinl  persons  ami  alenliolics,  or 
as  a  manifi'station  of  a  hemorrhagic  diathesis,  for  example,  in  seurvj- 


PERICARDITIS 


139 


ami  morbus  maculosus.  Tuberculous  and  carcinomatous  disease  of 
the  iMritardium  also  at  times  produce  this  appearance.  In  the  case  of 
dniiikiird.s,  the  condition  is  analo^us  to  pachymeningitis  hemorrhagica 
interna.  In  cases  of  some  standing  one  .sees  the  process  of  organization 
bepniiing.  Small  vessels  are  .seen  to  be  springing  from  the  deeper  layers 
of  the  jKTicardium  and  making  their  way  into  the  exudate,  which  now 
shows  signs  of  disintegration. 

If  tlie  heart  in  a  case  of  fibrinous  pericanlitis  in  the  early  stages  be 
examiniHl  microscopically,  it  will  be  seen  that  the  flattened  endothelial 
cells  lining  the  .sac  are  swollen  and  desquamating,  lying  free  in  little 
masses  ti|x)n  the  surface.  The  ves.sels  of  the  pericardium  are  congested 
and  there  is  l)eginning  extrava-sation  of  leukocytes.    The  pericardial 

Fig.  19 


OrKjiiiiziim  |i(>ri<-itntitis.       Spctioii  shows    newly-formed    capillaries^    in  the  pericardial    exudate. 
Zii->  ,.lij.  I>1)..  ocular  No.  I.      (From  the  Pathological  Laboratory  of  McCill  L'niver»ity.) 

coiimctive  tissue  and  the  superficial  layers  of  the  heart  muscle  are  oedema- 
toiis.  Ill  parts  where  the  process  is  somewhat  more  advanced,  there  is 
upon  the  surface  a  distinct  layer  of  fibrin,  forming  a  meshwork  mixed 
witli  IciikiHytes  and  containing  numerous  bacteria.  This  frequently 
stains  ratlier  badly,  as  if  undergoing  disorganization.  In  some  instances 
tlif  lihiin  melts  together  and  forms  hyaline  clumps.  In  .severe  ca.ses  the 
uiuleilyiiif;  heart  nuLsde  shows  marketl  cloudy  swelling  and  congestion. 
\Mirii  the  exudation  into  the  sac  is  marked  it  leads  to  pressure  upon 
' '  ;""<!  grt'at  vc.s.scls,  causing  more  or  less  .stttNis  of  the  ciieulution. 


fh.^ 


rile  i;;  often  l)ecomes,  to  some  extent,  atelectatic.  Acute  pericarditis 
nin\  I  xtcnd  to  the  pleura  and  peritoneum.  When  it  heals,  but  few 
tratv-  iii:iy  l)e  left  of  its  occurrence. 


if«pp«' 


t 


if 


140 


THE  PERICARDIUM 


Peilevditis  Ohronies. — Acute  pericarditis  may  evenMially  betome 
chronic,  in  that,  owing  to  repeated  relapses  with  partial  absorption  of 
the  exudate,  the  process  may  extend  over  weeks  and  result  in  thickening 
of  the  pericardium  and  fibrous  adhesion  between  the  two  leaves  of  the 
sac.  Many  cases  which  start  cUnically  as  acute  are  really  chronic  in 
their  nature.  Chronic  pericarditis  may  also  start  insidiously.  The 
disease  b  perhaps  most  common  in  young  persons.  In  developing 
cases,  where  pericardial  thickening  is  going  on  and  more  or  less  adhesion 
of  the  surfaces  has  taken  place,  one  can  see  remains  of  the  exudation 
in  the  form  of  disorganized,  granular,  rather  inspissated,  masses  of  fibrin. 
The  adhesions  are  partial  or  complete,  and  in  some  cases  calcifieation 
of  the  fibrinous  material  takes  place. 

An  important  type  is  the  indurative  m«di«Btinop«ilearditia,  where  not 
only  are  the  pericardial  layers  united,  but  the  connective  tissue  of  the 
mediastinum  is  thickened,  so  that  the  heart  may  be  firmly  united  to 
the  chest  wall,  the  lungs,  and  the  diaphragm.  The  etiology  of  this  form 
b  somewhat  obscure.  The  most  potent  cause  appears  to  be  acute  peri- 
carditb,  either  rheumatic  or  following  some  of  the  infectious  fevers.  A 
peculiar  form  of  chronic  pericarditis  is  that  in  which  the  pericardial  sac 
I  b  obliterated  and  the  two  layers  are  converted  into  a  thick  hyaline  mem- 
brane of  grbtly  consbtence.  Thb  form  b  nearly  always  seen  in  associa- 
tion with  similar  dbease  of  the  pleura  and  peritoneum,  but  Eichorst'  has 
recorded  a  case  in  which  the  pericardium  alone  was  affected. 

The  most  important  chronic  conditions  are  tuberculosb  and  syphilis. 

Taberenloni  Peric»rdi*i». — ^I'uberculous  pericarditb  may  be  hema- 
togenous or  extend  f"oni  the  mediastinal  and  peribronchial  glands,  or 
from  the  lungs  and  pleura.  It  begins  with  the  formation  of  small  grayish 
tubercles  on  the  inner  surface  of  the  sac,  which  are  surroundeil  by  a 
hyperemic  zone  and  often  cappetl  with  granulation  tissue.  As  the 
condition  progresses,  exudation  takes  place,  the  tubercles  enlarge  and 
coalesce,  forming  ultimately  caseous  nodules.  The  exudate  may  be 
serofibrinous,  fibrinous,  purulent,  or  hemorrhagic.  It  is  usually  moder- 
ate in  amount,  and  much  productive  change  b  going  on.  The  disease 
at  times  assumes  the  guise  of  a  simple  serofibrinous  inflammation,  or  the 
two  walb  of  the  pericardium  may  be  completely  and  firmly  uiiiteil  bv 
a  thick  layer  of  newly  formed  connective  tissue  containing  caseous  foci. 
Thb  layer  b  often  very  thick  and  may  have  a  semitranslucent,  struot'ir^ 
less  appearance  resembling  partially  solidified  celloidin. 

Syphilitic  Pericarditis.— Syphilitic  pericarditb  b  rare,  generally  dr[)end- 
ing  upon  sj-philb  of  the  heart  wall.     It  leads  to  adhesions. 

Actinomycosis. — Actinomycosb  of  the  lungs,  mediastinum,  (vsopha- 
gus,  and  peritoneal  cavity  occasionally  extends  to  the  pericanliuiii. 

The  results  of  pericarditis,  when  .lealing  takes  place,  may  be  that  the 
exudate  b  absorbed  and  there  b  complete  return  to  the  normal  condition. 
Or  the  fluid  portion  may  be  absorbed,  leaving  a  granular,  f;i?tv.  arJ. 
caseous-looking  detritus  between  the  layers  of  an  adherent  periivirdium. 

>  Eichorst,  Zuckergussherz,  llcutache  med.  Woch.,  28:1902:2<."3. 


TUMORS 


141 


Such  deposits  may  even  calcify.  Milk  spot!  (macule  tendinete),  which 
are  so  common'  or  the  front  of  the  right  ventricle,  are  by  some  thought 
to  he  due  to  preexisting  pericarditis.  Most  often  they  would  seem  to  be 
of  the  nature  of  "corns"  of  the  serosa,  the  result  of  intermittent  press- 
ure. A  more  important  sequel  is  the  formation  of  fibrous  adhesions 
between  the  two  layers  of  the  pericardium.  These  occur  in  about  3.5 
per  cent,  of  all  postmortems.  Fine  fibrous  bands  near  the  aortic  ring 
are  very  common,  and  are  due  to  extension  of  inflammation  from  the 
valves.  Local  adhesions  by  veil-like  processes  may  be  present  (partial 
sjfnechia),  or  the  two  layers  may  everywhere  be  in  such  close  and  firm 
contact  that  it  is  impossible  to  separate  them  (total  synechia).  The 
latter  form  leads  to  dilatation  of  the  heart  chambers.  On  the  other 
hand,  great  thickening  of  the  pericardium  may  lead  to  atrophy  of  the 
heart.  Such  a  condition  is  often  spoken  of  under  the  term  "chronic 
adhesive  pericarditis,"  but  since  it  is  a  result  and  not  a  process,  it  would 
be  more  correct  to  call  it  pericarditis  adhetiva  obsolescens. 

Parasites. — Trichinse,  cysticerci,  and  echinococci  have  been  found  in 
the  cavity. 

Foreign  Bodies. — Foreign  bodies  may  enter  from  without  or  from 
ulcemtive  processes.  It  is  peculiarly  frequent  in  cattle  to  have  needles, 
wire,  etc.,  which  have  passed  through  the  walls  of  the  first  stomach, 
find  their  way  into  the  pericardium  and  lead  to  sudden  deai..  by 
puncture  of  the  heart.    Analogous  cases  occasionally  occur  in  man. 


RETkOOKESSIVE  BtETAMORPHOSES. 

Swous  Atrophy.— Serous  atrophy  of  the  pericardial  fat  occurs  in 
effusions.  The  fat  is  yellow  and  gelatinous  in  appearance,  and,  micro- 
scopically, shows  swelling  and  hydropic  degeneration  of  the  fat  celb. 


PROGRESSIVE  METAMORPHOSES. 

Tumors. — Primary  Tomon. — Primary  tumors  are  very  rare.  Oar- 
cmoma  (?)  and  endotheUoma  are  recorded,  as  are  also  a  few  instances  of 
priinitrv  sarcoma.' 

Secondary  Tumors.— Secondary  growths  may  be  extensions  from  tumors 
of  the  inwliastinum,  lung,  oesophagus,  and  stomach,  or  may  be  metas- 
tatic. Of  the  first,  carcinoma  and  lymphosarcoma  mav  be  mentioned, 
and  of  the  second,  carcinoma  and  melanotic  sarcoma. 

Among  benign  tumors  Upomas  (polypi)  and  flbromas  occur. 

•  A. .  nr,ling  to  our  Montreal  statistics  they  are  to  he  found  in  more  than  14  per 
"Mi.  .11  ail  autopsies. 
'  J  '    W  illianis,  New  York  Med.  Jour.,  71 :  1900: 537. 


142 


THE  MYitCARDlUM 


THE  MTOOABDIUM. 


'      I 


OONOENITAL  ANOMALIES. 

Congenital  pociiliariJies  an-  said  to  Ik-  more  frrijiient  in  the  male 
than  in  the  female  sex.  In  jpMieral,  they  are  tlue  to  a  n'tjinlatioii  or  an 
aetual  vitium  in  the  (levelopnwnt  of  certain  pirts.  More  rareiv.  thn 
arc  to  Ik?  attrihiitwl  to  inflammatory  pnKTs-ses  (x-eurrinj?  during;  fnetal 
life.  Many  of  them  are  of  >»reat  praetieal  importanw,  iniusniiich  as 
their  presetiee  may  prevent  an  in«le|H'iulent  existence  on  the  part  of  the 
offspring,  or  if  life  Ik-  iM>ssihle,  grave  circulator.-  disturbances  may  he 
the  consequencv,  with  altnormal  sust-eptibility  to  disonlers  of  related 
parts  and  all  that  this  implies. 

The  numl)er  of  the  canliac-  anomalies  of  this  class  is  legion,  and  w 
cannot,  for  lack  of  space.  <lo  more  hen>  than  indicate  in  a  sketchy  fa-shion 
the  more  important  forms. 

In  a  gi'ticnd  way  the  developmental  anomalies  of  the  heart  and  it> 
sinu.ses  may  l)e  sinnmarizi-<l  as  follows: 

1.  Numerical  variations. 

2.  Displacements. 

3.  Anomalies  of  the  heart  as  a  whole. 

4.  Anomalies  and  def«-cts  of  the  various  septa. 

5.  Anomalies  of  the  lumina  of  the  various  ostia. 

().  Anomalies  of  the  semilunar  cusps  and  auriculoventricular  valvt^. 

7.  Patency  and  other  anoniali«'s  of  the  ductus  arteriosus. 

H.  Anomalies  of  tin-  vessels  in  inuntnliate  n-lationship  to  tlic  liean 
Under  the  category  of  numerical  variations  we  note  the  condition  uf 
total  absence  of  the  heart,  as,  for  example,  in  the  monstrous  hirtli  known 
as  ac-ardiacus.  This  is  asscH-iated  with  other  grave  anomalies  of  .Icv.lop- 
ment.  One  case  is  on  ni  rd,  also,  of  a  doable  heart.  Verocay  lias  tie- 
.scril)e<l  and  figuretl  a  case  of  seven  hearts  in  a  series  fouiul  in  a  diiiken 
The  heart  n«iv  Ih'  displacol  in  various  ways  as  a  n-sult  of  orn-- 
of  development  "or  accpiioHl  disease.  Thus,  it  may  be  rotated  u[xpr 
its  vertical  or  anteroposterior  axis.  Tiuler  the  term  dextrocardia  a> 
recogniw-d  two  conditions:  one,  in  whidi  the  heart  (K-eupies  a  ih>«iii.:: 
on  the  right  side  of  the  thorax;  and  the  other,  in  which,  while  the  hean 
is  found  at  its  normal  site,  its  vu  ious  chamln-rs  and  sinuses  arc  >iniplv 
reverse<l  (true  dextr(K-ardia\  The  latter  form  is,  as  a  rule,  tlioui;h  not 
invariably,  found  assm-iatefl  with  transposition  of  other  viscera.  Ectoiu 
cordis  is  a"  condition  in  which  the  heart  is  fountl  outside  the  thorat  i<  <  a^;.- 
Should  the  organ  remain  high  up  ir.  the  niH-k,  we  have  ectopia  <■■  n-iras.r 
shouhl  it  enter  the  alxlomen  through  a  .slit  in  the  diaphragm,  it  i>  called 
rrtop!a  ahdnminalix:  should  it  apj)ear  iH-neath  the  skin  of  th'  ihom 
through  a  defect  of  the  stermnn,  it  is  known  as  ectopia  ptrU'rvi.'..  a 
such  ea.ses  the  fiericanlimn  is  sometimes  wanting. 

The  chief  anomalies  of  the  heart  as  a  whole  are  bifld  apex,  divertientaa. 
primary  hypertrophjr,  and  hypoplasia.    Hypoplasia  is  not  ui    .lumoE 


CONGENITAL  ANOMALIES 


143 


and  is  usually  found  in  the  vesstls  as  wi-II  us  the  licart.  Tin;  lieart  i.s 
either  siuall  at  birth  ()r  the  whole  vaseiihir  system  ffrathiallv  lags  l)ehind 
in  tlic  >;eneral  iKxIily  development.  In  louK-stuiidin);  eases.  canJiac 
insufficit-ney  and  dilatation  come  on.  Itokitansky  has  not*-!!  the  ocea- 
sionai  asscK-iation  of  the  eondition  with  defects  of  the  external  f^enitalia. 
BanilMTfter  and,  later,  Virehow  (Miintcti  out  the  n-lation.ship  of  cardio- 

Fio.  20 


Hfart  .|„,«iri«  (.4)  lirfrit  ..f  intrraurirular  M-plum  Mow  Cpersi-tenl  n^liiim  primum),  with  (B 
oraviit,  "f  riitht  anteri..r  «itmpnt  ..f  mitral  valve.      (C)  Interaurioular  spptuin 

'■''""'  ''"'' ■'  "Villi-.      (/J)   I^ft  |H,-t-ri„r  Miitnil  »eKtn.-nt 

year-,  ,v  .     „,  tar.liar  -ynipt.imr..  dyinn  i.f  ixrfdrative  ap|xmli<- 
I  all,.  I, I    ,1  M,„euni,  MKiill  Iniveraty.) 


ahfive  MhnwiriK 

Kruin  a  wunian.  axril  thirty-two 

{Kn»m  a  specimen  in  t!ie 


viistiil,,,  liypoplasia  to  chlomsis.  Ortner  and  others  hold  that  the 
(•oiulin.m  prcdisfKxses  to  iiififtion.  We,  ourselves,  have  notietnl,  post 
mori,.,,,,  the  great  fre<|uency  with  which  the  condition  is  present  in 
(as,,  „|  lutHTculosis,  especially  in  vounj;  people.  The  vessels  are 
tliiii-u  ,l(r,|  and  show  a  tendency  to  fattv  change. 

Ill'  "iiiunonest  tlefcnt  of  the  septa  is  the  patent  foramen  ovale.    This 
's  -0  t'Miuent  that  it  can  hardly  be  culled  an  anomalv,  unless  it  is  so 


I  I 


144 


THE  MYOCARDIUM 


widely  open  as  to  allow  free  communication  between  the  auricles.  In 
1500  autopsies  at  the  Royal  Victoria  Hospital,  the  condition  occurred 
220  times,  or  in  14.7  per  cent.  When  patent,  the  opening  may  be 
merely  of  pin-point  size  or  may  admit  a  finger.  Defects  of  other  parts 
of  the  auricular  septum  may  also  occur.  These  defects  are  often  asso- 
ciated with  other  abnormalities,  such  as  cololioma,  or  mental  dcgra- 
datior 

The  inter\-entricular  .septum  may  be  partially  or  totally  wanting. 
Defect  of  this  kind  is  usually  associated  with  pulmonary  steno.si.s  and 
rechtslage  of  the  aorta,  and  constitutes  one  of  the  commonest  forms  of 
congenital  heart  disease.  WTien  the  septa  are  completely  wanting,  «e 
have  a  two-chamlx;rcd  heart  (cor  Wlocnlare).    Absence  of  the  ventricular 


Fia.  21 


I 


Defect  of  the  interventricular  septum  at  undefended  space.     Heart  of  infant.     No  other 
anomaly.     (From  a  specimen  m  the  McGiil  Pathological  Museum.) 

septum,  with  presence  of  the  auricular,  constitutes  a  three-chambered 
heart  (cor  biatriatum  trilocnlare).  A  remarkable  instance  of  tlii<  latter 
form  Is  to  be  found  in  the  Pathological  Museum  of  McGill  liiiversm. 
the  gift  of  Dr.  A.  F.  Holmes,  one  of  the  original  founders  of  the 
Medical  Faculty.' 

The  aortic  septum  may  be  partially  or  completely  defective. 

Pulmonary  itenosis  is  one  of  the  commonest  of  canliac  aiioraalie-. 
Both  it  and  the  severer  grade  of  atresia  are  commonly  associated  wth 
defects  of  the  septum. 

Aortic  stenosis  rind  ivtresia  are  rare. 

The  ductus  arteriosus  Botalli  may  lie  abaenf,  patent,  or  anomnhna  in  its 

'  Trans.  Medico-Chir.  Soc.  of  EUin.,  1824.  Reprinted  by  Abbott,  Mui  trral  Med 
Jour.,  30: 1901:  p.  524. 


Ik.. 


MYOMALACIA  CORDIS 


145 


coiirsi'.  Patency  of  the  diwt  is  .sometimes  aasoeiatecl  with  steiHxsi.s  of  the 
pulmonary  artery,  or  of  the  aortic  Isthtniu.  It  <K'cnrn'<l  (}  times  in  1500 
autopsies  at  the  lloyal  Victoria  Flospital. 

Thf  coronary  arteries  may  lie  incn-ase*!  in  numlier,  may  have  an 
al)tioriniil  origin,  or  may  take  an  abnormal  course. 

AlK-rrunt  chonlu"  tendincK  are  not  uncommon :  a  case,  giving  rise  to  a 
remiirkal)le  musical  murmur,  has  been  recorded  by  VV.  F.  Hamilton.' 

Those  desiring  more  detailed  information  than  that  given  here  are 
rcfernHJ  to  Dr.  Maude  Ablxitt's  admirable  article  in  Osier's  Modem 
Medicine  (vol.  iv,  1908,  p.  323),  an  article  that  will  be  for  long  the 
"last  wonl"  on  this  most  important  and  interesting  subject. 


OntOULATOKT  DISTURBAMOIS. 

Anemia.— This  may  be  part  and  parcel  of  a  general  anemic  condi- 
tion, or  may  l)e  a  local  condition  due  to  a  narrowing  or  obliteration  of 
tlie  branches  of  the  coronary  arteries.  A  pericanlial  exudate  or  hydro- 
pericanliiim  also  pnKluces  a  local  anemia  by  pressure.  The  affected 
muscle  has  a  pale  grayish-brown  color.  As  sudden  death  is  frecjuent 
from  aciit?  anemia,  the  coronary  vessels  should  always  be  examined 
for  .sclerosis,  thrombi,  or  emlx)li. 

Hyperemia.— ActiTe  Hyperemia.— Active  hj-peremia  occurs  in  acute 
infirlions,  in  abnonnal  ner\ous  conditions,  and  in  death  from  respiratory 
failure. 

Passive  Hyperemia.-  Pas.sive  hy  v  •emia  is  found  under  the  same 
conditions  us  elsewhere. 

Hemorrhage.- Interstitial  hemorrhage  is  often  due  to  obliteration 
of  the  arteries,  as  in  hemorrhagii  infarction,  or  to  sixintaneous  rupturt^ 
of  the  venules  in  the  state  of  jwssivc  congestion.  Apart  from  these 
coniiitioMs  it  is  not  common,  but  is  sometimes  present  in  certain  dvs- 
crasiiis.  as  in  the  various  infective  diseases,  the  hemorrhagic  diatheses, 
Icukeiniii,  |>ernicioiis  anemia,  and  in  poisoning  with  phosphorus,  arsenic, 
and  morphine.     In  some  cases  it  is  due  to  the  death  agonv. 

Myomalacia  Cordis.— By  this  is  understood  a  degeneration  of  the 
heart  nuisele  resulting  from  arterial  anemia.  Atheroma  of  the  coronary 
vessels,  with  its  attendant  thromlM>sis,  is  the  most  common  cause.  Eml)o- 
listn  III  the  eoronaries  is  a  less  fretjuent  cause,  inasmuch  as  these  vessels 
are  so  phicecl  that  foreign  bodies  cannot  readily  enter.  The  essence  of 
the  priMcss  is  that  it  is  a  rapid  one,  bringing  alxiut  what  is  practically 
a  tthitc  infarct,  with  suljseciuent  softening  and  degeneration  of  the 
miM-li'.- 

1  III  affected  area,  according  to  its  age  and  vascular  relationship, 
varir.  11,  apfM-arance  at  different  times.  At  first,  it  is  still  firm  and 
<'f  a  ,i,,li  vellow  color.     Later,  the  patch  l)ecomes  yellowish  white  and 

'  \li  iiinal  Medical  .Journal.  28:  1S99:  .508. 

■  "  •   1!   Marie,  1,'infarctus  du  Myocarde  et  ses  cons^^quenccs,  Paris,  1897. 


J 

r     p 


I    I 


?     ■ 

■It 

! 

s 
i 

l       I 

1      i 

146 


THE  MYOCARDIUM 


friable.  If  the  neijfhlKirinK  capilluries  rupture,  a  ml  infan't  i-*  the 
result,  preseiitinjj  a  cImII,  re<l«li»h  appearance.  I.«ter  still,  il.f  color 
changes  to  a  nwty  Wrown  ami,  h.s  filmwis  (xrurs,  to  a  dull  >jra.v.  Micn^ 
scopically,  the  affectc*!  inu.scle  filK-rs  apjKar  t(i  lie  .swollen,  liviiliiw, 
and  have  lost  their  eliaracteri.stic  .structure.  If  they  take  the  siiiiiiji 
is  with  a  diffuse  gla-ssy  appearance.  As  in  other  infan-toas  coiidiiiom, 
an  inflammatory  reaction  shows  itself  at  the  periphery  of  the  necrnhioiic 
area,  when  of  any  standinj;.  The  .site  of  election  for  this  pniccss  is  in  \\w 
wall  of  the  left  ventricle,  at  orlielow  the  junction  of  the  lower  and  iiiiddir 
thirds,  at  the  tip  of  the  papillary  nmscles,  sometimes  in  the  right  vciiiridr, 
more  rarely  in  an  auricle. 

Such  localized  areas  of  degeneration  may  protluce  a  rupture  of  the 
heart  wall  leading  to  hematopericanlium  ami  sudden  death,  or,  if 
fibrosis  has  had  time  to  develop,  may  result  in  the  formation  of  u  partial 
aneurism  in  the  wall.  This  is  mast  frequent  in  the  anterior  wall  of 
the  left  ventricle,  ne  t,  in  the  posterior,  and  occasionally  in  the  septum. 
Such  aneurisms  may  lead  to  an  imperfect  discharge  of  the  heart  s 
contents  and  to  the  formation  of  parietal  thrombi  with  their  attendant 
dangers.  Lazarus-Barlow*  has  descrilx^l  a  seemingly  unique  case  of 
dissecting  aneurism  of  the  right  heart  wall. 

Fibrosis  of  the  Myocardium.— This  cimdition  has  mmh  in  common 
with  the  last  mentionwl,  but  differs  from  it  in  that  it  is  a  fibrous  di'^^'cnera- 
tion  of  the  heart  mu.scle,  which  is  very  slowly  pnKluced.  It  is  often 
called  "ehnmic  interstitial  myocarditis,"  but  incorrectly,  simr  it  i> 
primarily  a  degenerative  pnK-e.ss.  Owing  to  .sclen»sis  of  the  coroimn 
vessels,  which  leads  to  a  narrowing  «>f  their  calilier  and  con.s(<|ncntl,v 
impoverlsheil  1)1<xkI  supply,  the  inu.scU-  bimdles  in  the  affeclts!  tract 
undergo  starvation  atropliy.  A.s.s(K-iated  with  this  is  proliferation  of 
the  preexisting  interstitial' connective  >  ■-  which  gmdually  iiivaifo 
the  degenerating  part— a  true  replacement  i.Drasi.s— and  is  n'lwrative 
in  its  result.  This  is  the  pure  ty|)e.  It  cannot  Ih"  denietl,  however, 
that  other  ca-ses  exist  in  which,  in  addition  to  the  "replacement  filmisis." 
there  is  the  prinluction  of  a  cellular  granulation  ti.ssiie  that  in:i,v  either 
develop  into  .scar  tissue  or  may,  in  its  turn,  participate  in  the  (lc<;(iierativf 
change.  Such  inflammatory"  changes  must,  we  think,  be  rc^'anied  a.< 
due  to  the  irritation  prodiicctl,  and  .secondary  in  nature.  It  would 
con.sequently  seem  more  rational  to  include  this  condition  anu)iig  the 
degenerations  rather  than  the  inflammations. 

The  scar  tissue  may  Ik-  fairiy  <liffused  thmughout  the  organ,  pivinj; 
it  a  tough  feel  like  leather.  Much  more  commonly,  the  chan^'c  is  hx-al- 
ized  to  certain  parts.  On  .section,  the  mu.scle  shows  grayish  streab 
running  parallel  to  the  mascle  bundles,  particulariy  in  the  wall  of  the 
left  ventricle  and  at  the  tip  of  the  papillary  muscles.  If  the  condition 
l^  more  extreme,  one  sees  irregular  areas  of  a  semitranslucent  appear- 

'  Brit.  Me<l.  Jour.,  ii:  1899:  1344.  For  ilissectiiig  aneurisnis,  see  alsn  \>stl)ei», 
Om  (lissekerande  hjurtancurismcr,  Nordiskt  Med.  Arkiv.,  Ny  Foljd,  7  :  N.s.  2Baai 
30 :  1897. 


INFLAMMATIONS 


147 


anoe.  mid  of  a  Krovwh  or  grayish-white  cokir,  shaqjly  defiiiwl  from  the 
heaUhy  imisfle,  which  are  MUiiken  lielc»w  the  ffeiieral  level  of  the  cut 
surface.  The.se  have  the  ap|K-aranc-e  of  teiidon.  Decides  the  favorite 
site  in  tlie  wall  of  the  left  ventricle,  .similar  an-a-s  inuy  Ih'  found  in  the 
coliiiiiiiie  cameie,  the  .septum,  or  even  in  the  rijfht  ventricle. 

Micntscopically,  the  condition  is  chunicteriMsl  Uy  tl.  •  presence  among 
the  inii.s<le  bundles  of  larp-r  or  .smaller  fil>r()U.s  (mtches  often  presenting 
a  stellate  apjiearance.     The  mu.s<'le  filn-rs  alNUit  the  margin  .show  «lefinite 


Fio.  Ti 


Mjwahlial  lil>n»i»  fmni  liiwaw  ,,f  ronmury  nrti-rirx.      Ia-iIi.  ,,l,j.  .N,, 
(Kniiii  tlie  riilli-rtidii  of  Dr.  A.  <i.  .Viili.,||.«.) 


wiihiiut  ocular. 


evKJeiKc  of  atrophy,  and  melt  away  into  the  fibrous  mass.  Sometimes 
in  the  (nitre  of  the  patch  can  Ih-  seen  a  few  isolatinl  miisch-  baiul.s, 
atr.)[)lne(l  by  compression.  The  .scar  tissue  is  generally  very  iKH)r  in 
nuelear  el<-inents,  but  towani  the  outer  margin  is  mon-  cellular.  New- 
foriiud  capillaries  can  Ix-  made  out,  with  jK-rhaps  small  arcius  of  inflam- 
matorv  infiltration.  The  more  heidthv  muscle  fillers  u.sually  .show 
mark..!  liv|H'rtn)phy,  as  evidenced  by  the  fact  that  the  nuclei  are  relatively 
lar;?',  simii  deeply,  and  are  blimttHl  at  the  ends. 


INTLABIMATIONS. 


Acute  InflammationB.-Inflanimation  of  the  heart  miLscle.  apart 
mm  that  which  .sometimes  accompanie.s  i.schemic  ne<Tosi.s,  i.s  mostly 
«ue  to  iNl.rnon  or  into.xication.    The  various  ageiit.s  may  reach  the 


IF 

If 

"ii 

iHi'^'l 

r 

'I'F 

■ 

' 

V. 


il 


I        i: 


i     i 


148 


THE  MYOCARDIUM 


Wiiimds 


muacle  from  the  pericardium,  or  by  means  of  the  lilood  stream 

alao  may  be  a  cause.  _  . 

A  diffuse  form  of  myocarditis  occurs  m  the  course  of  many  mf.rtive 
fevers,  notably  typhoid,  diphtheria,  stariatina.  rheumatism,  septi<nnim, 
pyemia,  and  other  similar  condition.  The  changes  m  thi-  litart 
muscle  here  must  be  regartled,  we  thinK.  as  to  some  extent  de^'iMrative. 
The  first  obvious  change  «  that  of  cloudy  swellinK,  ami  Virthow  is  pn,!^ 
ably  correct  in  regarding  this  as  the  first  stage  in  an  mflaniinaton 
process  But  liesides  thb  myocarditis  parenchifmiiU>»ii,  in  maiiv  (uses 
there  is  evidence  of  an  interstitial  process  as  well,  f«ir  wc  see  coll.rtioas 
of  inflammatory  leukocytes  between  the  mascle  filK>rs.  togt'thir  with 
connective  tissue  proliferation.  Thw  form  is  calle<l  by  Orth  mywardiU, 
deqenerativa.  The  affected  muscle  is  pale,  soft,  and  friable,  un.l  ..ften 
wdematous.  HemorrhaKic  points  may  often  be  seen  thmuKh  its  sulh 
stance.    The  cavities,  particularly  the  left  ventricle,  are  dilate<l. 

Microscopically,  the  fibers  are  swollen,  the  stnation  faint,  niul  the 
nuclei  indistinct  (cloudy  swelling).  Vacuolation  i.s  somt'tiin.s  s«-en, 
and  fragmentation.  If  the  process  continue,  the  nuclei  swell  and  .lividf 
and  the  fibers  show  fatty  or  hyaline  degeneration.  The  v.ss,"ls  are 
usually  congested  and  may  show  proliferative  changes.  Colh-  t.ons  o( 
inflammatory  leukocytes  in  many  cases  are  seen  between  tin-  tnastk 
fibers  and  in  the  later  stages  proliferation  of  the  connective  tissui-,  with 
the  formation  of  fibroblasts.  In  this  form,  suppuration  dot;s  not  .Krur. 
If  the  patient  survive,  the  inflammation,  if  slight,  may  eiitinlv  resolve. 
In  othercases  a  iliffuse  fibn>sis  of  the  heart  muscle  is  the  result.  In  this 
cH>nnection  it  might  lie  mentioiu'il  that  Asehoff  ami  Tawara'  have 
latelv  drawn  attention  to  a  special  form  of  acute  mycMnnlitis  ...(.imni- 
in  acute  rheumatism,  in  wliic-h  scattered  f.K-i  of  leiikmytic  iiifiltniiion 
an-  found  along  the  course  of  the  vessels,  in  type  suggesting  an  i..f.Ttivf 
origin,  but  not  g«)ing  on  to  suppuration. 

Pomlent  Myoearditli.— Purulent  inyocanlitis  can  unsc  iii  varioib 
wavs  Apart  fn>m  those  cases  whic-h  are  due  to  a  direct  vHmisk.ii  fnm 
a  purulent  pericanlitis  or  an  ulc-ernive  eml.Karditis.  an  *  >■  .lie  inf.rtwn 
is  the  c-ommonest  cause.  The  so-called  idiopathic  hcu  .oscess  where 
there  is  usually  a  .single  pus  collec-ti.m  of  s;)me  size,  distiii.t  y  rare. 
Formcriv,  maiiv  cases  of  myomalacia  were  erroneously  classc',!  uiider 
the  term*  abscess.  Most  cases  are  simple  expressions  of  a  genera  I  irtniia. 
On  examination,  the  affected  heart  is  seen  to  Ik-  rid.lle.l  wiili  n\m\»f 
eravish  or  gravish-vellow  dots  the  size  of  a  pin-head  or  larpi  Many 
of  these  are  .surniimded  bv  a  hemorrhagic  zone.  Small  luM.|.rrha).'es 
are  often  .seen,  and  all  grades  cK-c-ur  from  this  to  true  pus  oH  ■.  .m 
The  heart  mav  lie  dilated,  and  sh<»w  cloudy  or  fatty  changf\ 

MicroscH)picallv,  these  areas  are  .seen  to  consist  .>f  pus  nils  with 
cell  detriti.  The  vessels  are  often  found  to  lie  plugged  «iiii  micpv 
organisms,     in   many  cases  the   bacteria  have   penetrated   c.f  ve^-:: 

>  Die  heutiRC  Uhw  von  don  pathologischfii-anatomischen  Grundlai:.  Itr  Hen- 
■chwachc,  Gustav  FiHcher,  1906. 


: ll  i  :     ! 


CHRfiNIC  ISFLAMMATIONS 


149 


wnIN  iiikI  appear  within  the  leukocytes  or  are  lying  free.  The  muarular 
filMTs  sliow  t-loudy  MwcllinK  or  fatty  degeneration.  The  vessels  in  the 
tH>i|;lil)<irluMMl  are  greatly  congested. 

In  the  event  of  recovery,  the  detritus  may  be  absorbed  and  a  fibrous 
scar  1h'  |irodiice<l,  or  the  area  may  liecome  calcified.  More  often  the 
patient  (lies,  but  if  he  survive  for  a  time  the  abscesses  may  coalesce, 
ami  rupture  into  the  pericanlium  or  into  a  cavity  may  occur.  Thus 
comnuinieution  can  lx>  opened  up  between  two  cavities,  or  a  partial  heart 
aneurism  can  result. 

Aeats  Miliary  Tnbarenlotii. — Acute  miliary  tulierculosls  is  somewhat 
rare  only  one  ea.se  having  come  under  our  observation.  It  is  a  pert  of  a 
(iisst-niinated  miliary  process. 

Ohronic  Influnmationi.— TnbwenlosU.'— Most  frequently  the  tuber- 
riikiiis  atfeetioii  is  an  exteasion  from  a  tuberculous  pericardium,  especially 
from  the  ehmnic  cas(>atiiig  form.  It  is  rarer  to  find  smaller  or  larger 
tuseoiis  fmi  in  the  heart  wall.  The  differential  diagnosis  between  this 
ninditiuti  und  syphilitic  gumma  is  very  difficult,  and  often  can  only  be 
made  after  a  general  survey  of  the  whole  ca.se,  or  from  the  discovery  of 
the  H.  tiilHTculosis  in  the  affected  area,  (iummas,  however,  are  apt  to 
Ix'  en<l()s(s|  in  a  den.s«-  mass  of  hyperplastic  connective  tissue. 

Syphilis.-  Syphilis  is  an  infrequent  canliac  affection.  According 
to  H.  I'.  I^Mjmis,'  syphilis  of  the  mycx-ardium  takes  the  form  of  (1) 
jtinninulous  fcxi,  ainiiist  invariably  in  the  wall  of  the  left  ventricle; 
(2)  filmnd  induration,  either  localized  or  diffase;  (3)  amyloid  infiltration; 
(4)  endarteritis  obliterans,  often  causing  ii.  -ctions.  Indurative  inflam- 
mation is  perhaps  the  mast  common. 

.SolitarA-  gniTiinas  may  reach  the  size  of  a  pigeon's  egg.  They  are 
rare  in  inherited  syphilis.  Multiple  miliar}-  gummas  are  also  described. 
I'atty  (Icfteneratiori  of  the  muscle  is  a  more  frec|uent  manifestation  of 
the  sjH-cifie  virus.  Rupture  of  the  wall  or  a  partial  heart  aneurism 
may  rcsnit. 

Actinomycosis. — .\ctinomycosis  is  very  rare,  and  is  secondary  to  actino- 
mycosis of  the  mtHliastinum,  lungs,  and  pericardium.  It  takes  the 
form  of  small  granulomas  of  a  grayish  or  yellowish-white  color,  often 
.suppurative  in  character. 

Trauma.—Solution  of  the  continuity  of  the  heart  muscle  arises  in 
various  ways.  Wounds  inflicted  by  instruments  or  bullets,  either  wholly 
or  piirtiaily  pnetrating  the  wall  from  without,  are  not  uncommon.  An 
ni(rr  of  tiie  stomach  has  l>een  known  to  penetrate  the  wall. 

Foreign    Bodies.— Foreign    bodies    are   .sometimes    found    in    the 
heart  wall,    'i'hese  may  come  not  only  from  without,  but  from\the 
as,,p||,ijr„s  and  stomach,  and  are  usually  needles,  bullets,  fi.sh  bones, 
and  the  like.    The  condition  may  l)e  latent  or,  on  the  other 
^'idden  death. 


knifi' 
ham 


If.-iil  »( 


'  I  "r  M  lull  description  of  TuKrculosis  of  the  MvocaHium,  see  Anders,  Jour. 
Am.r.  \i,  ,|    Assoc.  1!H)2:  lOSl. 
■  ^ '■"'  Journal  of  the  M-dioal  Hcionces,  110:  1895:389. 


-Hi 


150 


THK  MYitCAHlilVM 


PUTMitM.  1'iirii.silt's  an-  fx»n-iiH'ly  ran-.  HrhinnctM-ri ,  tyiriirerri. 
atMl  pentaniiyit' I  I'^vf  iH-t'ii  foiiiMl.  Tr'whinir  an-  said  luM  to  In-  f.mml. 
EohiiMMtH  <  tw  (  i'  limy  hurst  into  u  ravity,  caiLHing  a  Krnrral  infection 
or  siMltlcn  i\vvk\     from  jmlinonary  I'mlKilinni. 


BFr^OOBBtllTB  lOTAllOftPBOIia. 


f'.i-  ,>U  A  rophy.    SinipU*  nfr«>phy  of  tin-  hwrt  \»  (IvHnr. 

A    '  minntion  in  tlu-  sizf  and  weight  of  th<'  orpin. 

I.I   not      iirtake  .««»  inufh   in  the  pRK-i-sw,  «>n.H<(|uiiHly, 

^  v\  \\    ;•■   /f  tlu'  iniis«ie,  thry  Im-j-ohm"  tortiK^  ;i.     Tlit  tpi- 

from  t*'*'  same  in\»y*'  pn-N«'nt  u 


▲trophy 

teriztMl  hy  i 
ITif  artfrii 
owin^  to  th»' 

cunlium  an  i<  •  i  i  .'  inlinm  alii* 
rumpled  aiiMMiun  .iJ  • '»'  i  ■<  nJary  thickening.  'IV  mns«lc  is 
firm  and  teii„li.  i  A  nuiv  .  f .  ;..ll,  dark  hrown  color  teown  •trophj. 
Microscciii  (I'v.  tin  lil  s  an-  thinner  than  normal.  'V\v  imtlinc 
of  the  cells  i.s  V,  il  n  rl.i...  owinjj  to  an  actual  .se|)aration  of  thr  tnusolc 
Imnd-s.  Tlii.s  rej;iii'l>i'  -  Ix'injj  due  to  a  di.sinte^cration  of  tlic  (ilK•^ 
in  ( « in.se(|ucn<  i  of  intOHiv  i  nutrition  of  the  cement  .sul»stanre.  In  hmwn 
atrophv,  in  ii«idition.'  then-  i^  a  >;r«'ut  irn-mw  in  the  amount  of  tin-  pig- 
ment which  is  tisually  sitimiiil  alxMit  the  jMile.s  of  the  iniciei,  and  the 
pigment  takes  a  <lark"l>rown  color.  In  s»'vere  ca.se.s  bn>wn  ({rainiles  ary 
.s»m  to  Ik-  MMttcrcd  tliroii>:hout  the  <rll. 

Whether  the  afTe«tion  can  <Kinr  as  a  pun-ly  senile  ehanp-  has  Imvii 
doul)te<l;  nevertheless,  nrntiiu-  examination  of  -«'ti«)ns  fniin  the  prt- 
inorteiii  rtnnn  shows  tliat  after  n>iddle  ajfe  .s«)nie  decree  of  hn»wn  iitniphv 
is  verv  common.  Mon-  certiiiii  cansj-s  are  marasnnis,  maligii.itit  diM-jsc 
and  tiilH-rculosis  of  the  hnijr^.  Some  ciises  are  clue  to  prt's-sun-,  us  fnini 
mc<lia.stinal  lesions  or  from  |)rof;nssive  n-liipsiiij;  peri«-anlitis. 

Local  Atrophy.  !,<K-al  atn»phy  is  due  to  pressure  .»r  to  .s<ler(isis  if 
small  hninclH's  of  the  conniary  arteries.  Atrophy  of  the  cohimiw 
carnea'  of  the  h-ft  venlrldt-  which  is  so  c<mimon  in  valvular  affc<li«)as  of 
the  lieart  mav  rtsult  from  either  of  these  causes. 

Degenerations.  Cloudy  or  Albnminoid  D«g«ier«tion.- 'Hiis  is  a 
very  common  condition,  'i'hc  heart  mn^lc  ha-s  a  prayi^h.  <ioHi|v. 
opatpie  ap|M'araiice  not  milikc  parlMiilwl  incut  or  raw  Ksli  Mi('n>- 
scopicallv,  the  filn-rs  are  seen  to  l>e  o|vi(pic  from  the  deposit  of  vm\  ■■rm 
minute  finumlcs  which  ol.sciire  the  nucleus  and  tran.sverse  stri.i  ITif 
condition  is  hcst  made  out  l>y  makin^j  a  thin  section  of  the  frc-l  hwIp 
The  nature  of  the  >rranulcs  is  not  definitely  setth-d,  Imt  they  .jixartn 
Ik-  alhuminoid  in  their  chanictcr.  On  achling  a  dr«)p  of  artt  Mciiif 
the  section,  the  };rainilcs  dissolve  and  the  normal  tran.sluceiK  .  of  tb 
filKTs  is  restored.  _  ^ 

Cioiidv  swcliiiif;  i-  \«  ry  connnon  in  the  course  of  the  itiftttifii-  t^f!"- 
and  is  (hie  to  the  action  of  ,|MH-ific  toxins  with  or  without  pi.  l.me«l 
hi^h  temjK-niturc,  or  to  disonlers  of  metalM)li.sm. 

Fatty  Degeneration.  This  conunon  condition  is  characteri/'  i  !>}  "In' 
pn-senw  of  minute  j;lol.ules  of  fat  in  tlit    mu.sele  fil)t'rs,  whi<      an  <ii- 


FATTY  DEtiESKkATlON 


151 


piiNittil  III  stniill  (lro|il«>t.<«,  K«>ru>rulK-  in  tlM>  liiM>  <>f  tlt*>  l«>n){ittuiinal  filirillip 
(if  llir  ttll  In  ll**"  ^'vi-n-r  nHftrtHiiiK  llu-  w\w\r  iiui.<m-I«-  HImt  inav  lie  firll 
{)(  flit.  Ill*'  rhaiij;*'  ofu-n  lK-}(iii.s  with  cliHuly  swelling,  hut  while  aeetic 
arid  Mini  |»olu.«.>timn  hy«lr»te  hav*-  ihi*  |N>wer  f>f  restoritiK  a  rlowly  cell 
t(i  its  iKimml  af»pearaiwe.  these  a)(etil.i  have  m>  efftn-t  on  fat  Kktlxilf^- 
(Kini*'  iMMJ,  li'iwpviT,  stiiiiis  the  fat  lilack,  and  Smlati  III,  a  rarmine 
rwi.  At  firftt,  the  traiisvers*'  .striHti<iii  of  the  eells  is  readily  maile  oat, 
iHit  tiiids  tti  U-f'oine  olweimil  the  iiMrn*  advaiK-f<l  the  de)(i'neration. 
'Hie  tiiiidition  may  affwt  tin-  wlH>le  heart,  one  side  of  it,  or  one  side  of 
the  wall  of  u  cavity. 

Mi('nis<i>|Hcally,  tlie  miistle  is  sittt,  friahle,  aial  of  a  fwle  color,  the 
depMcniti'*!    p<irtion  showing  up  as  yellowish   stn-ak*  or  speck-s,  hy 

Kl...  33 


f  .tt\  •{•KiMi'>rali<tn  of  thf  hnm  niu-^-le.  11. ♦•  (il»,-f  in  tin-  urii»*T  and  lowtT  pftrfidn-  tin* 
ftt-l-  :ic  iioriiial.  Thimr  in  llip  centre  rnntniii  f;it  tir»i|.lt»l?*.  ^l.-wing  an  t>l  ifk  dotrt.  Zt'l  uljj 
111'     .iilar  Nn    I,      (Kniiii  llic  l'Hlli..|iwii-al  ljil-r:itiiry  ..f  M.'i     II  I'liivpr-ify.) 


i>T  on  tin-  fiido(;inliuin,  the  |)apili  in  iniiscles,     itd  in  t 
i'ft  vciilrielf.      in  well-murkfl  nises  the  muselr  h;i.s  a 
a[)|M;ir,in<c     rln'  so-eallttl  'llirush-hrfHst"  heart. 


pre  I 
of  I 


In  .iiiMiiMiil   fallv  <lmnj;«-,  wiieii   tl»<Te  is  aiiemi;i  a>  w- 
mil  rh   ix  very  pale  and  uf  u  vellowlii  whiti-    r  clav  i  olor. 

it  i 


In 


ail 

-uUil 

heart 

.isst.-^te 


ti  and  cuts  like  clu-i 
1  iK'  iiiiiiii  ( aiiscs  of  fattv  def;«'ner!ition  are  fretv  tlm?  i*  to  sav, 

tlioM  ariiiii;  ihroii^'h  the  •   n-ulatiiin,  and  Icxid. 

1 1"  iiifictions  fevers.  j^rticulaHv  typhoid,  uiddiijhth*-?  la.     ieaiumia.s. 
as  [H -^niiiiMis  anemia,  and  leiikeiiiia;  |)oison.s,  like    'hovphoras,  arsenii  , 
l|'l'"ric  arid,  art-  the  connnon  pneral  cans     ,     Whet   "r  we  are 


iU'A 


152 


THE  MYOCARDIUM 


H 


i  f 


I 


to  regard  with  Virchow  the  fatty  degeneration  occurring  in  the  infections 
as  a  sequel  of  a  parenchymatous  myocanlitls  is  perhaps  doubtful.  Mam- 
cases,  however,  arc  beyond  a  doubt  pure  degenerations. 

The  local  causes  are  sclerosis  of  the  coronaries  and  valvular  loions. 
Whenever  hypertrophy,  dilatation,  and  incompetence  co-exist,  fatty 
degeneration  is  almost  certain  to  be  present. 

Fatty  degeneration  also  accompanies  inflammation,  as  in  acute  |)eri- 
carditis  and  acute  interstitial  myocarditis. 

Fatty  Inflltratioii. — Fatty  infiltration  is  not  to  be  confased  with  the  last 
condition.  In  this  the  normal  amount  of  fat  which  is  present  alnmt  the 
haae  of  the  heart  and  in  the  coronary  sulci  is  greatly  increa.se<l.  Tlie 
fat  forces  its  way  in  between  the  mascle  bundles  and  may  even  appear 
on  the  endocanlium.  ^^^lile  the  heart  is  much  enlarged,  it  is  at  the  same 
time  greatly  weakened,  since  the  muscle  fil>ers  are  markedly  atropliic- 
a  true  pressure  atn)phy  (atrophia  lipomaiosa).  In  advanceil  cases  the 
front  of  the  right  ventricle  ami  even  the  left  may  l)c  permeated  with 
fat,  in  addition  to  that  which  is  present  in  the  sulci  and  alH)ut  the  main 
vessels.  Often  the  apex  of  the  right  ventricle  in  cro.ss-sc<-tion  sliows 
scarcely  any  muscle.  Obesitas  cordis  is  always  a  manifestation  of  general 
corpulency. 

Microscopic  sections  show  merely  masses  of  fat  lying  iH'twj-en  the 
muscle  bundles,  which  are  usually  paler  and  more  yellowish  brown  in 
color  than  healthy  muscle.  The  fibers  are  atrophic,  often  gniniilar,  and 
may  show  signs  of  fatty  degeneration. 

Hyaline  Degeneration. — Hyaline  degeneration  is  a  gla.ssy  or  waxv 
condition  of  the  muscle  fil)ers,  in  which  they  gradually  lose  their  siriation 
and  become  homogeneous,  presenting  a  hyaline,  shiny  appearance  not 
unlike  amyloid,  but  not  giving  the  same  chemical  reactioiLs.  More  often 
the  hyaline  change  involves  areas  of  fibrosis. 

Vitreous  Degeneration. — The  vitreous  degeneration,  which  von  Zenker 
described  in  the  muscles,  especially  the  recti  of  the  alMlomeii,  and  (xtur- 
ring  in  typhoid  and  other  infectious  diseases,  is  prolwbly  a  1(  alized 
necrotic  change  (vol.  i,  p.  flOO).  The  filwrs  of  the  heart,  when  iitfected, 
become  brittle  and  break  up  into  lengths,  or  we  may  .see  gloliiiles  of 
hyaline  material  enil)e<lde<l  in  the  filn-r.  In  the  later  stages,  tlie  inter- 
stitial fibrous  substan!-e  proliferates,  and  we  may  find  it  passiiii;  in  \re- 
twi-en  the  various  muscle  fragments.  The  change  is  seen  mainly  in  the 
acute  infections  or  asscx-iati'd  with  parenchymatous  inflammation. 

Segmentation.-  Segmentation  of  the  filn-rs  is  seen  in  hearts  that  are 
dilate<l,  relaxe<l,  soft,  and  brittle.  The  individual  filM*rs  are  scpitniled 
and  broken  up  into  short  lengths,  the  "mywanlite  segmentaire"  of  the 
French  writers  {'{enaut,  Landou/.y).  The  parts  usually  atrccteii  are 
the  septum  and  the  papillary  nuisclcs.  Many  opinions  have  liccn  ad- 
vanced as  to  the  nature  of  this  condition.  It  cK-curs  in  cases  of  sadden 
«leath  from  aci.te  dilatation  of  the  heart,  in  prolonge«l  muscidar  strain, 
in  the  various  infwtions  and  intoxications,  in  Bright's  discuse,  in 
hyaline  degeneration,  and,  as  I^rfindry  has  shown  at  the  Royal  Victoria 
Haspital,  in  a  large  pn>|M>rtion  of  i  .wes  of  aneurism  of  the  aorta.    Others 


yi 


DEGESERATIOS  OF  THE  HEART  GANGLIA 


153 


think  it  is  prwiuced  during  the  death  agony.     It  can  be  produced  experi- 
meiitallv  by  the  action  of  digestive  ferments  upon  the  heart  muscle. 

Hi'ktoen'  recognizes  two  forms,  true  fragmentation,  in  which  the  mu.scle 
filKT  is  actually  ruptured  at  some  part  of  its  course,  and  segmentation, 
in  wliicli  the  primitive  segments  of  the  fibers  become  .simply  dissociated. 
The  first  form  is  due  to  strain  upon  a  weak  and  iasufficiently  acting 
miisclp.  J.  B.  MacCallum'  concurs  in  this  division  and  is  dispased  to 
repird  segmentation  as  a  form  of  "reversionary"  degeneration.  Both 
HrktiH'ii  and  MacCallnm  regurd  it  as  of  antemortem  occurrence,  but 
there  are  not  wanting  those  who  reganl  the  condition  as  a  simple  artefact. 


Fin.  24 


I  riiimu'TitBlion  of  the  (AieTf  iii  iIip  hrart.      Leiti  <)l)j.  No.  7,  without  ocular. 
coUertiim  of  Ur.  .\.  (i.  .Niiliolln.) 


(From  the 


Amyloid  DegeneraOon.— This  never  afftcts  the  muscle  fibers,  but  the 
nitirs«iiial  cement  substance  and  the  l)loo<lves.scls.  It  is  part  and  parcel 
of  a  jrcneral  amyloid  degeneration.  It  is  rare  to  find  the  process  so 
extrciiif  tliat  it  can  be  recognized  macroscopically. 

Calcification.— This  is  usually  a  terminal  event  in  the  course  of  myo- 
iiiahK  w  or  of  fibrosis.  The  deposit  of  lime  .salts  which  is  seen  .so  often 
"1  tlif  Ihi.kened  mitral  ring  in  •■a.ses  of  mitral  stenosis  may  encroach 
o'lMilcnil.ly  uiwHi  the  heart  nnisde,  ami  we  have  .s<hmi  one  ca.se  in  which 
a  larp. .  ahareous  mass  in  this  situation  all  but  penctratwl  the  wall  of  the 
vct!trii|c.  ' 

Degeneration  of  the  Heart  Ganglia.— This  iuts  l)een  descriljed.  Putjatin 
f'>iiM,l  ,1  i„  various  chronic  affections  of  the  heart  ami  aorta,  and  in 

'  A".  ^   I'mr.  M,.,l.  Sci.,  lU:  1S97:  .Wi>.         •  Jour.  ExiK^r.  Med.,  4: 1899: 409. 


.  i       I 


154 


ftiE  MYOCAkDWM 


syphilis.  The  chanRes  were  fatty  ami  pipnontary  dejccneration  ..f  the 
ganglia,  with  hyptTpmia  and  pnMliictivf  inflammation  in  the  nei>;lil)()r. 
htHxl.  No  doubt  some  nutritional  dlsturlMinee  is  at  work,  but  the  si);. 
nificance  of  the  changes  Ls  not  matle  out,  further  than  that  sericHis  inter. 
ference  with  the  power  ami  function  of  the  heart  Is  the  result. 

Suptnre  of  the  Heart.— Sfwutaneoas  rupture  is  a  rare  event,  and 
never  occurs  unless  the  heart  has  l>een  weakened  by  disease.  The 
most  frequent  causes  are  fatty  degeneration  of  the  muscle  and  <k( hision 
of  the  coronary  arteries.  Le.ss  commonly,  myomalacia,  aKs«'.ss,  frui.i;na. 
echinococcus  cvst,  -ind  new-growths  are  res|)onsible.  Rarely  an  luirtic 
aneurism  has  ruptured  into  the  auricle,  a.s  in  ca.ses  reporte<l  l>.v  von 
Wun-scheim'  and  A.  McPhe<lran.'  Death  is  u-sually  in.stuntiiiuH)us. 
but  a  few  ca.ses  have  lieen  recordetl  where  the  patient  has  live.1  several 
hours  or  even  davs.  Deposits  of  fibrin  are  usually  found  in  the  neijihlxir- 
hood  of  the  tear",  an<l  more  or  less  bUxxi  is  effused  into  the  p«-ri(anlial 


sac. 


PBOOBnUIVK  BIXTAMORPHOSU. 


Enlargement  of  the  Heart.— This  Ls  due  to  hyperirophij  or  torf/V 
Utthn,  or  Ixrth,  affecting  one  or  more  cavities.  In  gt-neral  li>T)tr- 
trophy  of  the  heart  the  organ  hius  a  more  n)unde<l  appearance  than 


Kin.  2.5 


A.  nmnul  linirt  "f  riil.liil:  H.  li.v|ierlr..|.l'i-<l  '"•"'■'  "'  "''''•''  ''•"•"  ""I*""'"'  '" 'ii"">«-;i 

Klniili  <l".«»  "f  mlreimlin  i-xl<-i..liti|t  "vpr  «.xeml  wwk».  Thr  mirennlin  .uu^s  .•..iitia.  ti..n  ■*  ta 
arteriolp-.  li.MKlit.-M«l  IiI.hkI  pressun-,  anil  in.  r.>u*.l  heart  work.  iKnilil  »|K-.iMui,-  1  l)r.  k>T> 
in  Ihe  MKlill  PatlioUwiral  Miwuni.      Natural  si«" J 

nornml,  and  its  transverse  breadth  is  greatly  inereased.  '1  1h>  niLiv^ 
ment  may  In-  so  great  that  the  heart  apprjMwhes  that  of  ili.  ItiilUl. 
in  size — atr  bovinum. 

'  I'rSpT  iiic<li/,in»chp  Worhoiisolirift,  IS:  1H93:  IT.'i. 
»  Cuniiiliuii  I'mctitiomT.  21 :  1S<H(:.578. 


li 


IH:, 


HYPEkTkOPllY 


155 


Bypertrophy. — Hypertrophy  is  in  most  cases  due  to  increased  resist- 
ance to  the  heart's  action,  pruvideil  that  the  mascle  is  able  to  respond 
to  the  increased  demand.  Or  otherwise,  anything  that  increases  the 
wori(  of  the  heart,  short  of  causing  cardiac  exhaustion,  leads  to  hyper- 
trophy.   We  may  classify  the  causes  as  follows: 

I.  Obstruction  to  egress  of  blood. 

(o)  Endocardial,  from  stenosis  of  one  of  the  valves. 

(6)  Arterial,  from  diminution  of  the  arterial  lumen,  sclerosis, 

contraction  of  the  smaller  arteries,  etc. 
(c)  Pericardial,  from  complete  synechia.' 


II. 


III. 


Increase  in  the  volume  of  blood  to  be  propelled. 
(o)  Actual    increa.se  in    the  amount  of    circulating  blood, 

plethora,  Munich  lieer  heart,  etc. 
(6)  From  regurgitation,  as  in  mitral  and  aortic  incompetence. 

Increase  in  rate  of  biood  flow. 
(o)  From  tachycardia,  as  in  exophthalmic  goitre. 
(c)  As  a  response  to  .systemic  needs,  as  in  the  athlete.' 


The  chamljcr  to  l)c  first  affecteil  is  that  one  which  first  experiences  the 
unusual  strain.  Thus,  in  arterial  .si-lercxsis,  Bright's  disease,  and  aortic 
endcxarditis  the  left  ventricle  is  the  first  to  suffer.  In  pulmonary 
en(l(xar(litis  and  many  lung  affections  (fibroid  tul)ercul(>sLs,  emphy.sema, 
ami  pleuritic  ailhesions)  where  there  is  obstruction  in  the  les.ser  circula- 
tiun,  it  is  tiie  right. 

(itMH-ral  hypertrophy  will,  in  time,  supervene  upon  partial  hypertrophy. 
It  may  (x-cur  fr  in  overexertion,  as  in  excessive  mascular  work,  hysteria, 
neurasthenia,  prolonged  mental  strain,  exophthalmic  goitre,  in  peri- 
eanlial  synechije,  and,  very  common!  from  overeating  and  drinking. 
The  Munich  "  Ijeer-heart"  is  a  go«xl  example  of  general  hypertrophy 
due  to  tile  prolonged  overdistension  of  the  vessels  with  fluid. 

H.  A.  I^fleur*  gives  the  following  statistics,  showing  the  proportion  of 
the  (iitrerent  causes  in  36()  autopsies  at  the  Johns  Hopkins  Hospital. 
Cardiiic  hyfMTtrophy  was  found  in  105  cases.  These  were  dividetl  as 
follows  (ill  percentages): 

'  lltiT  tlic  tnuRcle  contracts  agaiiiHt  an  incmiHed  load  and  the  increased  work  leads 
to  h\|iirtn)phy.  This  in  the  earlier  HtaRcs  of  complete  pericardial  n<lliewion- 
ThnnigU  .Mutirnl  exhaustion  the  hypc>rtn>phy  is  apt  to  give  placi;  to  dilatation  anil 

atn)piiv. 

'  II"'  imimnt  ol  :.!'«d  passing  from  the  actively  contracting  skeletal  muscle  is 
mucli  Kn  itir  than  that  fn..n  the  resting  muscle.  In  those  taking  active  exercise 
U  IS  niilv  at  first  that  the  blo,Kl  pri'ssun-  is  increased;  later  it  may  fall  to,  or  even 
lit'luw,  itir  iiiirmal.  It  follows  thus,  that  to  supply  the  nuitrncting  nuisele  the  ratn 
"f  rtmv  must  undergo  increase.  In  Ixilh  of  thew  cases,  n  and  h,  the  acct)mpanying 
incna^i  I  rale  of  heart  beat  favi.nng  this  more  rapid  lirculation  must  be  ascribeil 
to  n'lli  -  nervous  stimuli. 

'  M     ir.al  Med.  Jour.,  23:  \mi:  8.51. 


I 


I    <  *  [ 

ill 


156  THE  MYOCARDIUM 

A  rKTial  Heterosis 50 . 0 

Chnmic  nephritis 13.4 

Valvular  lesions 12.4 

Pericardial  .syncchi;!' T.ti 

K^cessive  muscular  work 3..S 

T'lmors l.!> 

Aneurisms (I.O.i 

Plethoni 0.«1.-. 

Fin.  26 


Cnws-sectitm  of   tlip  tieiirt,  tn 


»liiiw  li.v|)erlri.|ih,v  of  tin-  waW".      Tin-  cttUM';  iiicreiixil  |KTi|ilim 
(I'atliiilciiicul  Muwum.  Midill  IniverKlly.) 


I    i 


11^ 


Dilatation.— UfforciuT  lia.s  Imh-ii  made  in  the  prectnlinj;  cliaptor  to 
thf  (li.stiiH-tion  iM-twtrn  (phv.siolofiical)  distcn.sion  ami  (patliolopcali 
dilatation.  A.s  tlip  h_vp('rtn>j)lii«Hi  licart  JHromes  weab-r  the  latter  l)e- 
c()MM'.s  nianife-sti-d.  >I<)st  of  the  cause.s  that  produce  hypertropliy  m 
coinjK'tent  to  cause  dilatation  in  time.  It  i.s  a  fre<|iient  msult  nf  snilden 
strain,  a.s  in  prolonjunl  race.s.  The  nio.st  frtHpient  cau.se  of  siiii])l('  dila- 
tation is  dem'iieration  of  the  muscle,  usually  fatty,  such  as  tM(il^  in 
typhoid  fever,  pneumonia,  and  other  infective  fevers,  and  also  in  jxr- 
niciotis  anemia.  Acute  dilatation  nuiy  also  lie  inducetl  by  iilcoimlif 
e.xcess,  and  experimentally  hy  cliloroform  and  other  a>;eiits  Im%\ 
dilatation  (aneurism)  has  alreaiiy  Im-cii  referred  to. 

In  dilatation  the  heart  wall  is  jrpiierally  thin,  Hahhy,  softer  than  noniial. 
and  pale  in  color  from  fatty  chaufre. 

The  determination  of  tiie  presence  of  hypertrophy  is  l)est  made  liy 
ponsideration  of  the  volume  and  weight  of  the  heart.  The  li'  art  may 
weifth  from  (1(K)  to  S(Kt  >;rams.  .Stokes  ri-conls  one  of  19.S0  firiii  -  IV 
averaj^e  thickness  of  the  left  ventricular  mu.scle  is  from  15  to  -'0  mm., 


DILATATiny 

Fifi.  27 


157 


Simple  hypertrupiiy  i>f  the  heart.      Leitz  Nn.  7,  wiilxtut  <irular.      Slmwa  large  blunt-ended 
iiuflei,  uc-ruMiuiuUly  dividing.      ^I>r.  A.  O.  Nifliollit.) 


■m%. 


Fkj.  2S 


llib'.i.-  iliUiutiuu  of  th»  left  ventricle  of  the  heart.      Patent  foramen  ovale.      (Kiom  the 
Patholufical  Muaeum  of  HcGill  Univernity.) 


158 


THE  MYOCARDIUM 


It.  .1; 


tl^  ■  ^■ 


but  reference  to  this  staralani  only  jfivex  imperfect  information,  since 
other  factors  may  inter>'ene  to  prevent  a  correct  conclusion  beinj;  fi>nn«|. 

Tlie  hypertrophietl  muscle  is  of  a  marked  brownish-red  color,  with 
often  the  sheen  of  raw  ham.  Its  coasistency  is  increased  so  that  when 
cut  it  does  not  collapse,  bu*  remains  firmly  in  position. 

Microscopically,  the  muscle  fil)ers  are  increase*!  in  thickness  and 
pn)lmbly  in  numl)er  (hi»-perplasia).  The  nuclei  are  very  large,  deeply 
staining,  with  bluntly  roundetl  emls.  Sometimes  they  appear  to  lie  in- 
creased  in  numl)ers.     Often  fatty  changes  in  the  l)ands  can  l>e  made  out. 

Tumora. — Tumors  of  the  heart  can  Ih"  either  primary  or  .secDiularj-, 
By  far  the  majority  are  due  to  the  extension  of  malignant  growths  from 
neighlmring  parts,  as  the  pericardium,  mediastinum,  lung,  <e.sopiiagas, 
and  stomach,  or  to  metastasis. 

Fin.  29 


iiiviiiltvl  !>>■  niiunl-reUe,!  imrrdmu.      neirhert  i4>i.  Nn.  7a,  withciut  ' 
(Ciillertidii  of  Die  lioyal  Virtoris  Hoxpitul.) 


ular. 


Primary  iMH)plasnis  an-  excessively  ran*.  This  is  pnilwihlv  to  !« 
attribute*!  to  the  fact  that  the  heart  alnive  all  orgaas  is  constantly  in  a 
state  of  great  efficiency,  well  nourished,  well  innervate*!,  and  fuiictionallv 
always  active,  so  that  it  is  less  likely  to  take  on  alnrrant  growtli.  'llie 
usual  growths  are  fibroma,  myxoma,  and  lipoma,  the  relative  frtfiuency 
l)eing  in  the  order  namtnl.  These  are  generally  suliendocardial  in  situa- 
tion, and  form  ntxlular  or  jx)lyj)oid  outgrowths,  which  proje<t  into  the 
heart  cavity. 

Fibromas  have  l>ecn  found  in  various  parts  of  the  heart.  .\ge  has 
nothing  to  do  with  their  (Krtirrence.  One  case  is  reconled  in  a  child 
aged  three  months.     Many  of  the  ca.ses  are  congenital,  and  to  tliis  class 


i.:.     i 


THE  ENDOCARDIUM 


159 


heluii^  the  interesting  rhabdomyonu,  of  which  twelve  examples  have 
been  ivconled.'  These  are  hyperplastic  growths,  with  stellate  trans- 
versdv  striated  muscle  cells.  C)ne  of  them  was  also  telangiectatic,  and 
i\  no  doubt,  similar  to  a  recorded  case  of  cavernous  angioma,  which 
prol)iil>ly  was  originally  a  myoma.  The  secondary  tumors  are  carcinoma, 
sarcoma,  lymphosarcoma,  and  osteoid  chondroma.  Metastatic  growths 
may  be  found  in  any  position,  subpericardial,  subendocardial,  or  intra- 
mural. Metastatic  carcinoma  is  recorded,  but  is  rarer  than  secondary 
sarcoma:  of  the  latter,  the  melanomas  present  the  most  abundant 
metastases  throughout  the  organ. 

The  results  of  such  growths  are  various.  When  they  project  into  a 
cavity,  thromliosis  and  its  attendant  embolism  may  occur;  fragmentation 
of  the  tumor,  causing  dis.seminated  metastases;  sudden  death  from 
pulmonary  embolism;  or,  lastly,  rupture  of  the  heart. 


TBI  INDOOAKDroM. 

The  endocardium,  or  lining  membrane  of  the  heart,  consists  of  a  thin 
layer  of  connective  tissue,  containing  elastic  fibrillie  arrangeii  after 
the  fashion  of  a  fenestratetl  membrane.  The  inner  surface  is  covered 
with  a  single  layer  of  flattened  endothelial  plates  similar  to  thase  lining 
lil(H)(!ves.sfls  everywhere.  Further,  the  endothelial  lining  of  the  heart  is 
in  direct  continuity  with  that  of  the  blooilvessels. 

The  valves  are  formed  by  a  reduplication  of  this  membrune  in  which 
the  fihnnis  tissue  has  l)ecome  somewhat  thickened.  In  the  ca.se  of  the 
tricuspid  und  mitral  valves,  a  few  muscle  fil)ers  from  the  myocardium, 
to),t'thtT  with  a  few  small  bloodvessels,  pa.ss  in  to  the  l)a.se  of  the  valve, 
but  till'  aortic  and  pulmonary  valves  are  devoiil  of  even  the.se. 

The  ciKhKurdium  is  richly  supplied  with  lymphatics,  and  the  nerve- 
supply  is  from  a  plexits  situated  in  the  connective  tissue  lK>neath  the 
cndiK'iirdial  layer. 

Tlu'  anatomical  structure  of  the  membrane  has  an  important  liearing 
upon  die  character  of  the  pathological  prtx;esses  affecting  it.  Since 
that  |)orti()n  of  the  lining  usimlly  affected  by  disease  is  devoid  or  rela- 
tively dt\()i(|  of  bloodvessels,  we  get  in  inflammation  a  good  example 
of  the  priKfss  as  it  affects  a  non-vascular  structure,  and  for  the  same 
reason  infective  proce.s.ses  of  emlwlic  origin  are  of  the  rarest  occurrence. 

Furtlur,  when  erosion  of  the  endothelium  takes  place,  we  find  a 
deposit  of  IdcKxl  platelets,  fibrin,  with  resulting  thromliosis. 

Lastly,  the  endcx-anlial  cells  possess  a  marked  phagocytic  power. 


OOKOENITAL  ANOMALIES. 

.\piiii    fn)in    those   conditions   due   to   intra-uterine   inflammation, 
sevcnd  malformations  must  Ix;  mentioned.    Tenettration  of  the  aortic 

'  Wolbach,  Jour,  of  Med.  Hencarch,  16:1907:495. 


IflO 


THE  ENDOCARDIUM 


II 


and  pulmonary  similunar  valves  is  so  t-oinmon  (hat  it  need  only  !» 
referred  to.  An  abnomud  ihap*  of  the  valves,  owing  to  a  loss  of  sub- 
stance  on  the  free  niai^n,  b  occasionally  met  with.  The  nnabu 
of  the  cusps  of  the  aortic  and  pulmonary  valves  mav  lie  dimiiiislutl,  or 
increase«l  to  four  or  even  five.  The  pulmonary  valve  is  the  more  apt 
to  be  affected.  A  perfect  additional  casp  may  lie  in.serted,  or  tht-re  mav 
be  merely  a  septum  attaching  the  free  Iwnler  of  the  cusp  to  the  rin)!, 
thus  dividing  the  casp  into  two  jxirtions.  When  an  extra  cusp  Ls  inserted 
it  may  be  only  one-half  the  height  of  the  others.  Such  redupliciitinn  of 
the  cusps  is  not  excessively  rare.  Three  instances  have  been  met  with  hv 
us  in  1500  autopsies,  and  two  more  are  recortled  by  Powell  White.' 
Three  instanc-es  of  reduplication  of  the  aortic  valves  was  also  met  with 
in  our  series.  Complete  doubling  of  the  left  atrioventricular  (xstium 
with  doubled  mitral  orifice  is  much  rarer.  Dr.  M.  E.  Abbott  figures  an 
example  from  the  McGill  collection.' 

Mitral  stenosis  and  atresia  and  bicaspid  stenosis  and  atresia  are 
recorded. 

Hematoma  of  Valvos. — ^These  are  small  ImxHcs,  the  color  of  rasp- 
berry jelly  and  of  pin-head  size,  seen  most  frequently  along  the  ciasinj! 
eilge  of  the  mitral  segments,  more  rarely  near  the  eilge  of  the  aorta  cusps. 
They  are  seen  only  in  infants,  disappearing  in  childhootl.  Arcording 
to  Kaufmann,  they  represent  unused  remains  of  the  (vasculiir)  nodes 
or  eminences  {mm  which  the  valves  are  developed.  Wegelin,'  in  a 
quite  recent  publication,  points  out  that  in  the  course  of  ileveiopnient 
small  p<K'kets  lined  with  cndothclitnn  are  forme*!  on  the  ventricular 
aspect  of  the  auriculoventricular  valves  and  on  the  distal  side  of  the 
semilunar  valves.  These  cavities  eventually  l)e<-«)me  cover* d  in  by  the 
proliferation  *>f  the  endothelium  to  form  chwed  sa*-s.  Valvular  luma- 
tomus  are  always  found  to  be  {-ovcred  by  en«lotheliuni,  and  Wej.'eiin 
hoUls  that  they  are  f*>rnu'd  by  the  extravusati*)n  of  1>I*mmI  into  the 
aforesaid  p* 
thought. 


xkeLs.      Thcv   are   not   vascular   ecta.ses,  as   .some  liave 


OIKOULATOBT  DI8TTTRBAN0ES. 

(Edema.— Markc<l  (wlenia  <1«hs  not  *Krur,  but  a  slight  jrrade  may 
lie  evi*lence*l  by  a  .shiny  gelatinous  appt'aranic  of  the  etHlcK-iirdiuni. 

Hemorrhages. — Sul)en<l(xar«lial  hcmorrhagi's  *)ccur  from  hloal 
dyscrasias,  such  as  .scur\y,  niorbu-  iiia*-ulosus  Werlliofii,  iM-rniriou.* 
anemia,  leukemia,  an*l  in  the  infct-tions,  like  scarlatina  and  --inall|i«)s. 
^'cnous  hyperemia  or  iii*T<asf<l  art«'rial  pressure  may  lca<l  to  riiptiirp 
and  hemorrhage.     When,  in  <'on.stHiiience  of  inflamnmtion,  new  I'      med 

'  Lancet,  l,onil.  ii:  IWW:  1194.  .St-  also  Osier,  Montreal Cient-ral  ilusjiii 'I  i.  "■■. 
1880. 

'  Osier  aii.l  McCrae'H  Mmlern  Me<lirine,  4:1908:394. 
»  Frankfurter  Ztschrft.  f.  I'atliol.,  2:  IIMW:  411. 


INFLAMMATIONS 


161 


cspillarifs  are  present  in  the  valves,  plugging  of  these  may  lead  to  hemor- 
rhajfif  infarction  of  the  segments. 

nood  Imbibiticm.— A  midish  staining  due  to  blood  imbibition  ia 
often  met  with.  It  is  most  proliably  a  postmortem  change  and  is  specially 
comnum  in  septicemia  and  in  infection  with  the  B.  Welchii. 

Tirombi.— When  atheromatous  ulceration  of  the  endocardium  exists, 
or  sh-mwis  of  any  of  the  astia,  thrombi  are  apt  to  form  in  the  cavities. 
'rhes«-  may  form  a  dense  layer  over  the  atheromatous  plaques,  or  may 
form  polypoid  excrracences.  Occasionally  a  ball  thrombus  may  lie  pro- 
duced. This  form  is  fairly  frequently  seen  in  the  left  auricle  in  cases  of 
mitral  stctuxsis.  A  Imll  thrombas  may  soften  in  the  centre  and  form  a 
blaiitier-like  moss  containing  puriform  or  grumoas  fluid.  Thrombi  also 
ocr&sionally  calcify. 

Among  other  couses  of  thrombosis  may  be  mentioned  dilatation 
of  the  heart,  slowing  of  the  blood  stream,  and  changes  in  the  composition 
of  the  bl(Kxl.  Thrombi  are  usually  found  in  the  right  side  of  the  heart, 
particularly  in  the  appendix  and  near  the  apex,  hut  are  not  uncommonly 
presiiit  in  the  left  auricle.  A  distinction  should  be  made  between  true 
thmmlKwLs  ond  the  clotting  of  the  blood  that  is  so  commonly  produced 
at  the  time  of  death  or  suljsequent  to  it  (see  p.  58).  Postmortem 
clots  are  soft,  moist,  iraaslucent,  and  elastic,  and  ai«  of  a  yellowish-red, 
or  mixed  color.  Extensive  oily  looking  yellow  clots  are  common  in  thase 
(ILseases  where  leukocytosis  is  a  marked  feature,  notably  pneumonia. 
Ileal  thrombi,  however,  are  reddish  gray,  dry,  friable,  and  opa<jue.  They 
are  ^[eiHrally  firmly  adherent  to  the  endocordium,  which  often  shows 
some  pathological  change. 

The  thrombi  produced  intra  vitam  are  of  grave  significance,  as  they 
mav  lead  to  obstruction  of  the  valvular  orifices  or  to  emboli  in  distant 
prts.  Kwart  and  Ilolleston'  have  reported  a  case  where  a  throtnbus 
ansiii};  from  the  fossa  ovalis  passed  through  the  mitral  orifice  and  gave 
rise  to  signs  of  mitral  stenosis. 


INTLAMMATIOMB. 

Endocarditis. -Inflammatory  changes  in  the  endocardium  may 
affect  any  jx.rtion  of  it.  the  valves,  the  tendinoas  conis,  the  papillary 
mas,  I.  .s,  or  the  mural  lining.  The  valvular  form  is  bv  far  the  commonest, 
ami  IS  ofti-n  associated  with  inflammation  of  the  neighboring  heart 
wall.  J„r  the  mural  endocardium  to  lie  alone  affected  Is  one  of  the 
Rrcati'.4  niritie^. 

Acute  Endocarditig.— Pnmary  endocarditis  is  said  to  occur,  and  does  no 
doubt  troMi  a  clmical  point  of  view,  but  careful  search  past  mortem  often 
reAcais  an  external  caiLse  for  the  condition,  so  that  from  patholocrical 
exp,iu,M ,.  we  mu.st  believe  that  every  case  is  secondary  to  some  other 
comi.i.M.  such  as  intoxication  or  infection.     Indeed,  it  may  even  be 

'  Clinical  Society's  Transactions,  30:  1897: 190, 


\  .           '    \ 
!     ■        ''    ' 

ii 

1^ 

■>■     ■ 

?    t 


la 


TIIK  ESlMH'AHltlVM 


doubted  whether  iiituxicatiuii  hits  any  infliu-mr  exct'pt  ii.s  a  prcili^ixMinK 
caiue,  and  whether  all  acute  (■a.s4■^4  are  nut  iliie  to  iNictcrial  invu>i<in. 

Kepeate«l  studies  have  pn»v«l  tliat  the  vom's  asiutlly  c'las.s«>«l  a.s  "  simpk" 
arc  due  to  mienH>rpiniHni.s.  ('on.>u<4|uently,  the  old  division  i)f  ciMk 
carditis  into  "simple"  and  "ulcerative"  no  lon)(er  holds  mnxl  v\vv^ 
for  convenience  of  description,  for  tlies*'  teniw  ujcn-ly  repres«-nl  (.twIm 
in  the  one  process. 

Etiolo^cally,  the  comlition  cannot  In'  repirde<l  as  a  distinct  nititv, 
for  a  j»reat  variety  of  inicnMirpmisins  enter  into  its  causation.  Striniv 
sp«>akin)(,  it  Is  more  correct  tt)  s|H-uk  of  a  pnenincK-iKras  or  stn-ptiKiKrus 
infection,  etc.,  with  eiMhK-anlitis. 

Acute  emiocanlitis  may  ix-cur  as  a  sw-imdar}-  manifestation  in  the 
following  disea.<u>s:  chorea,  inflannnator>-  rheumatism,  septi(-<-niia,  pneu- 
monia, .scarlatina,  tonsillitis,  erythema  ncMlosum,  |M>lio.sis  rlu-iiinuti(?. 
Bright's  di.sease,  dialn'tes,  pyelonephritis,  tuU'rc-uhxsis,  small|>ox,  typhoid, 
gonorrhcm,  and  malignant  gn>wths.  That  overstrain  is  a  jxxssildr  (•a^L^e 
is  to  .some  extent  supportetl  by  experimental  evi»lence.' 

The  bacteria  at  work  an*  immeroiis  and  the  iiifwtion  may  In-  mixed. 
The  chief  organisms  are  the  DipliK-iKrns  pneumonia*,  the  Stn  ptixiifciK 
parvus,  the  Streptococcus  pyogenes,  an<l  (he  Sta|)hyl(H-<MTUs  i>y(^ne« 
aureus;  but  the  B.  coli,  B.  tliphtheria-,  B.  influenza',  B.  pyis  yanetts 
gonococcas,  B.  tul)ercul<)sis,  MicnK-cH-cns  endiH-arditidis  riigatiis,  Mkni- 
COCCU.S  emiocanlitiilis  capsulatus,  B.  end«K'aniitidis  grisens,  liavf  lnvn 
met  with. 

filndocarditLs  due  to  the  goncKiK-cus  is  now  well  riH-ognize*!,  iillliouirfi 
many  cases  occurring  in  gonorrhiea  are  the  resitlt  of  .s«-<()n<larv  infecticm 
with  pus  organisms.  Thayer  and  I.iazcar'  Iittvc  iiiialyzwl  sixteen  ea^x 
The  lesions  usually  are  ulcerative  with  large  vt-gctatioiLs,  aiul  tlie  aortic 
valve  may  l)e  afl'ei'ted. 

A  peculiarity  of  endocanlitis  that  dcser\es  mention  is  its  teiidencv 
to  relapse.  Athen>matous  valves  art'  also  liable  to  Im-ishuc  iiiflanieil 
Statistics  show  that  acute  intlainmution  sujktvciu's  on  clirKnicallv 
sclerosed  valves  in  from  IM)  to  !K)  jht  cent. 

With  regani  to  the  fwfiuency  with  which  the  various  vabis  are  in- 
volve<l,  Washliourn'  refers  to  '.yCf^  cases  of  infintivc  ciithKanliiis;  ilif 
mitral  was  alone  afl'ected  in  ll'i,  the  aortic  in  (>!),  the  aorti<-  iuni  mitral 
together  in  73,  the  tricitspid  in  2S,  the  pulmonary  in  10. 

Acute  OrunUting  Endocuditia. — Acute  granuliitingeiuliK-iinliti-^.  some- 
times calle<l  simple  or  rheumatic  cn(l(K'anlitis,  is  pro<luctsl  by  the  inva- 
sion of  the  endothelial  and  sul)endotliclial  cells  by  Iwcteria  rcHi  iiin);thes- 
tissues  from  the  bhKxl  stn'am.  The  germs  an-,  ik)  doubt,  tak.  ii  iiphv 
the  phagocytic  action  of  the  endothelial  cells  ami  .s™)ii  si>r«nil  to  the 
deeper  parts,  wher»'  they  pnMluce  swelling  and  ctMigulatioii  mk  nisls  of 
the  affecte<l  region.     This  prtx-ess  iK'gins  on  the  dosing  surtin  e  of  the 


'  Roy  ami  -Vilami,  Brit.  M(mI.  .Imir.,  ii:  1SS,S:1:125. 

'  Johns  Hopkins  lIoNpitul  liiilletin,  7:  IStHi:  .57. 

'  The  Pathologv  of  InlectioUH  Kndocanliti.s,  Hritish  .Mcul.cal  Journal,  ii:  l^'lt;  \M 


ACUTE  UHASVLATINd  K.SmHWhDlTIS  ](|3| 

v«l»r,  and  at  fiwt  Itwf « to  a  Krayisli,  cw'.  ,m-i\  u|>|N-anin<f.  Thi.  emlo- 
tMiiiiM  is  wMHi  shwj,  and  a.H  a  it-jiiilt  a  thn;.nlMis,  t„nmtl  at  first  of  hl<NN| 
pUtfltts.  but  iiltimately  of  l«.|ik.M-vtc.s  uinI  fibrin,  is  prodiHt^l.  This 
twtuils  ill  the  formation  of  warty  fx«n- »f mvs  or  Kniniilalioas  (•ndoeu- 
ditii  rmttCOtt),  wther  as  small  iiiNlulfs,  or  villous  «ir  iiolvi)«»i(l  oiit- 
(fTowths  (T«f«UtiT«  •ndoctfdltU)  that  may  n-a.h  the  siw  <'.f  a  plum. 
Those  an-  parlicularly  larjp-  in  pnoumocfMciis  ari«i  »,'onorrli<Hi>|  ms«'s. 
}»ulw«i|iHiitly,  th»>  intimal  <rlls  |.rolif.ratc  uihI  th.n-  is  an  cxiiitatiofi 
of  NukiK  vtrs.  'i'his  i«  a  latr  evrnt  in  thi>  <a.s«-  of  the  aortic  anil  pul- 
moirnrv  valves,  us  tlwy  do  not  i-ontain   blood vt-sstls.  but  may  Ik-  a 

r'i'i.  Ml 


.ii»T  "•'""•'""  •";''f««""  •""•tin,  the   mi.r.l    valv-       Th.  efll.,re„e„,  ,    ,,f  ,ra,mlali..,. 

i  marknl  fratiirt-  in  the  mitral  an.l  tricuspi.l  forms  fn.m  an  earlv  stace. 
-Vw  Nm,„Iv,.sso|s  may  Ik-  formed  and  gr,>w  int.>  the  exndation/so  that 
I  n-pical  Lraiiiilation  tissue  is  produced, 
i     riia,  ,Ih.  infwtion  may  take  place  throuKh  inft>ctive  emimli  in  the 

ex2t  '  I  "  "  ''*'''''  "  "^'f  **>■  ••"""*'  '"  "♦■'•'"••  •""  <»■•«•'•  i"  »  wide 
\Zl\  •  r  '"•"■'  ™''  *'"'  ""  '""**'"•*'  "^  ■'-  "'though  it  is  certainly 
|pos,>ibl,   „  relapsing  cases,  when  new  vessels  have  been  fonne.1  in  the 


IM 


THE  KSmCAHOlVM 


I        ^ 


catpM.     VVckh  has poinU-tl  out  tlw  strikinit  ;.iinil«rity  U'twtTii  tlif  . nk 
rnniitit-  jinK-*"**  aiHl  v«>n<»ii'<  thminliosiH. 

In  v»'ry  s«-vt>n>  i-om^  tin*  ii»-<'n»tic  pn«-««H.s  is  in  ivf-<  of  die  n-|Miriitivf. 
WlK'n  this  is  i\w  nis*-,  if  thi-  ftmniiliilioiis  Ih  l»r<ik  ;  »ff.  wr  ofii  n  mr 
little  an-a-s  of  sii|i|)nrntion  in  lh«-  Htr«l«il  viilvo  (aiM  ><••  rdltli  puituloui. 
'Iliis  Uwls  to  Htlual  nl<-«Tation  with  n«><r«i«i4.  rnptun",  nr  |)«rf..riiiion  ,rf 
the  valv«',  ami  the  formation  of  an  anitc  valvular  anrurisni. 


Acute  ulcermtive  iiid<iranliti«.  »fr«iin«  llie  «<>rtio  valvf  »n<l  the  wmll  "f  lli»  Wi  >.!.':;. 
(From  the  PalhDiiwipal  Muiwum  nf  McGill  Tniven-ity.) 

The  ehanuteristics  of  endocarditis  ulcerosa  kuU  are  that  ;i  jKirt  nf  iW 
valve  is  destmrnl  while  the  reniainder  slums  sipis  of  a  frtsli  i'lHainiii:;- 
torv-  proeess.  The  process  in  its  earlier  staff's  «'inin«ls  one  of  i«liiiryiicvai 
diphtheria,  and  inijjht  easily  Ik*  overhmked.  The  first  stap-  -  a  Miiall, 
somewhat  opatpie.  yellow  "patch,  with  a  slightly  uneven  >u:!a(f.  In 
other  parts  such  a  \n\U-h  in:iy  show  a  distinct  lo-**  of  siihstiiiH c  Ijwn 
these  shallow  uUvrs  retldish-jjray  thromlM)tic  masses  arc  i;i().)>iw|, 
which  mav  attain  considerable  size.  If  the  clot  Ih'  carefull  r.  movfu 
the  tissue 'iH-neath  Is  seen  to  Ir-  swollen,  uli-ersttetl,  and  <,f  '  <Hu™ 
color. 


i 

I       i 


CHKOMC  F.SDOC AHtilTIS 


MS 


wtwwn  tlu'  tinKi. 


ran-full;   nmovPi. 
and  <;f  :<  •flkmbli 


Mi.  i«.M-«»i>»<'ally,  siM-h  «  sf<-ti(»ii  woiiltl  n-v«il  in  •!»■  Hltrinoiis  lepueiit 
oiuiiili -liMil'riu.  TluMixsm-HlMiui  thciiiuru^irfoiii'^  .rw.showM(  ii^ik- 
iwii  iit<  nwis  with  liw.s  of  the  iiiuk-i.  Ij»i«t  on  in  th»-  pnHf!t.<i  »»re  m 
a  (It'liiiiic  lriik«K-ytic  infiltrution  of  tlu>  it,tn)itinj{  oh.  ,.  hi  n-lafisiMg 
(n-iN  wf  oftrii  str  nt'wlv  fonn«l  <ajMllari«s  dUtfiMlMt  with  Wood,  and 
fm|iitiiilv  }Hiiiurrhaf,i'  into  tJu-  intiHimtl  aiva.  True  -upp miiion  in 
this  foriri  is  (hn-ick-dly  rart*. 

'I'll.-  iiffii  (i(.(i  nmy  Hftn-Hd  'i>  tfM-  iMtse  of  llw  valv. .  to  the  tendinous 
r(>nl>,  <>r  to  thi-  «-ihI«k  iniium  '  th«'  vcntrkular  and  even  (»f  th«-  auricular 
wall. 

An  iiiihrokfn  (oiittixiity  t»f  the  infkinirnatory  i<r(K-ej«  is  not  necessary, 
a.s  llu  iiitlutncti  H«>a.s  niav  Ih-  .Hp«»rttiH<  in  their  di><tiii»iitk»n.  This  is 
tliif  I"  111.  vj-jjefutiiJiis  on  tfie  valve  coming  in  cY>ntii<(  with  the  lieart  wall 
iliiriii);  till'  MMivemeiit.s  of  the  lienrt,  thus  I  riii^injj  ..Unit  a  «lir»-<t  iiife<^ 
lion.  Ill  the  niikkr  forms  iM-alinj,'  iiiav  take  \,\  „i-  with  ibrobiaMic 
chniip-MiMlnilnlH-ution.  Generally,  however,  the  tot,. litwn  Lads  so.. iier 
(ir  liittT  1(1  (Icuih. 

On.  -.f  the  n-sults  of  mute  endiK-arditi.s  ii,.iy  In-  that  small  jKirtioiw  .»*" 
the  ihii.mlii  iiiay  l>rcak  hnwe  and  tau.se  inluiction  in  the  brain,  spleei 
or  ki.lmvs.  Thes*-  are  the  nion-  danfjermiv  if  ihev  c-ontoin  i!iicn>- 
(irpiniMiis,  for  in  tiii-  way  miliary  meta.sla!ic  abs<(  -«>s  ar-'  ;>itHluce<l. 
Ik-sidi-  tlM-  pnMluetion  of  iiicoin{H'teiice  or  -toi.osis  <.f  a  v.tvi .  ali-atly 
r.f.TH'.!  Id.  ihc  inHaniniation  may  .spitwl  to  tht  mvoiimiiiim  .ir  ■  \eii  the 
[irri.iinliiiiii.  and  M.metime.s  leads  to  alxs<r.s.s  of  the  iiiat  and  rupture. 

Chronic  Indocwditit.— 'J'lierr  are.  eti< ilo>{itall\,  two  <  ..rMJitioiis  whichi 
Sim.'  till  ir  e„d  rrsults  are  very  .similar,  have  until  the  last  few  vears  liera 
repinltil  us  ..iir  pnKess  under  the  common  hea<liiij;  of  Clinlnic  Endo- 
tanliiis.  Tlu  f  are  <hronic  endocarditis  pri>per  or  secondary  sclenjsis, 
and  [iriinii.-v  or  work  scleriKsis. 

Secondary  Weroils.  It  i.s  the  outer  non-va.s,  iilar  portions  of  the 
valv.  -  ilonj;  1  .  pr..xiiiial  iimrjrin  of  the  line  of  apfwxsition  of  thecu.sps, 
thai,  u  ill  rare  .xceptioiis,  bectmie  the  primary  seat  of  acute  inflainma- 
li-m.  .\ii.l,  to  n'peat,  the  .succession  of  events  oct  iirrinx  in  the  inflamed 
areas  iM,|,.Mtical  with  that  seen  in  the  cornea  and  other  non-va.scuhir 
an-as.  «r|,,  m  addition,  a  marked  liability  to  the  formation  of  thnmbotic 
vetrriaiiuiis  upon  the  ulcerut.il  surfaces.  Thus,  .save  when  the  proces.s 
U.S.1IIII.M1  rapid,  pn)>:ressiyel\  destructive  type,  there  occurs  a  vasc-i.lari- 
fatiPii  nt  the  cusp.,  -„|  later  a  new-growth  of  fibrous  cicatricial  ti.ssue 
in  III.'  I.-I..I,  of  the  previous  ulcer;  this,  in  part  throu^'h  proliferation  of 
•I'.-  ...iin.riive  tissue  of  the  deep  layers  .)f  the  cusi)s  in  part  through 
nrp.in/,.i,.,„  of  the  thn.nibi.  The  «.sult.  therefore,  of  a  single  localize,! 
l<«ip  ..I  111.  .nitive  inflammation  i,  a  K>cal  fibrosis  with  .some  contraction 
"I  till'  iiuc.lvcd  an;,  of  Oa'  cil.sp. 

lliiivl.Hulized  il.airidal  areas  may  siirelv  beascril)et»  ti<  nrevious  in- 

•im,,t,n„.      Ih.   ..,i.sp   ;o  affecte<l.  Iiecoming  deformed,  i-  niatively 
••■ii^'  !i..|.  aii.l  at  t;,e  .,aiHe  time  subject  to  increa.set!  -tniwi  i:s  the  per- 
"f  normal  function.    Hence,  in  the  first  pla^ »'.  a>  a  ioi-ns  minoria 
' .  It  IS  more  liable  .m  succumb  to  a  second  infection  if  patho- 


fiirni.11,1 
rai.ih 


160 


THE  ENDOCARDIUM 


genie  ageiiLs  again  appear  in  the  circulation,  ami  hence,  more  particularly 
in  acute  rheumatism,  in  whicli  recurrent  infection  is  peculiarly  Hahle  to 
occur,  we  are  apt  to  find  indications,  clinical  and  anatomical,  that  the 
same  valve  (most  often  the  mitral)  has  l)een  the  seat  of  repeated  attaeks 
of  inflammation,  and,  as  a  consequence,  exhibits  extensive  fibrcxsis  and 
deformity.  In  the  second  place  the  deformed  valve  cannot  function 
nonnally:  the  new  tissue  is  not  the  equivalent  of  the  old:  now  under 
what  for  a  normal  valve  are  normal  conditions  it  is  subjected  to  stmin, 
and  the  result  is  that  complicating  the  inflammatory  sclerosis,  there  is  a 
marked  liability  for  adaptive  or  work  sclerosis  to  show  itself  of  the  tj-w 
to  l)e  ilescribwl  imme<liately.  It  is  this  frequent  combination  =n  th* 
same  cusp  »)f  the  two  types  that  renders  it  difficult  in  C4ise  after  ease  to 
distinguish  the  stHpience  of  events. 


Fifl.  32 


('Bli'arPniiK  intiltniliiin  i>f  the  mirti.:  valves,  with  rf-KUiititalinn.      Uilatalioii  of  tlie  M<  vfDIride; 
almpliy  of  the  rnlumniD  cornnr.     (Krom  the  Patholtigical  Miweum  of  McUill  I  nivemiy.) 

Primary  Sclerosia. — In  <liscussing  the  nature  of  arteriosiltrosis  in 
Chapter  VIII,  it  will  ix'  (■.eimmstratetl  that  the  pnmounccd  filiroid 
thickening  of  tlie  iiilinia  of  the  arteries  seen  in  this  condition  is  thf 
direct  result  of  increaswl  stniin  to  which  this  layer  may  Ut'iiiie  sul)- 
jectwl:  ti'.at,  in  lirief,  increasjil  work  within  physiological  liniih  leadsto 
increasfl  growtii  of  connective  tissue,  as  of  other  cells  of  the  i.r),'anism. 
That  s'.niin,  we  shall  show,  may  In-  iirought  alwut  by  either  iirtiial  or 
relative  incn-ase  in  the  i>i<M)d  pressure.  Now,  acconijxinying  ll'is  condi- 
tion of  arteriosclerosis  we  encounter  time  and  again  an  identical  condition 
of,  more  jwrticularly,  the  aortic  valves,  although  in  success;,. ii  all  the 


i>  t 


"■■  '  ■ 


TUBERCULOSIS 


167 


valves  may  come  to  show  the  same  ehan;^.  (These  valves,  it  must  be 
rememlM-rf*!,  are  merely  f«il«ls  of  the  vascular  intima.)  Namely,  we  find 
that  the  cusps  are  the  seat  of  a  diffuse  fibrosis.  The  new  tissue  is  laid 
down  ill  onlerly  layers,  the  most  superficial  l)einjj  the  mast  recent;  it  is 
non-vasciilnr;  there  is  the  greatest  development  in  thixse  parts  of  the 
cusps  that  are  subjected  to  the  greatest  strain— at  the  liases  and  along 
the  marj^ns  of  app<»sition  of  the  aortic  cusps;  along  the  areas  of  appo- 
sition of  tiip  mitral  cusps;  the  deei)er  layers  like  those  of  the  sclerosed 
intima  are  apt  to  exhibit  hyaline  degeneration  necrobiasis  or  atheroma, 
calcific  (It ion  and  ulceration.  The  process  is  identical  with  what  we  find 
in  artcrio-scienxsis,  and  just  as  in  that  condition  we  conclude  that  the 
intimal  cliaiiges  are  non-inflannnatory,  so  we  cannot  out  conclude  that 
this  type  of  valve  thickening  is  e(|ually  non-inflammatory. 


Fio.  33 


Mian  ii.ivi.l  from  alx.ve.  fliooinn  nicmwixof  anrtir, mitml,  and  pulmunary  oniia.     (Krom 
Ibe  I'athob^cit'al  MuMum  of  McGill  rniveraity.) 

Hilt  now,  just  MS  in  the  inflammatorj-  type,  a  strain  sclemsis  is  apt  to 
sii|..Tv.iic.  so  it  has  to  \te  recogniml  that  in  this  there  mav  l)e  second- 
arv  ■••ilaininatory  disturbances.  The  valves  are  abnonnal- and  so  more 
liiiM.'  lo  irritation.  Thus,  it  is  not  uncommon  to  find  the  aortic  cusps 
iiii<liT};(.iiij;  fusion  along  tliei.  oppcxsed  angles. 

In  lioth  forms  of  sclerosis  we  find  certain  common  features.  The  new 
coniKKtivc  tissue  manifests  the  characteristic  tendency  of  new  connective 
fisMir  III  j;,,Hr.il  to  undergo  contraction,  hence  the  aortic  and  pulmonary 
cii>i.>  .iii,l,Tg()  shortening  along  their  free  «<lges,  with  resulting  incom- 
jxt.ii.  ,•  It  IS  usual  to  state  that  the  mitral  cu.sps  undergo  fu.sion  This 
IS  a  lal  ..  ,oi,c,.ption.  The  mitral  an.l  the  tricuspid  do  not  pos.se.ss  dis- 
tinn  ,  ,is|,s:  thev  form  a  veil  ortulje  hanging  into  the  ventricular  cavity, 
••iii'li  Mil  IS  MOW  longer,  now  shorter,  but  continuous  around  its  whole 
<ir.  ui,  I  „.,„  c.    The  length  of  the  different  portiims  varies  considerably 


168 


THE  ENDOCARDIUM 


■■■«  II 


I 


*     :!". 


ii.  : 


in  different  individuals.  When  there  is  fibrosU  and  contraction,  it  d^ 
pends  upon  the  rehitive  proportions  of  the  different  sections  whether 
there  develops  a  funnel-shaped  or  a  hutton-hole  stenosis,  the  luttn 
occurring  when  the  short  areas  joining  the  longer  so-called  cusps  are  of 
small  dimensions. 

In  lioth  forms  also,  degenerative  changes,  calcification  and  athero- 
matous ulceration,  may  show  themselves,  as  also  the  chordse  teiulinew 
may  undergo  thickening  and  contraction,  the  latter  at  times  so  fxtreme 
that  the  cusps  appear  to  be  inserted  upon  the  apices  of  the  papillai}' 
muscles. 

TaborenlOSiB. — The  occurrence  of  simple  (so-called)  endcx'arditb 
in  connection  with  tubereulosis  elsewhere  Is  not  uncommon  in  our 
experieiK-e.  True  tubereulous  lesioas  of  the  valves  are,  however,  rare. 
Miliary  tuliereles  have  been  seen  on  the  valves  in  cases  of  general  loiliarv 
affection,  but  such  are  more  common  on  the  mural  endocardium  aliout 
the  conus  arteriosus  pulmonaiis.  The  .specific  bacilli  have  been  tietrrted 
in  the  lesions.  The  experimental  work  of  Michaelis  and  Hhim  has 
demonstrated  the  possibility  of  this  form. 

Sjfphilis  is  also  rare. 

^annuitiun. — Baptnn  of  one  of  the  cusps  of  the  healthy  aortir  raire 
is  recorded,  but,  as  would  Ik"  expectetl,  is  more  often  found  in  u  disea^ 
valve.  It  is  due  to  excessive  mascular  strain.  The  tendinous  mnk 
may  give  way  from  the  .same  cause. 


f 


ALTKRATIOm  Dl  TBI  SIZE  OF  TBI  08TIA. 

Tricuspid  Valve.— Stenoiis. — Stenasis  of  the  tricuspid  valve  may 
be  congenital  or  a«|uired.  The  congenital  form  is  due  either  to  a  defect 
of  development  or  to  ftrtal  cndcK-anlitis.  It  is  rare  for  the  trieiispki 
to  Ih"  alone  affected.  Usually  mitral  stenosis  exists  as  well;  less  fre- 
quently both  mitral  and  aortic  stenosis  are  present,  llarely,  an  adhrreni 
thrombus  may  olxstruct  the  passage. 

Ininfflciency. — Insufficiency  is  usually  caused  by  relative  dihitationof 
the  right  ventricle  owing  secondarily  to  mitral  lesions  and  to  li'.'  .tion.- 
that  increase  the  va.scular  tension  within  the  lung,  such  as  einjihysfma 
and  fibroid  induration.  Primar>-  insufficiency  due  to  endo<aniitb  i> 
not  common. 

PtdmoiUUry  Valve. — Stenoiis. — Stenasis  of  the  pulmonary  ostium  L< 
almost  invariably  congenital,  and  is  generally  a-sstx-iated  wiih  fn\( 
defects  of  development,  suj-h  as  patent  ductus  liotalli  or  imperfect  septum. 
Rarely,  in  endocanlitis,  a  thrombus  may  more  or  less  completely  vMuik 
the  opi'ning. 

Insnfficiancy. — Insufficiency  is  exce.ssively  rare.  It  may  iMiur  from 
rupture  of  an  acute  aneurism  of  the  valve,  or  from  other  manifestation* 
of  endocarditis. 

Mitral  Valve. — 8t6no^ia. — Stenasis  is  nearly  always  mused  hy 
endocarditis,  and  is  usually  combined  with  insufficiency.  A-  a  rule. 
the  obstruction  is  brought  about  by  the  fusion  of  the  ."dve    <  gmeniv 


!  I 


ai.u 


RETROGRESSIVE  METAMORPHOSES  \(jg 

together  with  calcification,  m>  that  a  narrow  orifice  Is  produced.  An 
adherent  thrombus  upon  one  of  the  casps  may  produce  a  similar  effect. 
Not  only  does  the  thickening  and  fusion  of  the  cusps  lead  to  obstruction, 
but,  owing  to  the  impassibility  of  closure,  leakage  is  a  common  result. 
The  nlationship  between  the  stenosis  and  regurgitation  varies  con- 
siderahiy  in  different  cases. 

iMoffidMiey. — Inoufficiency  may  be  due  to  loss  of  substance  of  the 
cusps,  retraction,  or  dilatation  of  the  ventricle  (relative  innifficieney). 

Aortic  Valve. — fUnotit. — Pure  aortic  stenosis  is  rare.  It  is  due  in 
part  to  the  fusion  of  the  semilunar  valves  or  to  narrowing  of  the  aortic 
ring,  but  the  most  important  element  is  the  deposit  of  lime  salts  in  the 
cutps  and  ring.  This  prevents  the  proper  collapse  of  the  cusps  during 
systole.    Aortic  stenosis  is  commonly  associated  with  insufficiency. 

Aortie  ImolBeiaii^. — lasufficiency  may  be  due  to  ulceration  and  loss 
of  siilwtance  of  the  valve  or  to  the  contraction  that  results  from  chronic 
endiKurditis.  Ilarely,  it  is  due  to  rupture  of  a  cusp.  Relative  insuffi- 
ciem-y  is  not  very  uncommon,  and  is  usually  secondary  to  dilatation  of 
the  left  ventricle,  or  to  dilatation  of  the  first  part  of  the  aorta  from 
atheroma  or  aneurism. 

The  Lesions  Associated  with  ValvnUr  DiseMe.— In  acute  endo- 
carditis the  heart  mascle  Is  invariably  affected  to  some  extent,  owing  to 
the  action  of  the  same  toxic  cause.  We  find  not  only  cloudy  and  fatty 
degeneration  of  the  fibers,  but  also  in  some  cases  acute  interstitial 
mjxK-arditis,  and  hyaline  thrombi  in  t.he  smaller  vessels.  Again,  acute 
pericarditis  may  \n'  set  up.  This  is  more  fr«|uent  in  children,  and 
is  most  likely  to  occur  in  aortic  endocanlitLs,  for  the  reason  that  there 
is  hut  a  small  distance  between  the  valve  and  the  pericardial  sac,  viz., 
the  thickness  of  the  aortic  wall.  It  is  fairiy  common  at  autopsy  to 
find  in  cases  of  endocarditis  fine  adhesions  at  the  upper  cul-de-sac 
of  the  pericanlium.  Small  portions  of  the  vegetations  may  break  off 
ami  give  rise  to  embolism  in  remote  orgaas,  or,  if  infective,  to  multiple 
ahsc«'sses. 

In  the  case  of  chronic  endocarditis,  changes  in  the  heart  wall  are 
often  markwl.  In  the  degenerative  and  .sclerotic  form,  the  coronaries 
are  apt  to  Ik-  affected  from  the  same  eaiLse,  leading  to  myodegeneration. 
In  aorlic  insufficiency,  owing  to  the  imperfect  filling  of  the  aorta,  the 
IiI(khI  pressure  within  the  coronaries  is  diminisheil,  and,  in  consequence 
the  h.iirt  U>comes  at«)phic.  Banti  has  also  poiritetl  out  that  venous 
stasis  wiihin  the  heart  caus(>s  degeneration  of  the  muscle  Iwmls  and 
interstitial  fibrosis,  a  condition  that  he  terms  venoas  cirrhosis.  A  mast 
important  result  of  valvular  affectioas  is  hypertrophy  and  dilatation 
of  till  heart  mu-scle  and  cavities.  The  mechanics  of  this,  however, 
has  iH'iii  (iiscusstd  fully  in  another  place  (see  p.  12S). 


■ ';i 


in  il 


RITR00KI8SIVB  MXTAMORPHOSU. 

Degenerations.— Fatty    Degenmrtloii.— Fatty   ilegeneration    appears 
rni  of  slightly  elevated  scattered  patches  of  a  yellowish-white 


170 


THE  ENDOCARDIUM 


t 


color  upon  the  valves  and  less  frequently  on  the  mural  emlociirilium. 
These  are  due  to  the  transformation  of  the  protoplasm  of  the  connective 
tissue  and  endothelial  celb  into  fat.  In  advanced  cases,  fat  droplets 
may  be  seen  in  the  spaces  between  the  connective-tissue  cells.  'IV 
condition  is  .seen  usually  in  elderly  people,  but  is  not  very  uncommon  in 
younser  individuab,  in  cases  of  marasmus,  anemia,  valvular  diseaw. 
mtoxications,  and  infections.    The  first  stage  of  atheroma  is  fatty  thanf^e. 

Mneoid  DafMunttoB. — Mucoid  degeneration  occurs  particularly  in 
advanced  life  and  almost  without  exception  upon  the  valves.  Circum- 
scribed nodules  of  gelatinous  appearance  at  the  dasing  edge  of  tlic  val\-e 
are  of  this  nature.  They  may  contain  true  myoma  cells  or  nmy  be 
merely  mas.ses  of  gelatinous  substance.  ITie  condition  is  often  a-swH-iated 
with  fatty  degeneration. 

Amj^oid  DiMtM. — Amyloid  di.sea.se  not  infrequently  affects  the  sub- 
endocardial connective  ti-ssue  under  the  .same  con«litions  as  elstwhere. 
It  is  often  combined  with  hyaline  degeneration. 


PR0ORU8ITB  MRAMOBraoni. 

TunM)rs  have  already  l)een  dealt  with  under  the  hewling  "Myo. 
canlium."  Kanthack  awl  I*igg'  have  reconletl  a  uni<|ue  case  in  which 
a  carcinoma  of  the  testis,  »)r.  more  atrunitely.  a  teratc^nous  hla-stDma 
(see  vol.  i,  p.  WW),  fonned  .se«>ndary  growths  lying  free  in  the  rijjht  heart 
and  inferior  vena  cava. 

'Tranii.  Path.  Soc.,  Ixintlon,  48: 1897:  t.TOI. 


M    11     ii 


CHAPTER    VIII. 


THE  VESHEW.    VAHCUI^U   FUNCTION   AND  ITS   DI.STUUIUNCE8. 


Wk  are  apt  to  repeat  glibly  that  the  arteries  arc  composed  of  three 
coats— intima,  media,  and  adventitia — and  with  this  to  regard  the  whole 
arterial  tree  as  uniform  throughout,  save  that  the  coastitucnts  of  the 
different  coats  become  progressively  reduced  as  we  pass  from  the  aorta 
to  the  arterioles.  Undoubtedly  there  Is  a  certain  amount  of  truth  in 
thb  general  conception,  but  undoubtedly,  also,  we  have  thus  far  allowed 
the  view  to  prevail  too  fully,  to  a  neglect  of  the  study  of  the  histology  of 
individual  arteries.  We  still  need,  for  example,  more  exact  information 
repmiing  the  extent  and  variations  in  the  deeper  musculo-elastic  layer 
of  the  intima,  to  which  .lores  has  called  attention,  ami,  as  Meigs  points 
out,  until  we  study  the  arteries  of  tiiiTerent  regioas  not  under  various 
def^-cs  of  contraction  as  we  encounter  them  in  the  usual  run  of  past- 
mortt-ni  tissue,  but  uniformly  expanded  (ami  tin's  has  not  \teen  done), 
we  obtain  wholly  false  ideas  as  to  the  relative  development  of  the  dif- 
ferent layers. 

Failing  such  exact  study,  we  have  to  content  ourselves  with  laying 
down  that  the  arteries  may  be  divided  into  the  two  broad  groups  of  those 
of  the  clastic  type,  and  of  the  muscular,  respectively.  The  presenc-e  of 
aburohtiit  layers  of  yellow  elastic  tissue  such  as  we  fimi  characteristically 
in  the  aorta  and  its  main  branches  connotes  two  things:  (1)  That 
the  vcss<l  is  capable  of  imdergoing  passive  dilatation  up  to  a  certain 
point,  and  of  returning  passively  to  the  nonnal  when  the  distending 
fone  is  removed;  ami  (2)  that  only  with  difficulty  can  it  lie  contracted 
lieyoiid  a  certain  mean,  the  very  elasticity  of  the  tissue  acting  as  a  counter- 
actinj;  Utn-f  agaiast  obliteration  or  collapse  of  the  vessel.  Here  it  may 
l)e  holed  that  the  wrinkled,  wavy  appearance  of  the  internal  elastic 
lamina,  the  "plicate<l"  membrane,  or,  as  the  Frt-nch  term  it,  the  "bande- 
lette,"  I  if  medium-sized  arteries  is  a  ptxstmortem  appearance,  due  to  rigor 
and  contraction  of  the  mascle  coat.  This  appearance,  of  course,  must 
lie  r.|.i.H|iictHl  when  the  arterial  muscle  is  contracted,  but  !«  absent  in 
the  iiiii  oiitriicted  vessel.  As  we  shall  have  to  note  later,  even  in  arteries 
of  the  I  lastic  type,  there  is  fairiy  abundant  muscle  in  the  form  of  layers 
l)et\v..r,  ilic  elastic  sheaths  which  must  play  a  part  in  modifying' the 
ralilM  r  It  is  generally  accepte<I  that  this  musculature,  from  the  l>egin- 
nin;;  i  il  t  h..  aorta  down  to  the  smallest  arterioles,  has  the  property  of  auto- 
'" traction  similar  to  that  pas.sessed  by  the  heart  muscle.     It  is 


inatK 


172 


THE  VESSELS 


i  t        I 


l\ 


-ft     u  I 


If  , 


at  the  other  cxtrvme,  in  the  arterMJes,  that  (he  musmiar  sheath  is  nxw 
prominent,  the  elastic  lea.st.' 

Very  slight  changes  in  the  tonus  of  the  small  arteries  of  the  ImmIv  mu^i 
induce  great  changes  in  the  .stream  IhiI,  and  mast  materially  alter  tli 
volume  of  the  blood  passing  through  the  vessels  and  the  picsencc  of  the 
same. 

So  far  as  we  can  see,  capillary  contraction  must  be  left  out  of  aceoun 
as  a  primary  factor  in  causing  rise  of  blood  pressure.  With  .Meltzer 
and  Leonard  Hill  we  are  prepared  to  admit  that  the  capiltaries  ]itmms 
some  power  of  contraction;  we  doubt,  however,  whether  this  is  stittjcicntlv 
great  to  be  of  any  effect  when  the  arterioles  are  uncontracted  and  supplV 
blood  to  the  capilkiry  area  at  relatively  high  pressure;  only  when  the 
arterioles  are  contracteil  and  the  blood  supply  low  does  it  appear  |)os,sii)le 
that  the  contraction  can  Ih'  effective.  It  is  by  capillary  contraction  imkt 
those  conditions  that  we  would  explain  the  rather  striking  pallor  of  the 
ordinary  arteriosclerotic  individual.'  The  size  of  the  capillaries,  that  t*. 
depends  in  the  main  upon  the  amount  of  arterial  bloo<l  supply  on  the 
one  hand,  the  venous  pressure  on  the  other.  At  the  same  time,  the  capa- 
city of  the  capillary  .system  is  so  much  greater  than  that  of  the  arterioles, 
that  were  the  latter  generally  dilated,  the  free  pas.sage  of  blotxi  into  the 
wider  capillary  channels  woidii  almost  immetiiately  empty  the  arteri»| 
tree  and  bring  the  circulation  to  a  stop  by  the  individual  hlmliny 
into  his  own  capillaries.  We  know  that  this  may  happen  when  dilata- 
tion occurs  merely  »>f  the  arteries  of  the  splanchnic  area.  The  iiuisciilar 
arteriole-  then,  as  giianling  the  gateway  into  the  capillaries,  arc,  with  the 
li    ■'•• 

ii.KMilute  harmony  with  the  heart  on  the  one  hand,  with  the  needs  of  indi 
vidual  organs  on  the  other.  Now  one,  now  another  organ  may  <leinajHi 
a  larger  blood  supply,  and  presumably  in  the  main,  through  retlcx  stitnu- 
lation,  the  arteries  to  that  organ  undergo  dilatation,  but  with  this,  pre- 
sumably also  ill  the  main  umler  the  i-ontrol  of  the  vasomotor  centres. 
other  arteries  contract,  and  tints  a  mean  arterial  bUxxl  pre-ssim-  of  aUmt 
120  mm.  Hg  is  prc.ser\i>d  with  gn'ut  regularity. 

'  It  nmy  well  1«>  thtit  the  iiizc  of  n  plain  muwli>  filler  relative  to  the  ralilierofa 
vcs-scl  (letcrniiiii-s  to  some  extent  the  nei-d  or  lack  of  nivil  of  iin  eliuilir-ti^Mio  (rame- 
work;  that  in  un  arteriole,  for  example,  the  ruiiKe  of  contraction  of  a  inii-*!!-  tif^r 
reUtive  to  the  lna<l  that  filler  lam  to  In'ar  (namely,  to  the  bliMiii  pn-sMin-  may  l» 
such  that  there  is  little  ilanp'r  of  overextension  of  the  miiHcle:  lti:it.  iti  stmri 
the  preneiice  of  elaxlic  tissne  in  the  aorta  and  larger  arteries  is  a  faet.r  ■  f  safety 
pieventinif  excessive  strain  on  the  muscular  elements  of  the  wall.  In  a  ^in.ill  aner 
a  very  slinl.t  ex|)ansion  or  contraction  of  the  circular  (iliem  will  imhiei  .!  nLiiiuh 
great  alteration  in  the  size  of  the  lunieii,  altogether  out  of  projxirtioii  !.•  liit-  rhanp 
in  size  of  the  largi-  aorta  pnKluce<l  liy  the  same  extent  of  cuntraction  nl  '-  muscula- 
ture. 

'  With  pndonged  n-duction  of  blood  supply  to  a  part  we  should  e\|ic!  tiii>t>UiE 
a  vcnoua  congest  ion  owing  to  the  lack  of  ii«  o  Uryu:  this,  cliaracteristicali^  i-  »aiitiij 
in  the  arteriosclerotic  us  coiitrastiKl  with  the  sufferer  from  liaynaud's  di-i  i*. 


)'      main  agents  in  maintaining  the  cir^-ulation;  and,  a.s  a  rule, 
ii   the  marvellously  developed  vasomotor  apparatus,  they  act  in 


VASrHaOTOR  MECHANISM 


173 


Kvcrvoiie  Ls  familiar  with  the  existence  of  vaiwieiiiuitrictor  ami  vastv 
dilator  lu-rves;  we  need  not  here  enter  into  a  de-scription  of  their  action; 
what  is  important  is  to  <ietennine  whether  these  abne  determine  the 
contraction  and  rxpansion  of  the  arteries.  The  iiulicatioas  are  that  we 
Imvp  the  identical  problem  l»efore  as  that  we  had  in  connection  with 
the  iieiirf.  'I'here  is  eviilence,  that  is,  that  Ijesides  the  central  nervous 
(■ontri'l  cxcrte*!  from  centres  in  the  bulb,  there  exists  a  system  of  nerve 
cells  >vitli  pnxrsses  tending  to  form  a  plexus  in  the  arterial  wall,  and 
furthfr,  that  the  raascle  fillers  of  the  media  are  capable  of  dint-t  stimula- 
tion. (  III  tliroiigh  the  nerve  supply  of  ii  limb,  uimJ  immetliately  the  arte- 
ri*>N  liH4-  their  tone  and  dilate,  but  eventually,  although  still  unconnected 
vtiifa  tijc  central  nerv«ius  system,  they  re^^ain  their  tone.  There  Ls  one 
>Trr  ini)><(rtant  series  of  arteries  in  which  n<»  one  lias  yet  lieen  able  to 
(lismvcr  any  proper  vasomotor  system — namely,  the  cerebral  arteries. 
At  nnist,  imlividual  nerve  cells  are  to  l>e  made  out  in  the  arterial  walls, 
pnivi«le<l  with  processes;  from  which  it  woubi  appear  that  these  cerebral 
vps.sels  |x).s!<ess  a  .self-re^ubitin^  apparatus — that  the  condition  of  the 
brain  matter  and  the  nature  of  the  cireiilating  i)l«x)d  determine  the  blood 
How  throiijfh  them.  The  indicatioas  are  that  the  brain  is  superior  to 
all  other  (irgan.s.  and  that  it  jjoveras  its  own  blcKxl  supply  untrammelled 
hy  va.'M>mot(ir  interference  fnnn  <rther  parts. 

The  al)<)vc  conditions  mi^^ht  Ih'  detenniiic«l  thn>uf;h  the  liK-al  nerve 
mpfhaiiisin.  On  the  other  hand,  we  know  how  rapidly  ner^e  <rlls  die 
wlicii  (lit  olf  fnmi  their  blcNMl  supply  or  when  reniovj-d  from  the  living 
Ikkjv.  Now,  us  .MacAVilliam  has  shown,  tin-  larper  arteries  removed 
fniin  the  IkhIv  after  death  re.s|)ond  to  direct  stimuli,  and  are  capable  of 
ii  strong'  contraction  many  hours  after  death.  More  pre<-ise  data  to  the 
same  ctlVct  have  (K-en  supplied  by  BnMlie  and  Di.xon.'  who  have  shown 
that  the  vastK-onstrictor  ner%es  to  the  limbs  are  no  longer  irritable 
three  lioiirs  after  death,  while  six  hours  after  death  the  arteries  still  con- 
tract iiiiiler  the  iiiHuence  of  adrenalin.  This  indicates  independent 
•■"ntriictihility  of  the  arterial  muscle  filters  in  rcs(M)nsc  to  direct  stimuli. 
\\e  will  not  here  discuss  the  finer  points  brought  out  by  those  ol>ser\'ers, 
Kllie.iit'  and  H.  H.  Dale,  as  to  the  existenc-e  of  mo«ies  of  stimuUtion 
thn)ii(,'li  the  neunmitisculur  junction  and  through  the  muscle  sukstance 
pn)|)er.  .Vdn-nalin,  pituitary-  extract,  and  crgirt  have  all  l»>en  shown  to 
act  .lir((tly  up«m  the  arterial  mu.s<-Ie,  and  judging  from  the  similarity 
of  their  etftrts,  the  same  is  true  of  a  large  nunilicr  ui  other  Inxlies,  barium 
cliloriile.  nicotine,  etc.  We  mu.st  ant-pt,  therefore,  all  threi'  moilcs  of 
sliiniil.ition  as  inducing  contra<-tion  ,i'  the  arterial  muscle,  giving  the 
phur  of  honor,  in  normal  con<litions,  to  control  from  the  va.somotor 
ct'iitn  V  It  is  this  that  determines  the  dilatation  with  pn)found  lowering 
Uxl  pressure  .se«-n  in  sync-ojie  and  shock.  Whether  it  is  the 
iiiise  of  gi-neral  rela.xation  (jf  the  arteries,  with  lowering  of  the 
-Mirc  si-en  in  the  acute  fevers,  is  still  a  matter  of  .some  del«te. 


;l!i! 


of  tli.. 
pssei'li 

hllNHJ 


ll 


'  .lour,  of  I'hyxiol,,  :«):  I'MM:  4!M. 
•  Iliid.,  32:  !!K),i:  4(11 


174 


THE  VESSELS 


i  :  !'■ 


That  rplaxation  may  .nhow  itself  early  in  a  fever  is  evidenced  by  the  liirratje 
pubie,  and  then  it  may  lie  accompanied  by  no  weakening  of  thv  heart 
action,  but,  if  anythinfi;,  by  the  very  reverse.  It  has  to  be  admittttl  rroo 
the  experiments  uf  Rt^r  ami  others  that  difTerent  bacterial  toxins  act  in 
different  degrees  upon  the  different  segments  uf  the  coardinatin^  appt- 
ratus;  some,  like  the  dipiitheria  toxin,  appear  to  act  directly  upon  the 
heart,  others  directly  upon  the  arterial  wall.  But  the  general  tn-nd  it 
the  present  time,  strongly  supportwl  by  the  experiments  of  Itombeij; 
and  his  pupils.  Is  to  lay  the  greatest  stress  upon  the  direct  action  of  tlie 
bacterial  toxins  upon  the  va.somot«r  centres  in  the  medulU.  The  oppo- 
site condition  of  vasocontraction  has,  of  late  years,  attracted  not  a  littlr 
notice,  and  that  from  a  clinical  point  of  view.  The  indicatioas  are  that 
arterial  spasm— pn>lcinge<l  extreme  contraction  of  the  arteries  of  imli. 
viilual  areas  is  a  niii  uncommon  condition.  To  this  condition  and  its 
results  we  hii.c  refemtl  in  discussing  Raynaud's  disease.  Pal'  more 
particulariy  lia.s  studied  the  vascular  crises  affecting  the  splanchnic 
vessels;  O'sler  and  others,  the  contracture  of  arteries  of  the  lower 
extremities  leading  to  intermittent  dandieatioii  or  limping,  due  to  the 
sudden  eii'tiug  off  of  bloo.  iip|>ly  ami  musculiir  anemia.  As  Sir  I^wler 
Hrunton  indicates,  arterial  contraction  proliably  pUys  an  important 
part  in  u  very  common  form  of  migraine  known  at  times  as  "bilious 
iiiwlache."  In  this  form,  with  the  development  of  premonitory  symp- 
tt)ms,  the  l>lo<j<l  pressure  is  founl  distinctly  raised  well  aliove  the  normal, 
ami  it  continues  to  rise.  Such  rise  can  only  l)e  due  to  arterial  or  arteriolar 
contraction,  ami,  as  a  matter  of  fact,  superficial  arteries,  like  the  tern 
porals,  can  Ik»  seen  firm,  contracte<l,  aiHl  whipconl-like.  When  the 
comlition  has  lieeome  almost  unendurable,  and  the  patient  finds  himself 
thoroughly  exhaustetl,  the  attack  passes  off,  the  headache  disap|)ears, 
tiie  pulse  iK-comes  soft,  the  cireulutijwi  resumes  its  normal  eotMJition. 
In  sut'h  cases  there  would  seem  to  have  l)een  not  merely  a  l(Kai,  but  a 
general  vascular  crisis;  it  is  difficidt  to  explain  the  raised  blood  pressure 
otherwise.  How  this  is  hn)Ught  alK)ut  we  cannot  jK)sitively  say;  those 
liable  to  the  i-ondition  know  full  well  that  e  lain  errors  in  diet  surely 
invoke  this  N'eniesis.  It  is  possible,  on  the  one  hand,  that  certain  pnMlucts 
of  imperfei't  metalnflisnt  or  other  jxiisons  act  generally  on  tin-  arteries, 
but  the  «lire<'t  action  of  the  same  tm  the  vas«)coastrictor  centres  wi.dil 
e<|ually  explain. 

Here,  leading  up  to  the  coasideration  of  arterio.sclenxsis  and  ii-  <"ausa- 
tioii,  a  phenomenon  must  iw  note*!  which  has  liecn  empha>ized  hy 
Ix-onard  Hill— namely,  the  paradox  that  arteries  tend  not  to  expand  but 
to  contract  under  heighteneti  internal  pressure,  and  this  so  ininicdiately 
that  the  contraction  must  In?  a  Icxml  reaction,  not  reflex.  \Yheii  in  con- 
junction with  this  we  realize  that  the  smaller  the  cireumfeniiK  of  the 
artery  the  greater  is  the  effect  of  the  contraction  of  the  muscle  1 1  lis  upiffl 
the  reduction  of  the  arterial  lumen  an<l  the  diminution  of  iK''  blood 
stream,  we  are  l«l  to  see  that  this  phenomenon  leads  to  the  estaliiishment 

■  Pul,  GeriiMtkriMcii,  Leipz.,  imi.').    8.  Hirael. 


J     i  i-      !  i; 


ARTERtOaCLEmSIH 


176 


of  a  vic'ioai  cycit    TTie  hiicher  the  blood  prrasure,  the  Kremter  becomes 
thr  i-ontraction  of  the  arterioles;  the  less,  therefore,  the  blood  supply 
to  the  ti-wues  and  the  greater  the  call  upon  the  central  nervous  system 
for  more  blood.     Whether  from  reflex  stimulation  of  the  heart  to  in- 
crau»i  activity  in  order  to  supply  the  tissues,  or  from  direct  autoiiuitic 
action  of  the  increased  aortic  pressure  in  raising  the  intraventricular 
preisurp,  and  so  stimulating  the  ventricles  to  more  foreible  contraction, 
the  blotxl  pressure  bectnnes  yet  higher,  ami,  as  a  result,  the  arteries  still 
further  runtracted.     It  is  along  these  lines  that  we  would  explain  the 
pro|(ressive  rise  of  blood  pressure  and  contraction  of  the  smaller  arteries 
in  mi)j'raine.    In  this  order  of  cases  we  must  suppase  that  the  eventual 
result  is  a  veritable  spasm  of  the  arteries,  which  continues  until  the 
mascle  fillers  become  exhausted,  dilate,  and  cause  lowering  of  the  blood 
pressure  and  return  to  the  nomul.    That  exluiustion  is  the  only  means 
whereby,  in  general,  the  blood  pressure,  once  raised,  becomes  retluced, 
we  do  not  for  a  moment  mean  to  suggest.    These  v&scular  crises  are  the 
exception  and  not  the  rule;  there  must  lie  other  reflexes;  must,  for  ex- 
ample, 1m'  the  means  of  pouring  into  the  blood  sulvstances  which  neutralize 
the  agents  causing  arterial  contraction  and  high  blood  pressure  in  the 
first  place.    But  in  this  class  of  cases  these  opposing  agencies  must  be 
either  inadequate  or  temporarily  inhibited.    The  studies  on  the  ductless 
glands  have  demonstnited  that  the  .system  produces  Iwth  internal  secre- 
tions, which  raise  the  blood  pressure  («.  g.,  pro<lucts  of  the  activity  of 
the  adrenal  and  pituitary  bodies),  and  others  which,  on  the  contrary, 
r«luce  it  {e.  g.,  the  thyroid  extract).    At  most,  what  we  desire  to  empha- 
size here  is  that  arterial  conlrartion,  and  jxirtieidarly  a  generdized 
arteriolar  contraction,  is  the  primary  cause  of  heighttned  blood  pressure. 
It  would  rwjuire  a  very  much  greater  increase  in  force  and  frequency 
of  the  cardiac  contractioas  to  raise  and  maintain  the  blood  pressure  that 
we  onlinarily  encounter  if,  with  rise  of  blood  pressure,  the  arteries 
untlerwiMt  a  corresponding  dilatation.    The  drugs  which  characteristic- 
ally cause  hcightene<l  blo<»d  pressure  of  any  duration  act  by  contracting 
the  artt  rioies. 

("liiiically,  what  is  a  more  common  event  than  arterial  spasm  is  a 
ix'wist.'iit  rise  of  bUiod  pressure,  or  state  of  "  hyperpiesis,"  as  Sir  Clifford 
Allhntt  has  termed  it.  In  this,  for  long  periods  the  blood  pressure, 
lastead  of  In-ing  in  the  neighborhood  of  120  mm.  Hg,  Is  raised  to  180, 
200,  or  iM)  mm.  Hg.,  or  even  higher.  It  Ls  this  continued  rise  of  blood 
pressMH',  due  as  we  have  said  to  increased  contraction  of  the  arterioles, 
that  IS  the  commonest  precursor  of  arteriosclerosis. 


ABTIRI080LSR08I8. 

'Stnni|:,.  to  say,  for  that  which,  in  civilize<l  lands  among  those  attn'n- 
'njl  iiiliiK  lif,..  IS  the  commonest  of  all  mori)id  .stiitcs,  we  pos-sess  no 
H'I<<||'"'  Mild  comprehensive  name.  It  Ls  a  condition  in  which  evi- 
'iemi\  ii ,.  arteries  are  primarily  involved,  and  what  is  the  mwt  ob  ious 


lit 


ARTEHIOSCLERtiSia 


I    ' 


if 

i     i  ■ 
if 


Imion  i'  n  fibrotic  thickening  of  the  ini  ina.  whfii.r  the  term  nrterio. 
srlermis  has  obtained  witle  at  i-eptance.  It  is,  however,  (ioubtftil  wliPtlMt 
sclerodw  (hardening)  is  the  eswiilial  change,  and  certainly  the  Ultr 
stages  in  th<'  larger  ves.'wU  are  «»f  iIk-  nature  of  a  softening  ami  dt-piter*. 
tion;  whew-*'  Marrhand  has  suggestetl  the  natne  n/Arron*.  and  thu  jj 
being  widely  talien  up  by  (lerman  workt-rs  But  here  apiin  the 
"Ad^pij,"  or  porri«igy  state  of  intinul  degeneration,  only  atfc. '^  thf 
larger  arteries,  and  w  a  .s.-<-omlary  ami  not  a  primary  i-umlition.  !V 
name  given  thirty  years  ap»  by  (lull  ami  Sutton  of  "arteri«Manill«rj' 
fibrusLi"  Ls  f|uite  as  defeasiWe,  ami  that  Ik  caaw  a  fibrosis  of  the  artfriolfs 
chararterizes  the  m«wt  important  group  of  eases,  and  has  a  very  >\»tr 
relationship  to  the  dev«'lopment  of  the  changes  seen  in  the  largi-r  vessels. 
We  shall  speak  of  general  arlcriostleri»-<i»,  waiting  for  some  thou.iiuhly 
satisfactory  name  to  lie  pru[)ose<l  in  the  fiitiire. 

More  accurately  then-  an-  two  main  causi's  of  artericjsclerosis,  either 
(1)  increas«><l  strain  thrown  upon  the  arterial  wall  by  heightcnetl  htoml 
pressure,  or  (2)  a  weakene<l  .slate  of  the  wall,  either  from  conp-niui 
causes  or  fmni  disease  of  the  same.  If  the  pressure  l)e  nonnal  ImiI 
the  walls  weakened,  the  results  are  of  the  same  onler  as  when  the 
pressure  Is  heighteiu-d  but  the  walls  of  mirmal  resisting  power.  It 
IS  the  lack  of  r«-ognition  of  this  central  fact  that  is  at  the  l>i)tt()m  of 
the  confasion  that  has  reign«il  all  these  years  reganling  the  elii.|.>KK)f 
arteriosclenisls.  It  is  mrt  high  pressun>  alone  that  causes  arterios*  ierusw; 
that  condition  nuiy  show  itself  without  rist>  of  blcKxl  pressure  alHivc  thf 
normal;  but  it  Is  the  rniio  between  the  retutiny  ptmvr»  of  the  irtturl  imll 
mid  the  pretaure  to  which  they  nre  subjected  from  within.  If  this  I*  a.- 
cepte<l,  then,  secomlly,  we  are  forced  to  realize  that  the  nrtrrinl  tm  it 
fry  no  means  necesmrily  eqwdly  re»i»tmit  in  all  its  parts.  In  some  indi- 
viduals, whether  fmm  hereditary  or  accjuireil  conditioiLs,  the  aortic 
wall  Is  relatively  weak  compan-d  with  the  walls  of  the  smaller  vc.s.sels; 
in  them  the  aorta  may  liecome  affe<'te<l  when  there  is  little  or  no  ehanp 
in  the  smaller  arteries  or  arterioles.  In  others  the  aorta  Is  resistant  and 
the  smaller  arteries  weak  and  apt  to  show  arteriosclerotic  chanfje.  in 
others  the  change  is  universal  .ilthough  in  these  the  .series  of  alterntlDib 
seen  in  the  smaller  ves.seLs  are  from  a  histological  |)oint  of  view  whoiiv 
different  from  those  seen  in  the  aorta. 

Before  going  farther  and  adducing  the  observations  \\\vn\  which 
these  statements  are  l>ase«l,  it  U'comi's  essential  to  descrilx'  Itrietiv  the 
changes  seen  in  arteriosclerosis  of  arteries  of  different  size,  that  the  s»riw 
of  changi's  to  which  we  miLst  refer  may  Ik>  clearly  umlerstoixl. 

Aortic  ArteriOBClerOBis.— The  slightest  change  obser\al)le  in  tlieaorH 
Ls  the  appearance  of  .small  streaks  in  the  intima,  opa(iue,  white,  fatty 
looking,  and  tending  in  general  to  a  longitudinal  arrangenieii'.  'ITiev 
are  most  cortunon  in  tho.se  living  from  infection  and  acute  intoxication. 
Microscopic  examination  shows  that  they  are  not,  as  asualiy  eoiisidered, 
confined  to  the  endothelium,  but  represent  a  fatty  degeneration  of  thf 
deepest  layer  of  the  intima,  the  mu.sculo-el!i«tic  layer.  Thiii  arijai^e- 
mcnt  and  position  makes  us  doubt  whether  these  "fatty  stre;ik.s"  beir 


AORTIC  autkriosclerosis 


177 


any  ri'latioiuhip  to  the  leries  of  changes  to  be  presently  noted  con- 
ititutinK  arteriosclerosis  proper. 

Baklcit  these,  m  demonstrated  by  Kloti  and  confirmed  by  Saltykow, 
crrtain  bacteria  and  their  toxins  \caA  to  a  ilrfinite  proliferation  of  the 
aortk-  cmiothelium  and  intima— a  true  proliferative  intimitis.  Again, 
we  are  doubtful  whether  this  should  be  rffjarded  as  a  true  arterio- 
sderwLs,  or,  more  accurately,  we  lack  evidence  that  this  intimal  thicken- 
ing prtxtwU  onward  to  afford  the  familiar  picture  of  the  atheromatous 
aorta.  'ITie  typical  arteriosclerotic  aorto  shows  changes  which,  to  the 
naiwii  eye,  characteristicallpr  affect  the  intima.  ITiat  undergoes  a 
notabk-  thickening,  not  uniform  but  nodose,  although  in  advanced 
caws  the  thickened  plaques  may  be  so  close  that  they  fa<te  into  huge 
arras.  I  n  these  plaques  we  ol)serve  a  succession  of  stages.  ITie  slightest 
eases  are  those  of  either  proliferation  of  the  superfioial  layers  of  the  in- 
tima, fwrming  a  Uyer  of  dense  fibrous  tissue,  the  fillers  running  parallel 
to  the  surface,  or  of  a  .somewhat  similar  proliferation  of  the  deeper, 
musculo-clastic  layer  of  the  intima,  not  so  purely  fibroas,  but  exhibiting 


Fin.  34 


Hwtum  «(  the  wirtB  from  a  ran  of  nodtMW  urtrritMclcniiiU.  to  •hi>w  tlic  liul«inc  ami  lhinnin« 
.i(  Ihf  mxlia,  iTPpand  by  Dr.  Mallhewxon.  X  8  .llameler..  The  wli.in  >huwi<  alMi  ihi-  hyaline 
ilnwraiii.n  .if  llw  (Ifcper  layrn  of  ttrt  ovrrsniwn  intima.  and  th«  |ienii>tenit!  of  a  Kns  layrr  of 
Iwiltfml  intima  tiaMW  immcdUtt-ly  beneath  the  media.  Tlio  media  in  lliii.  law  xlxiwed 
eviJtiipm  „\  ralraraoua  degeneration  in  patchea  with  aome  hyaline  rlianie. 

also  u  proliferation  of  yellow  elastic  tis.sue.  In  either  ca.se  we  deal  with 
simple  liy|KTpla.>iia  of  the  intima,  with  no  sign  of  leukocytic  infiltration, 
of  new  vi-.s.sci  formation,  or  of  inflammation  as  asuallv  accepteil.  More 
often  wf  encounter  degenerative  changes  in  these  plaque.s.  The  layers 
nearest  to  the  intimal  surface  may  show  little  or  no  change,  hut  (l«'pc>r 
<lown  (I)  the  layers  liccome  .swollen  uiul  hyaline,  or  (2)  as  a  more  ad- 
vanced cliaiifie,  exhibit  fatty  degeneration,  loss  of  nuclear  staining,  di.s- 
inteKraiioM  t)f  the  tissue,  with  presence  of  tablets  of  cholesterin;  in  short, 
evideiur  of  netrosis  and  autolysis;  this  is  the  t\pical  atheroniatou.s 
material     CJ)  .Suitably  stainetl,  as  by  von  Kossa's  m'etlHxl,  such  .s<.ftened 

I  areas  >lmv  also  the  presence  of  calcareous  matter,  ami  this  mav  accumu- 
ate  Ik.  oming  more  and  mtm-  abundant,  until  gritty  ma.s.ses  antl  extensive 
hnttje  |,l,.i,.s  of  cHU-ifitation  liecome  developed!     In  cither  of  these 

I  later  siaj..  s  the  .siijHTfioial,  thin,  but  hitherto  intact  laver  of  the  intima 

'  myjw,'  way  and  \yo  torn  off,  an  atbaromatooi  uleer  bcc-ominc  formed. 

I  shalloH  ;,n.|  with  rough  necrotic  floor. 

'I'l'  <     1  l>rief  are  the  changes  undergone  by  the  intima.      Normallv 

I  ihJt  MM     ,  |),..sscss  no  vessels;  its  nutrition— and  that  also,  we  may  add 


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178 


ARTERIOSCLEROSIS 


of  the  inner  portion  of  the  mttlia— is  gained  in  part  from  thi-  aortic 
lumen  by  infiltration  of  the  hUnxi  plasma.  Obviously,  with  the  progres- 
sive laying  down  of  layers  of  dense  fibroas  tissue,  the  nourishment  of  the 
older,  deeper  layers  becomes  cut  off  and  necrosis  results.  Save  in  ,s\-phi- 
litic  cases,  it  is  only  exceptionally  that  we  encounter  a  secondary  granu- 
lation process  occurring  in  the  atheromatous  plaque,  with  entry  of  capil- 
lary loops  from  the  vasa  vasorum  of  the  mnlia,  and  when  this  is  the  case 
we  meet  with  a  distinct  reparative  process,  absorption  of  the  atlitroma- 
tous  material,  and  laying  down  of  new  fibrous  tissue  to  replact-  that 
which  has  undergone"  necrosis.  Where  this  is  the  ca.se,  the  |)laques, 
instead  of  remaining  flattened,  become  puckennl,  often  with  an  oliscurcly 
stellate  depression.  This  puckering  is,  we  may  add,  the  i.iain  iiakttl 
eye  indication  of  .syphilitic  aortitis. 

'  Hut  while  thas,  macroscopically,  the  intima  is  the  site  of  the  most 
marked  change  in  a»jrtic  arteriosclerosis,  microscopic  examination  with 
the  employment  of  suitable  stains  <lemonstrates  that  the  nii-dia  is  also 
involved— nay,  is  the  seat  of  ihc  primary  chnmje.  This  change,  so  far  as 
we  have  at  present  determintnl,  may  l)e  of  one  of  two  orders. 

Sjrphilitic  Mesaortitis. — A  fre<iuent  .source  of  aortic  arteriosclerosis 
in  those  of  early  micUlle  age  is  .syphilis.  The  researches  of  Heller  and 
his  pupils  and  of  Chiari  (which  since  have  l)een  abundantly  confirmed 
in  other  lalx)ratories)  hrvc  proved  that  the  primary  lesion  here  is  a 
small-celle<l  or  granulomatous  infiltration  of  the  metlia,  along  the  course 


Sfclinn  from  aorta  nf  nyiiliilitic  mpsaortilis  tii  fliuw  extreme  ilegeneratiiin  (if  iiu'li^i  ami  al> 
iKirptiim  of  elaclii-  tissue:  /.  thickened  intinrn;  M,  media,  tlic  darkest  purls  Ikmhk  ilic  fl»=in 
tixKUe.      At  .Y  tliis  lia»  disappeared.     .\t  )',  round-ielled  iiiKltratiiiti. 

of  individual  va.sa  va.sorum.  Klotz,  Bruns,'  and  Wiesner^  havi  jiointed 
out  that  a  similar  change  may  1h'  ciicouiitertHl  in  congenital  -ypliilis. 
Accompanying  the  infiltration  there  is  a  well-marked  localizfil  iitrophv 

'  Bcrl.  klin.  Wooli..  S:  19(Mi:  217. 
'Centralb.  f.  uIIr.  I'atli.,  1<>:  1!»05:  822. 


SEMLf:  DEGENERATION  OF  MEDIA  AND  ARTERIOSCLEROSIS     179 

and  disappearance  of  both  elements  of  the  medial  coat,  of  the  muscular 
and  elastic-tissue  layers,  the  absorption  of  the  latter  being  very  striking 
(Hotz).  This  is  the  primary  \ange.  Tu^  process  does  not  extend 
beyond  the  media  into  the  intima,  but,  as  a  secondary  process,  that 
intiraa  undergoes  proliferative  thickeneng.  It  is  only  at  a  later  period, 
when  the  fibrosb  has  given  place  to  atheroma,  that  the  vessels  above 
noted  txteiid  into  the  necrotic  area.  We  see  here  a  sj-philitic  mesaortitis 
followed  by  intimal  sclerosis  and  its  secjuehi-.  As  to  the  relationship 
of  the  sv-philitic  lesion  to  aneurism  production,  we  shall  speak  later. 
This  form  of  arteriosclerosis  is  frequently,  but  not  necessarily,  accom- 
panied hy  high  pressure  and  peripheral  arterial  sclerosis— frequently 
because  your  syphilitic  is  apt  to  indulge  his  various  appetities,  and  if, 
according  to  Cabot,  alcoholism,  contrary  to  the  general  opinion,  is  not 
a  cause  of  arteriosclerosis,  all  are  agreed  that  overeating  is. 

Senile  Degeneration  of  the  Media  and  Arteriosclerosis.— 
Another  well-marked  type  of  aortic  arteriosclerosis  is  the  senile.  This 
also  is  not  necessarily  accompanied 

by  high  pressure,  and  that  in  spite  fio.  so 

of  well-marked  signs  of  peripheral 
sclerosis.  With  advancing  age  the 
force  of  the  heart  l)eat  becomes  pro- 
(fressively  weaker,  and  the  blood 
pres,siire  tends  normally  todiminish ; 
and  thus,  what  for  a  middle-aged 
adult  would  l)e  a  normal  blood 
pressure  is  relatively  a  high  pressure 
in  an  old  man.  The  main  feature 
is  the  widespread  alteiation  in  the 
mcdiii  of  the  aorta  and  lai^r  ves- 
sels witii  dilatation  and  tortuosity. 
In  these  cases  the  internal  thicken- 
ing; of  the  aorta  is  apt  to  be  not 
nodular,  but  more  diffuse,  without 
puekeriiifr,  and  whereas  the  syphx- 
litie  lesion  luusasits  site  of  election 
the  first  part  of  tin-  aorta,  here  we  not 

infwMiu.iitly  find  comparatively  little  intimal  change  in  thearc-h.  which,  on 
the  contrary,  may  show  thinning  of  its  wall  and  .some  diffu.se  enlargement ; 
where  the  condition  is  not  generalize.1  it  is  the  lower  part  of  the  abdominal 
aorta  tli:it  is  most  involvefl.  Working  in  our  lalmratory  at  the  Royal 
Y'toria  Hospital,  Klotz  has  called  attention  to  the  fact  that  if  the  aortas 
'•f  those  thirty-five  and  upward  l)e  ex.i mined— aortas  not  necessarilv 
sliowini:  My  sign  whatever  of  intimal  sclerosis— and  if  these  be  treated 
to  (ieiiioiistrate  the  existence  of  calcareous  deposits,  it  is  rare  to  encounter 
a  s(rfi„„  which  dws  not  show  some  degeneration  of  the  media.  ^Hw 
ear  lest .  I,,,„tre  ,s  in  the  middle  layers  of  this  coat,  and  then  in  connexion 
,  "  "".  '""■*:•'•'  tf"'^-  The.se  show  first  .some  fattv  change,  later  a  fine 
powdetii,.'  with  calcareous  granules;  later  the  m'uscle  cells,  as  such. 


Section  of  human  aorta  of  elderly  individual 
trealetl  by  von  Kniwa'a  method,  to  demonstrate 
ralcilicalion  of  meilia,  and  more  particuhiriy  of 
the  muscular  bandH.      (Klott.) 


Fio.  30 


SESILE  DEGENERATION  OF  MEDIA  AND  ARTEHIOSCLEROSIS     179 

and  disappearance  of  both  elements  of  the  medial  coat,  of  the  muscular 
and  elastic-tissue  layers,  the  absorption  of  the  latter  being  very  striking 
(Hotz).  This  ia  the  primary  \ange.  Tu^  process  does  not  extend 
beyond  the  media  into  the  intima,  but,  as  a  secondary  process,  that 
intiraa  undergoes  proliferative  thickeneng.  It  is  only  at  a  later  period, 
when  the  fibrosis  has  given  place  to  atheroma,  that  the  vessels  above 
noted  extend  into  the  necrotic  area.  We  see  here  a  sjphilitic  mesaortitis 
followed  by  intimal  sclerosis  and  its  seijuela-.  As  to  the  relationship 
of  the  syphilitic  lesion  to  aneurism  production,  we  shall  speak  later. 
This  form  of  arteriosclerosis  is  frequently,  but  not  necessarily,  accom- 
panied by  high  pressure  and  peripheral  arterial  sclerosis— frequently 
because  your  syphilitic  is  apt  to  indulge  his  various  appetities,  and  if, 
according  to  Cabot,  alcoholism,  contrary  to  the  general  opinion,  is  not 
a  cause  of  arteriosclerosis,  all  are  agreed  that  overeating  is. 

Semle  Degeneration  of  the  Media  and  Arteriosclerosis.— 
Another  well-marked  type  of  aortic  arteriosclerosis  is  the  senile.  This 
also  is  not  necessarily  accompanied 
by  high  pres-sure,  and  that  in  spite 
of  well-marked  signs  of  peripheral 
sclerosis.  With  advancing  age  the 
force  of  the  heart  l)eat  becomes  prt)- 
pessively  weaker,  and  the  blood 
pres,sure  tends  normally  todiminish ; 
and  thus,  what  for  a  middle-aged 
adult  would  l)e  a  normal  bloo<l 
pressure  is  relatively  u  high  pressure 
in  an  old  man.  The  main  feature 
is  tile  widespread  alteiation  in  the 
mcHliii  of  the  aorta  and  larger  ves- 
sels witii  dilatation  and  tortuosity. 
In  tiicsc  cases  the  internal  thicken- 
ing; of  (he  aorta  is  apt  to  be  not 
nodular,  but  more  diffuse,  without 
puckering,  and  whereas  the  syTihi- 
litic  lfsii)ti  luusasits  site  of  election 
the  first  part  of  the  aorta,  here  we  not 

infrc(|u<iitly  find  comparatively  little  intimal  change  in  die  arch,  which,  on 
the  contrary,  may  show  thinning  of  its  wall  and  some  diflfu.se  enlargement; 
where  th<' condition  is  not  generalize*!  it  is  the  lower  part  of  the  abdominal 
aorta  that  is  most  involvefl.  Working  in  our  lalwratory  at  the  Royal 
\Ktoria  Hospital,  Klotz  has  called  attention  to  the  fact  that  if  the  aortas 
of  thoM'  thirty-five  and  upward  l)e  ex.i mined— aortas  not  necessarilv 
sliowiiii:  iiny  sign  whatever  of  intimal  sclerosis— and  if  tlie.se  be  treated 
to  deiiiniisirate  the  existence  of  calcareous  deposits,  it  is  rare  to  encounter 
11  s.rti,.,i  which  does  not  show  some  degeneration  of  the  media.  71» 
«ir  .est .  h.,„tjt.  ,s  i„  the  middle  layers  of  this  coat,  and  then  in  connexion 
Mill  tlu  HiMscle  c-ells.  The.se  show  first  .some  fattv  change,  later  a  fine 
pott.lcni,/  with  caleareoas  granules;  later  the  m'uscle  cells,  as  such. 


Section  of  liuman  aorta  of  elderly  iiiilivitlual 
trealetl  by  von  Kn.'wa's  method,  to  demoiir-trate 
ralcilicalion  of  media,  and  more  particularly  of 
the  muscular  bandx.      (Klot<.) 


M' 


'J  I 

i  i 


180 


ARTERIOSCLEROSIS 


become  indistinguishable,  much  shrunken,  so  that  the  elastic  hands 
on  either  side  become  approximated,  separated  by  a  collection  of  the 
fine  calcareous  granules;  later  the  elastic  lamellae  exhil)it  also  cal- 
careous degeneration.  It  is  at  times  remarkable  what  extreme  ilcgen- 
eration  of  the  media  may  be  found  in  a  comparatively  thin  aixi  not 
particularly  rigid  aorta  exhibiting  none  of  the  onlinary  signs  of  arterio- 
sclerosis. These  observations  are  in  complete  harmony  with  i-arlier 
observations  upon  the  progressive  loss  of  elasticity  of  the  aorta  with 
advancing  life.  Whereas  strips  of  the  aortas  of  young  individuak 
have  great  elasticity,  there  is  little  stretching  power  in  strips  taken  from 
elderly  individuals.  These  observations  of  Klotz  show  that  not  only 
the  elastica  but  also  the  muscle  cells  participate  in  the  pn)f;n-ssive 
degeneration. 

Moenckeberg's  Sclerosis. — Moenckeberg  was  the  first  to  direct 
attention  to  the  widespread  degeneration  of  the  media.  He  was  of 
the  opinion  that  it  was  a  condition  quite  distinct  from  intimal  sclerosis. 
Now,  it  is  quite  true,  as  we  have  pointed  out,  that  it  may  occur  in  a 
diffuse  fona  without  accompanying  thickening  of  the  intima;  indc«l,  with 
some  thinning  of  the  same.  Indeed,  it  can  immetliately  be  diagnosticated 
in  the  lower  abdominal  aorta  and  the  common  iliacs  and  their  hninches 
by  the  development  of  a  succession  of  what  are  truly  shallow  aneiirismal 
pouches  lying  with  their  long  axes  transverse,  with  intervening  ridges. 
but  here  we  have,  only  on  a  somewhat  larger  scale,  the  phenomenon 
noted  in  connection  with  syphilis,  namely,  that  one  and  the  same  cause 
now  leads  to  intimal  thickening,  now  to  aneuns-n.  Why  this  i.s  we  .shall 
explain  later.  We  would  only  note  hoie  ^'lat  »»11  j»rtorio.sclero.sis  of  the 
senile  type  presents  this  underlying  nuHlial  deger.eration ;  that  this  is 
very  common;  that  it  involves  also  the  middle-sized  arteries  in  which 
medial  calcification  may  be  extreme;  and  that  the  "pipe-stem  radial," 
for  example,  is  not  an  example  of  ii.tinial,  but  of  medial  calcification. 

Nodose  Aortic  Sclerosis:  Hsrperpiesis.— It  is  dear  that  the  un- 
ceasing recurrent  strain  of  the  pulse  wave  .seventy  times  a  niimite  or 
thereabouts,  through  the  whole  twenty-four  hours,  day  after  dav, 
year  after  year,  eventually  wears  out  the  elastic  tissue  of  the  aorta. 
The  rate  at  which  it  doe.s  so  varies,  and  undoubtedly  there  enters  an 
hereditary  factor,  .so  that  in  some  families  this  .senile  change  apjMars  at 
a  comparatively  early  pericxl,  in  others  is  long  delayinl;  but  in  all,  sooner 
or  later,  this  loss  of  ela.sticity  shows  itself,  ^^^le^e,  in  addition,  there  are 
causes  leading  to  marked  continuetl  contraction  of  the  arterioles,  there 
the  prolongeil  rise  of  blocxl  pressure  materially  hastens  the  giviii);  way 
of  the  media.  It  is,  we  admit,  <lifficult  to  draw  a  sharp  line  In'tween  the 
senile  arteriosclerosis  and  the  arterio.sclerosis  accompanying  tiiis  slate 
of  hvperpiesis.  The  two  merge  one  into  the  other;  but  when  dinicaily 
we  encounter  high  bloml  pressure  in  tho.se  without  .syphilitic  tai  t,  there 
anatomically  we  find  not  so  much  a  diffuse  intimal  thickening  as  i  nodose 
arteriasclerosLs.  And  here,  as  Thoma  was  the  first  to  lay  (!«■■> n  with 
precision,  we  find  evidence  of  local  and  restricted  giving  wa  of  the 
media.    As  he  showed,  the  first  localities  to  give  way  are  those  i-'  natural 


NODOSe  AOkfiC  SCLEttOSiS:  HYPERPJESIS 

weakness.  Thus,  the  earliest  regions  to  show  the  arteriosclerotic  rhuit  s 
are  at  iiiid  around  the  mouths  of  the  intercastal  and  other  artTles,  where 
the  rfjjiilar  order  ot  the  muscle  and  elastic  bands  of  the  media  becomes 
interrupted  or  pashed  to  one  side  to  allow  the  exit  of  the  lateral  arteries. 
Herv,  we  find  the  intima  presenting  the  same  proliferation  and  fibroid 
change  noted  in  u\e  other  conditions,  passing  on  to  necrotic,  and  later 
calcareous  change  in  the  lower  layers.  With  this,  other  scattered  or 
sporadic,  plaque-like  foci  of  fibrosis  show  themselves  along  the  length 
of  the  aorta,  and  these  may  eventually  show  atheromatous  change  and 
ulceration.  That  the  media  gives  way  in  these  cases  was  demonstrated 
in  a  striking  manner  by  Thoma.    Post  mortem,  when  the  aorta  is  opened, 


Fio.  37 


Aiheromat.ms  plaques  on  the  lininf  of  the  aorta.     (Graupner  and  Zimmennann.) 


these  iKHles  of  intimal  thickening  project  well  above  the  general  surface; 
Ihoin.i  sliowetl  that  if  the  recently  removed  aorta  be  filled  with  warm 
tallow  at  blood  pressure,  and  it  be  cooled  and  the  aorta  cut  away 
from  til.'  solid  core  of  tallow,  this  is  found  perfectly  cylindrical  with  no 
(lepr..ss,„ns  corresponding  to  the  plaques;  or  otherwise,  in  life  these 
intimal  llackenings  evidently  fill  little  bays  in  the  media,  the  intimal 
prolifriad,,,,  compensating  for  the  giving  way  of  the  middle  coat,  and 
tne  an,!,,-  lumen  being  thus  kept  of  even  diameter.  This  experiment 
pt  ih.Hn;.  s  does  not  always  succeed;  there  are  even  cases  in  which  the 
mtima!  .I.ickenmg  is  m  excess  of  the  medial  giving  way— cases  of  over- 
rompr:  irion;  and  there  are  those  who  deny  that  in  every  case  the  media 
sliow>  1  imung  at  the  regions  corresponding  to  the  intimal  plaques. 


'iSL 


^! 


u 


m 


ARTERlOSCLEkoSlS 


But  if  in  certain  cases  this  thinning  is  not  very  obvious,  appropriate  stain- 
ing shows  often  that  the  media  at  these  areas  is  degenerated;  that  the 
thickening  is  only  apparent,  due  to  the  elastic  contraction  which  causes 
the  intimal  mass  to  b-^  projected  post  mortem  into  the  aortic  lumen. 

It  should  be  added  regarding  the  extent  of  necrosis  and  ealcificiition 
that  this  ma>  involve  the  most  internal  layers  of  the  media.  As  al  reach- 
noted,  the  nutrition  of  these  inner  layers  is,  in  part,  at  least,  from  the 
lumen  of  the  aorta,  and  consequently  suffers  when  there  is  this  deposit 

of  impermeable  fibrous  tissue  in  the 
Fio.  38  intimu.    So  as   not  to  confuse  the 

reatler  by  the  introduction  of  minute 
details,  we  have  purposely  neglected 
to  lay  stress  upon  the  minute  anat- 
omy of  the  arteriosclerotic  change. 
Many  recent  workers,  notably  Jores 
and  Marchand  and  Aschoff  and 
their  schools,  have  paid  attention 
to  the  histology  of  the  changes  hen 
descrioed;  they  have  more  particu- 
larly called  attention  to  the  increase 
in  yellow  elastic,  as  well  a.s  white 
connective  tissue  in  the  intinut,  and 
there  ha-s  been  not  a  little  diver- 
gence regarding  the  respective  parts 
played  by  mascular  and  elastic  tis- 
sue degeneration  in  the  media,  the 
existence  or  non-existence  </f  spon- 
taneous rupture  of  the  elastic  tissue 
lamellie,  etc.  But  these  matters  do 
not  mo«lify  our  conception  of  the 
Immd  nature  of  the  main  process. 
To  epitomize  so  far  as  coiicerns 
aortic  sclerosis  we  have  determined: 

1.  In  the  vast  majority  of  cases,  if  not  in  all,  a  weakness  and  piving 
way  of  the  media  is  the  primary  anatomical  lesioi.. 

2.  There  is  the  pcssibility  that,  as  the  result  of  a  subacute  proliferative 
intimitis,  due  to  bacteria  and  their  toxins,  the  thickening  of  tlu  intima, 
by  cutting  off  the  nutrition  of  the  inner  layers  of  the  media,  may  weaken 
that  coat,  and  .so  cau.se  a  local  dilatation  of  the  aortic  lumen,  followed  by 
a  .secondary  and  further  thickening  of  the  intima;  but  it  is  also  possible 
that  the  infi-ctive  endaortitis  which  undoubtetlly  exists  has  no  direct 
association  w!th  the  general  process  here  describetl,  and  that  when. 
after  typhoid  .md  other  infections,  there  develops  a  premature  .irterio- 
sclenxsis,  here,  a^ain,  we  deal  with  a  primary  sporadic  degi>neration  of 
the  media,  .set  up  by  the  luicterial  toxins. 

3.  The  affection  of  the  media  may  In;  either  a  primary  degciicration 
without  signs  of  preceding  inflanunation,  or  may  l»e  of  inflaniuiatorv 
origin  (as  in  syphilis). 


/,  mf>ilia  weakenpti  at  A/'  witli  overgrowth 
of  intima  tilliiig  in  the  Uepretwion;  //.  with 
potttmortem  riRor  and  contrarfi^in  v(  tlie 
muwle  of  the  niecUa  anil  removal  of  the  l>lt>ud 
pressure  from  within,  the  wtretrhed  meilia  :  t 
M"  oontracts.  the  intimal  thirkeninK  thus 
projecting  into  the  arterial  lumen. 


SCLUKOSIS  OF  TUS  SMATLER  ARTERIES  AND  ARTERIOLES     183 

4.  'I'lic  intimal  change  .s(>c<>n(lary  t(»  tlie  medial  defreneration  has  none 
of  the  features  of  an  extension  of  the  morbid  pnjeess  tnnn  the  media, 
but  is  i)f  a  wholly  different  nature.  It  is  primarily  of  h)-perplastie  type 
—a  .simple  connective-tissue  hy|M>rplasia  unaccompanied  by  the  phe- 
norat'iia  which  we  assoc-iate  with  inflammation. 

Sclerosis  of  Arteries  of  the  Second  and  Third  Degree.— These 
same  ciiaiifiies— syphilitic,  senile,  and  ordinary  nodose — affect  also  the 
branches  of  the  aorta  and  their  ramifications,  but  with  this  main  dif- 
ference, that  only  in  th  •  larger  branches  do  we  encounter  anything 
like  extensive  necrosis  and  athen>ma  of  the  intimal  thickening.  These 
thickenings,  compared  wit!i  the  size  of  the  artery,  may  \\e  extreme,  but 
in  absolute  size  they  do  not  compare  with  what  may  be  found  in  the 
aorta.  The  al)sence  of  necrosis  is  to  lie  ascril»e<l  to  the  fact  that  in  general 
th^irsize  is  not  .such  as  to  inhibit  the  pen>olation  of  lymph  through  them; 

Km.  .19 


fnmi  .  -vpliilitii-  a.irlii.  ."liLwiiiK  »  m.«UTate  grmic  iif  ineilial  .Iciteiieralii.ii  ami  xivitiK  way. 
!■•  tlTOLTiXrale  ll.p  simj.le  ronneilive-tisMue  hyiH-riilasia  r.f  Hie  i„tima.  in  regular  layer-.  The 
outer  lajirs  at  a  exhihited  dill.  «  fatly  degeiieratio.  ..t  c  th.-y  were  more  hyaline.  (Fn.m 
Dr.  Alui7,'«  collection.) 

all  parts  are  able  to  gain  some  nourishment.  Saying  this,  it  mast  not 
Ije  thi)iif;li(  that  these  arteries  do  not  prtsent  calcification ;  on  the  contrary, 
that  iiii> ,  k-  extreme.  Long  stretches  of  such  arteries  as  the  radiab, 
the  (in li-  of  Willis  anti  its  branches,  the  splenic,  etc.  may  be  found  con- 
yertetl  into  rigid  tiilx-s.  But  this  depo:iit  is  in  the  media,  and  at  most 
mvolv,  s  IJH'  internal  elastic  lamina  and  the  deepest  portion  of  the  thick- 
ened iiitiiiia.  It  may  lie  added  that  it  is  the  smaller  arteries  that  demon- 
strate most  strikingly  the  thinning  and  giving  wav  of  the  media  beneath 
the  ovtilving  great  thi;-kening  of  the  intima. 

Sclerosis  of  the  Smaller  Arteries  and  Arterioles.— There  is  gnat 
yarialioM  n,  the  appearance  of  the  arterioles  in  different  eases,  and, 
inuenl,  ii;  different  organs  from  the  same  case— differences  which,  never- 
theless. ^u■  Ih-lieve  represent  different  stages  in  the  .same  process,  mo<Ii- 
hetl,  It  m;,v  !«>.  by  variations  in  the  reactive  powers  of  the  different  ti.s.sue.s, 
intiniMl  ,1.1.1  iiuMiial,  to  like  noxic.  In  this  way  two  b-oad  groups  of  coses 
raay  l„  .iisi,„guished:  (1)  That  in  which  pronounced  thickening  .and 


1  nr 

^ 

II 

i 

1     0 

f 

<i 

184 


ARTERIOSCLEROSIS 


hypt'rtrophy  of  tho  miLsculari.s  is  the  most  marked  feature,  and  (2)  that  in 
which  a  generalized  proliferation  of  the  intima  dominates  the  fieM.  We 
arc  inclined,  on  jjeneral  principles,  to  Ix'lievc  that  the  first  represi-nts  the 
earlier  condition ;  that  tiie  first  effwt  of  sul)stanc(>s  circulating;  m  the  hlaxl, 
stimulating  the  smaller  arteries  to  inerease<l  contraction,  must,  of  nrces- 
sity,  lie  to  bring  alM>ut  an  hypertrophy  of  the  muscle  cells;  it  hasalrradr 
been  noted  that  to  this  generalized  contraction  of  the  smaller  arteries  anil 
arterioles  miLst  be  ascrilteil  the  continued  elevation  of  the  blood  ]>rf.s.surr. 

But  just  as  in  the  heart  hj-pertrophy  lieyond  a  certain  point  is  suc- 
ceeded by  im-ompetency  and  deg»-neration,  so  here  eventually  the  muscle 
fibers  degenerate  and  fail  to  maintain  the  narn>wed  lumen;  and  wherr 
this  is  a  pnigressive  process,  and  the  artery  as  a  whole  tends  to  pve 
way  under  the  internal  pressure,  there  Is  developed  a  compfMisaton- 
fibrasis  anil  thickening  of  the  intima,  with  simultaneous  evidence  of 
atrophy  and  fibn>sis  of  the  m<>4lia,  so  that  now  we  encounter  ves.sels  with 
greatly  increase*!  intima,  a  mwlia  which  approximates  now,  it  may  be, 
to  the  normal  width,  or  if  thickenetl  is  fibroid  and  hyaline,  pn-senting 
a  replacement  fibrosis.  The  indications  are  that  in  some  individuals 
ami  tissues  the  mascular  elements  are  incapable  of  pronounced  h\-per- 
trophy,  and  give  way  at  an  early  stage  in  the  process,  so  that  in  them  the 
intimul  change  is  the  more  pronounced ;  in  others  the  muscular  h\-per- 
trophy  is  exceptionally  well  marked,  the  intimal  change  slight.  This 
pronounced  muscular  hyp-rtniphy,  we  should  add,  is  by  no  means 
confineil  to  the  arterioles;  it  is  to  Vte  oKserved  in  arteries  of  much  larger 
size,  in  the  radials,  for  example;  and  then,  as  Savill  and  liusscl  both 
twint  out,  it  may  be  present  either  with  or  without  intimal  thickening. 

What  is  a  characteristic  feature  in  connection  with  the  arterioles  is 
the  very  fretjuent  surrounding  fibrosis,  or,  as  it  is  termed,  chronic  p«i- 
arteritia.  We  know  little  or  nothing  reganling  its  causation-  whether 
it  is  irritative,  <lue  to  .seepage  of  irritative  snostances  out  of  the  vessels, 
or  whether  it  is  of  compcn.satory  nature,  or  of  the  .'iame  order  as  the 
intimal  fibrosis.  That  it  is  due  to  main"  -^"  '  on:  the  les-seiuHl  circu- 
lation, the  fibrous  tissue  replacing  nc  "  elements,  is  scaree 
likely;  the  histology  does  not  suggest  t-  .irther,  any  siuh  mal- 
nutrition should  show  itself  at  the  yen  ..  ?  capillary  area  sup- 
plied by  a  given  arteriole,  rath»-r  than  i.  .  ntre.  Vs  Huclianl  has 
pointed  out,  we  occasionally  encounter  examples  >■■  this  dijxlrofhk 
p'ripheral  fibrosis.     They  clearly  are  of  another  order. 

In  the  arterioles,  as  in  the  aorta,  we  encounter  a  very  ilefinite  infective 
or  toxic  endarteritis  that  causes  confusion  from  its  similarity  ti>  certain 
phases  of  arteriosdercxsis.  Mort*  particidarly  in  connection  with  sec- 
ondary subacute  .syphilitic  di.sturbances,  in  the  neighlwrhcMxl  of  tulier- 
culous  fwi,  and,  as  our  former  colleague,  Duval,'  has  shown  in  cniniection 
with  subacute  glanders,  the  .same  is  to  Ik*  met  with.  His  very  tiiii  studv 
.shows  that  this  is  primarily  a  proliferation  of  the  endotheliiim  of  the 
arterioles;  the  cells  attain  great  size,  exhibit  mitoses,  and  ><  mi  com- 


■  Journal  of  Exp.  Medicine,  9:1908:241. 


XPERIUESTAL  ARTEHlOSCLEROSrS 


185 


pletely  (ill  the  lumen.  At  times  they  form  pant  cells.  More  often  their 
over>rrowth  results  in  the  production  of  several  layers  of  a  flattened  tvpe 
of  rell.  Acconling  to  him,  dej^eneration  of  the  me<lia  is  secondary  to 
this  proliferation.  His  figure,  however,  shows  the  familiar  picture  of 
lotali7,f<l  giving  way  of  the  me«iia  with  overlying  intimal  proliferation, 
and  as  he  expressly  notes  that  the  internal  elastic  lamina  at  the  region  of 
this  giving  way  loses  its  plicated,  wavy  appearance  and  In-comes  even 
and  without  curves,  the  alternative  explanation  seems  to  as  possible  that 
wlitre  this  occurs,  the  giving  way  of  the  media  is  primarj-,  the  intimal 
overgrowth  a  secondary  phenomenon.  We  admit,  frcH'ly",  that  is,  the 
endothelial  proliferation  <lue  to  bacterial  toxins;  we  doubt  whether  the 
medial  degeneration  is  truly  secomlary  to  this,  believing  it  to  Ik-  e(|ually 
primar\',  and  due  to  the  action  of  the  toxins. 

Izperimental  ArterioideroBis. — >\'hat,  then,  is  the  exact  meaning 
of  all  these  changes?  The  answer  is  supplied  by  the  abimdant  ex|K'ri- 
ments  of  the  last  few  years  upon  artificially  produced  arteriosclerosis. 
Then-  had  been  many  attempts  to  reproduce  the  condition  by  setting 
up  internal  and  external  injury  to  the  arteries,  ami  by  causing  localized 
infection.  None  of  these  were  surely  succ-essful  until  Jores  reporti-d  his 
results  with  adrenalin.  It  is  now  one  of  the  most  familiar  facts  of 
physiology  that  intravenous  injections  of  adrenalin  induce  a  mast  pro- 
nouneed  rise  of  blood  pressure.  As  I^ngley  has  shown,  these  injections 
reproduce  I'xactly  the  effects  of  sympathetic  stimulation;  or  otherwise, 
adreniilin  directly  acts  upon  the  muscle  of  the  smaller  arteries  and  causes 
these  to  contract.  The  effect  is  temporary,  but  if  the  injections  be  re- 
peated in  the  rabbit,  eventually  there  is  developed  a  profound  alteration 
in  the  aorta.  I'here  have  l)een  doubts  as  to  whether  the  changes  pro- 
duced correspond  accurately  with  those  of  human  arteriosclerosis.  Cer- 
tainly they  do  not  correspond  with  thasc  '  he  ordinary  nodose  sclerosis. 
They  are,  however,  indistinguishable  fro.a  e  changes'seen  in  Mocncke- 
berjj's  ty|M-  of  me«lial  degeneration.  There  i;  .he  same  atrophy  and  giving 
way  of  the  media,  with  the  production  of  pouchings  which  at  times  are 
so  extreme  as  to  become  definite,  small  saccular  aneurisms.  .\nd,  as 
Klotz  has  shown,  what  happens  is  a  fatty,  followetl  bv  a  calcareous, 
degeneration  of  the  muscular  layers,  with  subsequently  a  similar  cal- 
careous degeneration  of  the  elastic-tissue  elements  of  the  coat.  Identical 
chaups  iuive  been  produced  by  other  obser\ers.  using  barium  chloride, 
nicotine,  und  other  drugs  which  cause  pronounce<l  rise  of  blocxl  pressure. 

Tli.r.'  has  U-en  great  debate  as  to  what  precisely  is  the  action  of  these 
druf.N;  do  they  act  directly  as  poisons  of  the  muscular  coat,  or  of  the 
elasiKa;  do  they  contract  the  vasa  vasorum,  and  so  brmg  alwut  mal- 
nutrui.m,  or  is  the  degt'neration  due  not  to  the  drugs  but  to  the  high 
pressur,  ihey  induce?  This  last  has  U-en  shown  to  be  correct  bv  Harvev' 
(of  Tonrnto),  working  in  Professor  Dixon's  lalxiratorv  at  Cambridge, 
and  UMl,|Mndently   by   Klotz'  in   our  laboratory.     Harvey   employed 

'I  in.  oi  .MiHl.  Research,  17:1907:2.5;  Virchow's  .\rchiv,  19(i:  1909:  303. 
t   '  "all>l.  f.  Allgem.  Pathol.,  19:1908  5.35. 


;|  1 


!■   I 


186 


AHTf:RinsrLEKf>sis 


t('in|Miniry  <li);ilHl  cimiimvision  of  tlif  iilMloiniiml  nortH  of  a  mliliii  for 
miiiiy  .Hii<-(<'<*sivc  ilav.o;  Klotii,  taking  hi-ultliy,  /oiiiik  rabbits,  siisihihIk! 
thi'in  liiwl  (liiwnwnni  for  thn-«>  minutes  dnily  forotio  humlretl  hiwI  Iucdiv 
tlRV.s  or  inon*.  In  lM>tli  rust's  the  only  tlistiirlMnce  iiuiiK-ed  wns  rise  lif 
blotMl  |>n>!wiin>  ii-  the  thomcie  iiortu  anti  it.s  braiH-ht.^;  no  cirii;:  was 
intHMlucetl;  but  changes  wer«>  gained  of  the  .same  onh-r  a.s  those  olnainn] 
with  ailn'iialin.  Klotz's  n>siiit.s  wen-  espeeially  vahiable.  The  heart 
w&s  foiiml  distinctly  hypertrophied;  the  thoracic  aorta  show«>4l  a  diffasr, 
almost  aneuristnal  enlargement  <iHn|mrpd  with  the  alidominid  itnr 
There  was  little  sign  of  intimal  .s<'lert»sis,  but  sections  showed  well-inarkd 
medial  degi-neration  (»f  the  M(K'nckel>erg  type.  Hut  now  upon  exaniina. 
tion  the  main  vessels  of  the  neck,  which,  if  anything,  had  through  gmvitv 
experienced  the  daily  rise  of  bliMxl  pressure  to  an  even  greater  lUyjvt 
than  the  aorta.  exhibite<l  most  ex(|uisitely  a  s|)oradie  intimal  silenMu 
of  the  nodose  ty|M>.  'I'he  con<lition  was  indistinguishable  fmiii  thai 
s<<  ri  in  man. 

I'm.  4n 


rn 


Traiiavrr.ie  -leilii.n  nf  thiirwii'  mirla  nf  riilihit  Ihiit  Imil  rH^n  Hiln|i<-iiilnl  by  ■  .f  IiukI  lej-  (  i 
thl»e  minutes  duily  tor  130  diiyii:  /,  intima;  .1/',  unulTmeil  inner  laytr  nf  nieilia:  W".  •ifgfwr- 
ated  middle  layer  oi  media  with  calcaieouM  deicenerutioii;  j/'",  outer  layer  (»f  iiie.lia.  Tt* 
portion  nf  the  artery  between  yl  and  <'  ban  not  undergone  exlrem"!  dislenwnn;  iil  (  thftr  i. 
becinning  degeneration  of  tl'-  media;  at  .1  and  II,  nlight  palrhen  of  ini't         'veixmwth    .  I  ir  Kloti  > 

Ix't  «is  put  these  fac.s  toijethpr.  P.iisinl  bloo«l  _  ssure  iiuiy  imliKf 
(1)  localize<i  giving  way  of  the  metlia,  or  (2)  diffuse  giving  wny  of  the 
same  with  no  acconij)anying  tjvergrowth,  in  the  first  place  cniisiii);  a 
saccular,  in  the  second  a  diffuse  fusiform  aneurism;  or  (."{)  it  iii;iy  ca-w 
a  slighter  degeneration  and  giving  way  of  the  media,  which  now  is  at  wm- 
panied  by  pronounctHl  pniliferation  of  the  intima.  How  an-  we  to 
reconcile  these  apparently  contradictory  results? 

The  reconciliation  Is  simple  anil  straightforward  once  we  ati "pt  the 
existence  of  what  one  of  us  has  termetl "  strain  hypertrophy"  (vol.  i.  p.  41:'l 
and  of  "overstrain  atrophy."  It  is  a  matter  of  common  teacliiii;;  that, 
provided  the  nutrition  lx>  ad(>quate,  mu.scle  fibers,  whetliir  -triated 
or  plain,  subjected  to  strain  slightly  above  the  normal,  untit-  ■  Inrth 
hypertrophy  and  hyperplasia;  such  moderate  extra  work  is  a  stiiiiiilii'i  to 
increased  growth.  Siibjtititl  to  greater  strain,  they,  on  tht-  ...itran, 
become  exhausted  and  tend  to  atrophy.     Now,  this  .same  law  1.  .Ids  for 


KXPKRIMKNTAL  ARTERIOHCLEROSIS 


187 


thi-  tin-ius  in  KciH-ral  (vol.  i,  pp.  .VII  iiixt 
MM),  ir  tilt-  iiuHliu  ftivc!*  way  only  .Hli^lidy 
atMJ  Krailiiuily  at  th(>  Ttfpon  wh<>rc  it 
\)\i\ff.'*,  tli<-  ovcrlyin);  I'liijothclium  and 
intinia,  U-in;;  piV!w«Ml  outwnni,  iNHoinc 
sirptthni,  .snl)JM-l«l,  that  is,  t«)  IncreM.stil 
strain;  and  the  strain  not  Ix-ini;  i>x- 
(■e*tivt',  till-  «tII.s  pnH-tf*!  to  multiply 
until  tilt'  concavity  is  tilled  up  atui  the 
strain  is  nwovwl.  The  explanation  of 
the (lifftrfiice  in  the  n-sults  in  Dr.  Klot/.'.s 
exptTinunts  U-tween  the  aorta  and  the 
rarotiils  is  that  the  artery  of  .smaller  lumen 
and  n-lntively  mon-  powerful  media  ean 
stami  a  greater  dilating  force  than  the 
arten-  of  larj^f  lumen  and  n-latively 
weaker  walls.  Ue^nled  thu.s,  the  .scle- 
rotic thickening;  of  the  intima  Ls  in  no 
scase  an  inHanunatory  proces.s,  any  more* 
than  is  cardiac  liypi-rtrophy.  At  tlu' 
most,  it  is  compensatory  to  the  weaken- 
ing of  the  media.  When,  on  the  other 
hand,  liic  giving  way  of  the  meilia  is 
more  extreme  ami  nion>  rapid  in  it.s  pro- 
grfS'i,  there  the  strain  to  which  th"  intima 
and  entiotliclium  are  sul)je<'teil  l>eccmies 
(•\ct'ssiv<',  and  pniliferation  of  the  cells 
is  inliiltitcd.  so  that  aneurism  formation 
takes  the  place  of  com(H'nsatory  intimal 
Khrosis  or  sclerosis.  These  views  were 
tnun,iatc(l  l>y  one  of  us'  in  ;,S!Mi,  but 
then  caintd  little  acceptance;  the  results 
of  tlii>  ixpcrinicntal  pnxiuction  of  arte- 
rii)s<ltrii^i^     have     demonstrated     their 


rio.  41 


Int. 


-  Jietf. 


Schrmatic  rrpmentation  of  the  in- 
rreoMd  Rtrain  bruuffht  t>'  hnr  uptin 
the  cells  of  the  intima.  Int.,  wh^»  the 
mc'lia  underrim  a  localiieil  •  >!i  iin. 
Ihruucb  relative  weakneaa. 


Fill.  42 


1"  »lr.«  n  ..1..-,?  xl.-r..M»  of  intima  of  (•ariitid  of  saine  rabbit:  .4.  outer  layers  of  new  fibmu!i 
iwnf  -h  vM  L  liilledeiteneration;  B,  atheromatous  tleseneration  of  deeper  layers,  apparently  of 
muj.iU.-ri,.:,.  h.yer;  C.  unaffected  intim.i. 


.\.lai 


Mi.lillctonGolilsmith  Lectiirr,s,  New  York  Med,  Record,  1896:46«.ind505 


188 


ARTKBtnsCLEHoaia 


acourary.  llir  final  oral  (>«>mpli>tp  iimof  ha.<i  lirrn  afTordn:  :>y  ('arrrl's 
reiiiarkahk*  uiiaervatiuii,'  that  if  n  lenii^h  of  vein  lie  tnniiplantcil  into 
the  ruune  of  an  arterv,  that  vein  in  the  roiine  of  a  few  month-s  is  found 
to  prnwHt  an  extraoniinary  fihruitl  h>-pertn>phy.  It  Li  unnemwury,  with 
Thoma,  to  invoke  the  .iiffk-iiitiy  rornprehen-sihle  loral  changes  in  mtrof 
blood  flow  and  nutrition  to  ncrount  for  the  intimal  hyperplaflia. 

Throuj{hoiit  the  whole  of  tlii-s  arteriowlerotic  pnioesn  we  see,  (luTeforr, 
relatively  simple  forces  at  work.  In  one  important  series  of  casi-s,  ilimt 
stimuli  acting  upon  the  media  of  the  smaller  arteries  cause  increasiij  tonir 
contraction,  or,  as  IttMsel  terms  it, kupertonusot  the  same,  ami  this,  raising 
the  blood  pressure,  affects  sccontiarily  the  mnliu  of  the  aorta.  The 
masculatiire  of  the  niediit,  liecoming  overworkwl,  undergoes  atrophy  and 
degeneration,  ami,  graduallv  giving  way,  imiuces  a  local  compeiuatorr 
fibrosis  of  the  intima.  Similarly,  the  masculatun-  of  the  smaller  arterlM 
giing  way  imiuces  in  them  also  fibrosis  of  the  intima.  In  the  other 
series  of  cases,  without,  «if  neces.sity,  any  contraction  of  the  peripheni 
arteries  ami  rise  of  blood  pressure,  weakness  of  the  media  of  the  aort* 
and  larger  vessels,  whether  inheritetl  or  ac(iin''v<i,  makes  tht-  nwli« 
give  way  umler  the  normal  bloo«l  pressure,  and  again  the  dilatafi'  .1  iv 
be  followetl  by  compensating  fibrosis  of  the  intima,  with  the  su(xt.vsive 
stages  leading  up  to  atheroma.  In  either  series  of  cases,  if  thi-  (fivinjt 
way  be  widely  diffasetl  ir  sudden  and  e-xtreme.  in  place  of  this  com- 
pensatory sclerosis  aneurism  formation  results. 

In  these  cases  of  hyperpiesis  and  hypertonus  of  the  more  p«riph(Tal 
arteries  with  the  increase  in  blocxl  pressure  there  is  also  increuseti  strain 
thrown  first  upon  the  casps  of  the  aortic  valve,  ami  next  upon  those  of 
the  mitral.  The  arteriosclerotic  thickening  and  fibnxsis  of  thf  caniiac 
valves  in  these  ca.ses  is  of  exactly  the  same  nature  as  th*-  intinul 
thickening  of  the  arteries;  the  cusps,  indeed,  are  but  infoldin^rs  of  the 
intima,  or  its  homologue,  the  emlocunlium.  These  also  afford  examples 
of  strain  hj-pertrtjphy  and  fibrosis,  and,  as  already  noted,  a.t-  apt  to 
present  identical  degenerative  pnicesses,  atheroma,  calcification,  and 
atheromatoas  ulceration. 

Sclerosis  rFnnctional)  and  Eegeneration  of  the  Uterine  ud 
Ovtrian  Arteries. — A  remarkable  condition  to  which  attention  was  first 
directed  by  Westphaien'  in  188(j,  that  has  come  in  for  renewal  atten- 
tion during  the  last  few  years  by  P:;nkow,'  Sohma,*  Szasz-.Shwan,' 
Goodall,  and  others,  (leser\es  mention  here.  The  increased  Wood 
supply  to  the  uterus  during  pregnancy  is  accompanied  by  greai  dilata- 
tion of  the  uterine  arteries,  so  great  and  .so  long  continued,  iliat  after 
childbirth  they  would  seem  unable  to  contract  to  their  previ'Hl^  dimen- 
sions. And  now  there  may  \ye  the  development  of  a  coniplete  new 
artery  fas  rejtanls  adventitia,  media,  ami  intima),  within  the  ciM,  vhich 
exhil)its  fibrosis,  hyaline  and  other  degenerative  changes.     Fniliiig  this, 


•  Jour,  of  Exp.  Mcnlicinc,  10;  I90S:fi,«). 

•  Arch.  1.  Gynak.,  W):  19()7:pf.  2. 
»  R«vue  de  Gynec.,  7: 1903:59.3. 


'  Virch.  Arcli.,  106:I^Mi:420. 
•Ibid.,  84: 1908:  pt    ' 


ANISURiS%r 


i8g 


liifie  is  exteaiive  intimal  oveiY^ntwth.  Our  ciilleague,  I)r.  (tuoilall,  htu 
foilowecl  the  succeMiun  of  rhan^ri,  and  concluileM  that  there  in  an  intti  • 
mediate  ^'tj^  of  active  prolifc  ntiion  aiul  waiiilerinjf  inwti  nl  of  cells  fro'i 
tlieviri>  It  cnata  resulting  in  thew  ni  .  celU  a-H-suminK  <-rderiy  relation 
shim  with  the  production  of  a  new  arterial  wall. 

'rhe  fH<-tor<  determining  thin  remarkable  process  have  not  l)et  li'v 
workfti  out.  It  may  \te  .su^r^^eHted  that  with  the  contraction  of  the  uterine 
mturle,  umi  it  may  lie  the  contraction  also  of  the  terminal  arteri'  lett,  there 
1.1  pnmoiinced  olxttruction  to  the  outflow  of  i he  arterial  hlood  and  the 
produrtion  of  incva.sed  strain:  that  the  condition  is  identical  with  the 
inlimal  ihirken'*  which  Thoma  noted  an  affectinf;  the  proximal  part  of 
Rii  arter}'  after  ,'nture.  But  this  is  not  sufficient  to  explain  the  devel- 
opment of  a  w*  •orroeil  new  artery  within  the  (>'''  .Vscholf'  places  this 
in  •  special  clh...^  as  functional  sclerosis. 

The  pnx-ess  affecting  the  ovarian  arter'  ...  er  menstruation  and 
ovulation  in  of  the  same  order. 


AHinUflM. 


We  shall,  in  the  next  chapter,  pa.s.s  in  review  the  various  forms  of 
am-urism,  or  localized  "xpaiLsion  of  the  arterial  wall.  We  would,  in 
this  contuHtion,  merely  emphasize  again  that  the  factors  which  are 
productive  of  arteriosclerosis  are  the  .same  as  those  producing  ai:eurLsm 
—only  that  in  the  case  of  aneurism  wc  have  a  .severer  disturliance  of  the 
oquilihriuni  l)etween  the  pressure  within  the  ves.sels  and  the  strength  of 
its  wails.  The  studies  t)f  the  last  thirty  years  have  amply  confirmed 
Scarpa's  oUscn-ation  (1S()4)  that  the  strength  of  arteries  depends  upon 
the  middle  c-oat,  and  that  either  lix-alized  degeneration  or  localized 
inflani'-'ution  of  the  n*  nlia,  particularly  .syphilitic  mesaortitLs,'  is  '.le 
main  (..  ■  of  the  cor  :  m  i  Kiister,  Eppinger,  'ITioma,  Heller,  CK  tri, 
Bi-nda).  'i'lic  distens.  induced  is  .s.»  murkctl  that  characteristically 
in  the  iinciiris  o  there  .  no  compen.satory  hyperplasia  of  the  intima. 
On  the  (■(  riir.irv,  {!.c  .strain  thrown  upon  this  ami  the  other  coats  is  so 
great  tiiut  the  i-tuicncy  is  to  atrophy,  and  with  this  a  gradual  al).sorption 
'•'  ;*>e  tiiiiiiiwi    :mi  ;  may  l»ecomc  followe<l  by  a  complete  di.sappearunce 

•'  ■  same  and  the  production  of  a  "false"  aneurism,  the  walls  of 
wtiKh  are  formed  of  ilic  condensed  tissue  of  surrounding  parts  and  organs. 
There  is  liiit  one  po.ssil)le  factor  for  the  prodi'ction  of  aneurisms  which, 
so  far.  has  not  been  recognizable  as  inducing  arteriasclerosis,  namely, 
traiitT'a;  sudden  mechanical  injury  to  the  arterial  coats  is  most  apt  to 
be  folliiwcd  by  sudden  giving  way  of  the  vessel,  ond  such  suiidcii  <li.s- 
tension  nl  tiie  intima  ceiiainly  does  not  favor  hypertrophic  changes. 

'Bfihi  I,  /urmeil.  Klinik.,  4:1908:pt.  t. 

Then:  .i'lriiyof  »lati»tic»Kive  from  60  to  85  percent,  of  anruriRms  as  of  Mvphilitie 
ongin.  I  ri  cent  workers,  HaUKinann  M  the  only  one  who  depreciates  this  c  use, 
ascribiiif;      'v  18.75  per  cent,  of  cases  theretc 


u 


H 


CHAPTER    IX. 

PATHOLOOUAL  ANATOMY  AM)  IlISTOI.OtiY  OK  THK  AlMKIilts 
VEINS,  AND  LYMI'lIATIC  VKSSKLS. 

As  will  be  readily  underst(xxl,  tlie  various  portioas  of  the  vasiular 
system  stand  in  such  close  functional  and  anatomical  r,'lation.slii|)  to  each 
other  that  the  pathological  processes  involving  them,  while  |m  ssessiiio 
some  few  characteristics  and  peculiarities,  on  the  whole  present  much 
similarity. 

ARTERIES. 

The  walls  of  the  arteries  are  compose*!  of  three  layers,  tlic  tunica 
intima,  the  tunica  media,  and  the  tunica  adventitia.  The  Krst  is  avascu- 
lar, deriving  its  nourishment  from  the  circulating  hliMnl  witliin  the 
vessel,  while  the  adventitia  (h-rives  its  hlood  supply  from  small  arterial 
twigs,  the  vasa  vasorum.  In  the  case  of  the  mtnlia  the  condition  varies 
in  tlifferent  plact>s,  the  media  of  the  aorta  having  vascular  twij;s  which 
reach  to  the  intima.  The  intima  is  an  endothelial  lining  dircclly  con- 
tinuous with  the  cii.il K-ardium  and  the  wall  of  the  finest  capillaries. 

The  thickness  of  the  arterial  walls  and  the  <-alil)er  of  the  vessels 
varies  at  different  periods  of  life  and  with  dilferent  individuals.  Acconl- 
ing  to  Orth,  the  thickness  of  the  aortic  wall  from  the  age  of  twenty-five 
to  seventy-five  is,  on  the  averagi',  1.5  to  2  mm.  The  circujnference  of 
thejiorta  jitst  alM)ve  the  valves  isti.l  toHM  cm.;  of  the  thoracic  aorta,  4.4 
to  5.i)5T.i.;  of  the  alMlominal  aorta,  3.2  to  4.33  cm.  The  cinninferpnce 
of  the  pulmonary  artery  just  alK)ve  the  valvi-s  is  from  0.4  to  7.5  cm. 
In  early  life  the  pulmonary  artery  is  .somewhat  larger  than  the  aorta;  in 
middle  life  they  are  the  .same  size;  an<l  in  old  age  the  a<jrta  is  (lie  larpr. 
This  last  condition  is  due  to  the  fact  that  degenerative  processes  in  the 
aorta  are  so  common  after  middle  life. 


OONOENITAL  AND  DEVSLOPMEirTAL  AKOMALIES. 


Defects  of  development  have  a  close  relationship  to  those  of  the 
heart,  and  have  alreaily  Ikvii  touched  upon.  Ahnonnalities  in  tiie  come 
or  number  of  the  arteries  have  no  pathological  interest. 

The  aorta  may  participate  in  the  condition  of  tranaposition  of  the 
viscera,  or  may  Ik-  duplicated,  either  in  whole  or  in  part. 

More  important  is  general  bypopUiia  of  the  arterial  .system,  which 
may  exi.st  alone  or  in  combination  with  a  similar  defect  in  the  heart. 
The  condition  is  found  in  Injth  sexes,  but  is  most  common  in  i  lilomlic 
girls  about  the  age  of  pulwrty.    We  have  found  it  with  striking'  rie(|uencv 


INFLAMMATIONS 


191 


in  yoiiiii;  people  who  have  died  of  tuberculosis.  The  aorta  is  narrowed 
ami  tlic  lircumference  may  lie  only  2  cm.  At  the  same  time  the  wall  is 
thinned  and  the  elasticity  is  decreased.  Other  physical  defects  may  be 
associiittMl,  particularly  hypoplasia  of  the  genital  system.  Arterial  hypo- 
plasia iiiis  also  been  met  with  in  cases  of  hemophilia. 

OIKOVLATORT  DI8TUKBAN0ES. 

Blood  Imbibition. —Owing  to  the  avascular  character  of  the  intima, 
circulatory  disturbanc-es  in  this  portion  do  not  occur.  At  most,  we  may 
find  a  diffuse  rosiness  due  to  blood  imbibition,  which  is  most  likely 
a  ixxstmortem  change.  This  is  found  in  septicemia,  passive  congestion, 
and  infection  with  the  B.  Welchii. 

In  tiie  adventitia  and  media,  and  even  in  the  intima,  where  newly 
formwl  vessels  have  invaded  this  coat,  small  bomonluges  are  found  in 
passive  congestion  and  in  inflammation.  Of  special  interest  to  the 
medicoiegid  expert  an-  hemorrhages  into  the  wall  of  the  carotid  in  those 
who_have  Int'ii  liunged  or  throttled. 


OnrLABOIATIONS. 

Arteritis.— Arteritis  may  be  hematogenic,  or  may  arise  from  trauma, 
from  direct  extension  of  inflammatory  processes,  or  as  a  complication 
()f  degenerative  changes.  Traumatic  causes  arc,  rupture,  wounds,  or 
ligature  of  a  vessel,  .\part  from  injury,  the  most  important  factors  are 
infections  an<l  intoxications,  due  to  pus  organisms,  tulx-rcle  iMicilli,  and 
the  svpliilitie  virus.  A  very  common  occ-urrence  is  the  inflammation 
of  a  vessel  from  the  presence  of  a  thrombus,  either  infective  or  simple. 

Thrombo-arteritis.- Thrombo-arteritis  is  the  fonn  associatetl  with  the 
prcsciuc  of  an  autix-hthonous  thrombus  or  an  embolus.  Kxamples  of 
the  former  an"  found  in  traumatism  to  the  vessel  wall  and  in  the  infections. 
.^  a  rule,  inflanmiation  of  the  artery  is  primary  and  the  thrombus  is 
s«i)n(larv,  but  umloubtedly  the  reverse  can  occur.  The  character  of 
the  inHaintiiation,  whether  suppurative  or  proliferative,  depends  upon 
the  nature  of  the  oiistruction. 

Sui)|)iiration  is  the  result  when  the  thrombus  or  embolus  contains 
pus  orfiiiMisnis.  The  affected  spot  is  of  a  yellowish-white  color,  swollen, 
and  more  friable  than  usual.  The  intima  is  first  swollen,  and  later  there 
IS  rapid  infiltration  of  all  the  coats  from  within  outward,  with  inflam- 
matorv  aneurism  or  a  local  abscess. 

Thrombo-arteritis  proUferans  occurs  when  the  thrombus  or  embolus  is 
not  int..,  live.  Aeconling  to  the  degree  of  proliferation,  Ux-aliztHl  patches 
of  till,  k,  nil,-;  or  th«>ad-like  projections  are  formed  upon  the  vessel 
wall,  i!  the  prwess  lie  extensive  enough  to  obliterate  the  artery,  we 
can  sptiik  ,if  an  enddrtnitis  oliUternm. 

Tlie  |,im1  iterative  change  consists  in  the  substitution  of  the  thrombus 
by  eoiii     live  tissue.    The  arterial  wall  is  infiltrated  with  leukocytes, 


II 


i 


1  *' 


102 


THE  ARTERIES,  VEINS,  AffD  LYMPHATIC  VESSELS 


and  many  fibroblasts  can  be  seen,  which  invade  the  intima  and  p«'netnite 
the  substance  of  the  thrombus,  eventually  bringing  about  complete 
organization.  Newly-formed  capillaries  can  be  made  out  within  the 
fibrous  mass.  If  the  intima  be  preserved,  it  may  also  show  changes 
of  a  proliferative  character.  The  thrombus  may  thus  be  convertinl  into 
a  solid  mass  of  tissue  or  may  be  tunnelled  through  (canalization),  the 
various  channels  being  ultimately  lined  with  endothelium  and  the  blood 
flow  thus  restored  (see  p.  7-1).  In  some  cases  a  calcareous  deposit  takes 
place,  and  an  arteridith  is  the  result. 

Arteritis  also  arises  by  the  extension  to  the  vessel  of  a  neighlwring 
inflammatory  process,  such  as  an  abscess,  ulceration,  infected  wounds, 
tuberculous  cavities,  and  the  like.  In  these  cases  the  inflammation 
begins  first  in  the  adventitia,  and  subsequently  ir  ides  the  other  coats. 
It  may  lead  to  thrombosis  of  the  vessel  or  to  rupture. 

Proliferative  arteritis,  leading  to  gradual  thickening  of  the  ves,sel  and 
even  to  obliteration,  is  also  found  in  the  arteries  of  a  tissue  which  is 
chronically  inflamed.  It  is  well  seen  in  cases  of  chronic  interstitial 
nephritis,  tuberculosis,  and  syphilis,  and  is  very  common  in  almost 
every  form  of  tumor,  as  in  soft  sarcomata  and  carcinomata,  but  par- 
ticularly often  in  those  forms  which  contain  much  connective  ti&sue, 
such  as  elephantiasis,  fibroma,  and  scirrhous  carcinoma. 

Periarteritis  Nodosa. — This  is  a  curious  condition,  first  fully  descrilwd 
by  Kiissmaul  and  Maier,'  in  which  small  nodules  are  formed  in  the 
w'alN  of  the  smaller  arteries  of  the  muscles,  serous  membranes,  spleen, 
abiloiiiinal  glands,  uterus,  and  mucous  glands.  Acconling  to  Freund, 
who  has  publishe<l  a  careful  research,  the  changes  are  sometiint-s  most 
niarkinl  in  the  adventitia,  sometimes  in  the  intima,  but  usualh  the 
pn)ce.ss  affects  chiefly  the  media. 

The  adventitia  shows  cellular  itifiltration,  chiefly  of  the  mononuclear 
variety,  together  with  spindle  cells.  The  intima  is  often  thickened  and 
hyalirie.  The  hyaline  change  also  extends  into  the  media.  In  the 
earlier  stagi's  n)und  cells  fn>m  the  adventitia  penetrate  the  media. 
From  this  description  of  the  lesion  it  will  lie  seen  that  the  ttrin  "|Hri- 
arteritis  is  not  strictly  applicable.  The  character  and  the  nuiliipliciiv 
of  the  afftvtion  render  it  probable  that  infective  agents  or  cinulatin); 
toxins  arc  the  cause  of  the  condition  (H.  Morley  Fletcher'),  'riimmtiosk 
and  acute  amurisinal  dilatation  often  accompany  the  process. 

Tuberculous  Arteritis. — Tuberculous  arteritis  may  ari.se  from  infection 
through  the  bl(KKl  or  from  the  extension  of  a  tul)erculoas  pr(Mt->  outside 
the  vessel  'i'he  latter  event  is  the  more  common.  In  the  arterial  wall 
typical  tul  rcles  can  1h»  .swn,  or  a  more  diffuse  inflammatory  iiililtration. 
'i'lie  tulH-nies  sometimes  caseate,  and  rupture  of  the  ve.s.sel  take  s  place; 
the  vessel  may  InH-ome  throml)o.sed,  or  the  infective  substaiu «  inav  be 
discharge<l  into  the  lumen.  Under  favorable  conditions,  fihinii-^  h}per- 
plii.si:i  takes  place.     Most  frequently  the  adventitia  is  affecte  !;  ''Vt  the 


'  Dtut.sch.  .\rcli.  f.  klin.  Mod.,  I:  1866:484. 

'  L'eber  (lio  siigeimiinte  I'eriarteritis  nodoHu,  Ziegler's  Heitruge,  11  M*-"'   K3. 


RETROGRESSIVE  METAMORPHOSES 


193 


intima  may  be  considerably  thickened  as  well.  In  the  case  of  the  smaller 
vessels  the  lumen  may  be  entirely  occluded.  Tuberculosis  of  the  large 
arteries  is  rare.    Blumer'  has  recorded  two  c&ses. 

Sypbilitie  Irtwltta.— Syphilitic  arteritis  occurs  as  a  distinct  entity 
or  as  an  extension  of  a  local  .syphilitic  infection.  The  arteries  of  the 
brain  and  heart,  and  the  aorta  are  ihe  vessels  chiefly  affecte<l.  In  the 
first  form  a  thickening  of  the  intima  and  adventitia  occurs  either  as  cir- 
cumscril)ed  gray  or  grayish-white,  semitranslucent  masses  (gummata),  or 
the  section  of  a  vessel  may  be  transformed  into  a  firm,  grayish-white 
cord.  Or,  again,  the  vessel  wall  is  infiltrated  with  gummatous'masses  or 
is  eiiclosed  in  dense,  fibrous  tissue.  In  the  aorta  the  disease  affects  pri- 
marily the  adventitia  and  media  with  secondary  fibrosis  of  the  intima 
(see  p.  17S).  Reuter,'  Wright,  and  others  have  detected  the  treponcma 
pallidum  in  cases  of  specific  aortitb. 


RETBOORESSIVE  MET1MORPH08E8. 

Atrophy.— Atrophy  of  the  arterial  system  occurs  in  general  maras- 
mus and  severe  anemias,  or  a  particular  organ  may  be  affectetl.  Stenosis 
of  the  aortic  ring  and  extreme  atrophy  of  the  heart  may  also  result  in 
this  condition.  In  amputated  liml)s  the  vessels  of  the'stump  become 
smaller.    Increa.sed  bIcxKl  pressure  leads  to  atrophv  of  the  tunica  media 

Degeneration.— r»tty  Degeneration.— This  is  a  verv  common  con 
(iition  found  at  autopsy,  and  while  it  usuallv  affects  the  intima,  is  also 
met  with  (xrasionally  in  the  media  and  adventitia.  It  is  due  to  anemia, 
to  eirc  ulj.tory  toxins,  or  again  to  increased  blood  pressure.  The  last  form' 
IS  ofteii  seen  in  the  pulmonary  artery,  for  instance,  in  pidmonarv  tuber- 
culosis, and  111  prolonged  congestion  of  the  lesser  circulation.  The  toxic 
form  IS  well  illustrated  in  the  case  of  tvphoid  fever  and  pulmonarv 
tulxTnilosis.  The  fatty  patches  appear  in  small  streaks  or  flecks  of 
a  whitish  (jr  yellowish-white  color,  which  mav  or  mav  not  Ix-  sliglitlv 
elevatcl  alK)ve  the  general  surface.  Micros(^)picalIv,'  the  cells  of  thie 
deep»r  liiv.rs  of  the  intima  are  filled  with  fat  droplets.  The  condition 
can  result  in  a  small  local  loss  of  suKstancc,  which,  in  the  caijillarics  of 
the  liraiii  and  lungs,  may  even  lead  to  rupture  of  the  vessel. 

In  the  larger  vessels  a  locus  resisieniia:  mhioru  mav  be  thus  prwluced, 
which  nii.y  very  possibly  prepare  the  wav  for  sclerotfc  changes. 

Necrosis  and  OalcifiMtion.-These  ar^  also  fre<,uent  sequels.  The 
media  is  tl.e  ihief  seat  of  calcareous  deposit,  and  the  intima  mav  at  the 
same  i,,,,,.  .-x  ubit  productive  change.  The  thickened  vessels'  of  the 
aged  are  no  d„„bt  of  this  ty^.  Such  arteries  are  a  fre<,uent  cause  of 
inrom  M,.i>  and  anemic  necrosis,  as  well  as  glandular  itrot)hies. 

Hyaline  Degeneration.-Hyalii.e  degeneration  affects  chieflv  the  intima 

0     ...  I.,,.,. r  vessels  or  the  wall  of  aneurismal  sacs,  but  is  fn^iuentlv 

ouml  v.:    ,.  f„,est  capillar.es.     It  is  a  co.uiuun  aci-ompaniniei.t  of  arteric^ 

scieron,- ,  hange      It  is  oft.;,  present  in  the  glomerular  tufts  of  the  kidney 

in  chro„„    nephritis,  m  the  choroid  plexus  of  the  brain,  and  in  the 


'  AniiT 


T.  -Med.  Sci..  117: 1899: 19.         »  Zeitschr.  f.  Hygiene,  54: 1906:-t9. 


194 


THE  ARTERIES,   VEINS,  AND  LYMPHATIC   VESSELS 


capillaries  of  atrophic  l^mph-glands.  The  chati)^  consists  in  thr 
formation  of  a  hoinoj^netjas  hyaline  sulwtaiKf,  re-seinhlin);  umyloid, 
but  not  giving  the  same  chemical  reactions,  in  the  c-ell  pnUoplasin.  |t 
is  due  to  mechanical,  chemical,  or  dyscrasic  causes.  In  certain  iiiinors, 
hence  called  "cylindn)niata,"  the  vessels  are  found  converted  into 
thick  tul)es  of  this  material. 

Amyloid  Inflltratioii. — Amyloid  infiltration  attacks  l>y  prefen-nre  thr 
smaller  arteriole's  of  the  various  organs,  though  in  very  severe  ciiscs  of 
the  affection  the  large  trunks  do  not  altogether  escajie.  The  (it'|)osi| 
is  seen  first  in  the  media,  following  the  course  of  the  cmuliir  nuiscle 
fibers.  The  condition  may  sprc-ad  to  the  adventitia  and,  in  large  vessels, 
to  the  intima. 

Arterioicleroiii. — Arteriosclenisis  is  an  affection  of  the  arteries  most 
fre(|uently  found  in  the  aorta,  but  often  also  in  the  arteries  (if  the 
brain,  heart,  extn-miiies,  the  kidneys,  anil  the  spleen.  It  is  soniewhal 
rare  in  the  mesenteric  and  pulmonarj-  arteries.  The  lesions  varv  much 
in  their  distribution ;  at  one  time  the  major  trunks,  at  another  the  incdium- 
sized  vessels,  or,  again,  the  finer  arterioles  show  the  most  ailvuiiced 
changes.  Kven  the  i'a|)illaries  may  1k>  involvwl  in  a  widespread 
process,  the  arterioeapillary  fibrosis  of  (Jull  and  Sutton  (aiijrio- 
■sdenxsis  of  Thoma).  If  the  lesions  are  extensive  and  widesjiread,  we 
recognize  an  «r/<T/a<i<7(T(w/.v  f/Z/fiMd ;  if  seatteriMl  and  IcK'.dized.aii  (jr/cr/o- 
ftcUrosiii  mxlona.  Accortling  to  Uokitansky,  the  following  is  the  oiiier  of 
fre<|uency  with  which  the  vessels  nrv  affcctj-*!:  Ascending  a()rta,  the 
arch,  the  thoracic  aorta,  the  alHlominal  aorta,  iliaes,  crunils,  eoron,  ries  of 
the  heart,  ceri'brals,  vertebrals,  uterine  arteries,  sjH-rmatic-s,  liypd^astrics. 

At  an  early  stage  of  the  priK-ess,  gniy,  semitninslueent  pate! les,  some- 
times of  a  gelatiiM  us  apjX'anuice,  are  foimd  in  the  intima  iplaijuoi 
gclatiniformen).  These  have,  in  part,  the  structure  of  i.iueoid  tissue, 
the  cells  of  which  are  either  well  pn-  ;erve<l  or  mori'  often  fattily  degener- 
at(Hl  (»r  necnxsed.  loiter,  the  patches  are  hanier,  of  a  eartihij;inoii.s 
appearance  and  gray-white  color,  forming  round,  oval,  or  irrcfjular 
ari'as  more  or  less  raised  alM>ve  the  gen«'ral  surface.  These  are  <-iiin|K)se(i 
of  newly-form' d  eonne<-tive  tissue  whieli  alreaily  iH'gins  t<i  sliow  mn>- 
gressive  changes.  The  tissue  has  lost  its  stratificati  mi,  the  (til-  are 
swollen  and  stain  |KH)rly,  the  whole  eventually  forming  a  sinitnireless, 
hyaline  mass.  Assin-iated  with  this  may  Ir'  fatty  degeneiation  of  ihi' 
cells  and  thepnxluelioii  of  a  granular,  ,shre«ldy  detritus  (athvrima  i.  \  true 
necrosis  is  tlnis  the  result,  and  in  the  advanced  stages  we  frcijuently 
find  a  de[K)sit  t)f  lime  salts  in  the  areas  of  degi-neration  (calrijiid  jila(ju<:t . 
Very  frtniuently  the  ncerobiotie  tissue  bre'iks  down  into  a  shallow 
ulcer  (athennnatoux  ulcer),  the  base  of  which  is  fornietl  of  clidlcsterin 
and  granular  debris.  On  such  uWrs  thnmsbi  may  form,  :dtlioU);h 
more  often  they  are  chanieteristically  not  prcxluced.  If  the  ili  ^irnclive 
proce.ss  gcK's  on  in  thedii-jM-r  layers,  leaving  the  mt-rotic  area  still  covere;! 
by  the  *hiekene<l  intima  and  endotlielium,  an  ab.strs.s-iike  iomH  i>tlif 
result.  The  degt-nerative  changes  ju.st  dcserilx-tl  are  by  no  imans  re- 
stricted to  the  intima,  but  may  extend  (piite  deeply  into  the  nit  ilia.    Tiie 


ARTERIOSCLEROSIS 


19£ 


muscle  fillers  are  atrophic  and  show  hyaline,  fatty,  ami  calcareous  change. 
The  eiiistic  fihrillae  are  usually  diTgeneratcd,'  and  often  torn.  New 
formation  of  elastic  tissue  takes  niace,  especially  in  the  intima.  In 
additiDii  to  the  appearances  mentioned  in  the  class  of  case  jast  descrihed, 
tiiere  an-  others  of  an  inflammatory  nature  which  have  led  many  patholo- 
psts  to  regard  the  whole  process  as  inflammator}-.  Both  in  the  media 
and  the  ailventitia  small  collections  of  leukocytes  are  found,  situated 
••mund  tlu  vasa  vasorum,  which  also  seem  to'  proliferate,  for  we  find 
newly-formed  capillaries  developing  in  the  me«lia  and  even  pushing  their 
vrav  into  the  intima,  indications  of  a  reparative  pnx-css.  Where  this  is 
iiotal)!y  the  case  we  «leal  with  STphilitic  mesMrtitii  (see  p.  1 7S).  With  the 
ves.sels  i  certain  numlx-r  of  fibroblasts  arc  carrie«l  in  which  go  to  form 
scar  tLs.siie,  thus  -issisting  repair.  WTien  the  vessels  come  in  contact  with 
calcareous  dep<i.sits  these  may  be  absorbe<l,  and  in  the  aorta,  at  least, 
a  formation  of  Iwne  may  take  place.  AH  stages  of  the  affection  are 
found  in  the  vessels  at  the  same  time. 

'riie  recent  studies  upon  experimental  arteriosclerosis  ha'-e  de.non- 
strated  that  ,1'  'cast  three  forms  of  sclerotic  disease  of  the  arteries  must 
lie  recognize.  1  1)  Monckel)erg's  type  of  medial  degenenitio.  followe<l 
l<y  medial  caUiHcation;  this  is  the  form  present  in  the  nulials  of 
.'  ..cal  arteriosclerosis,  and  may  be  reprotlutrtl  by  adrenalin  injections. 
(2)  PnKluctive  endarteritis;  this  may  be  reprtxluce*!  experimentally, 
even  in  the  aorta,  by  injections  of  pyococcus  toxins  (Klotz'  and 
Saltykow');  and  (3)  inflammatory  periarteritis  extending  into  the  nie<lii 
hv  injury  to  the  outer  walls.  The  .syphilitic  virus,  it  niav  In-  note<l, 
more  parlicidarly  invades  the  arteries  through  the  vasa.  The  relation- 
ship of  the  common  nodose  type  of  arteriosclerosis  of  the  aorta  to 
these,  whether  in  the  main  compensatory  to  meJial  giving  wav,  or 
prmluctive.  is  still  a  matter  of  dispute. 

.\.s  would  naturally  1*  expecttnl,  such  grave  disturbances  bring  in 
their  tram  further  sccondarj-  manifestations.  The  largt>r  %  .-ssels  l)ocome 
elongated  and  dilate.)  in  whole  or  in  part.  In  the  smaller  vc.  els.  such  as 
those  of  the  brain  and  heart,  owing  to  die  thickening  of  the  intin.a,  the 
iimuii  IS  greatly  obstructc>d  o-  even  obliterated.  Such  vessels  on  cross- 
section  sliow  a  characteristic  signet-ring  appearance. 

.\eeording  to  Thoma,  the  thickening  of  tiie  intima  is  compeimtorv 
to  the  alrophy  and  weakening  of  the  mwlia,  Sut,  unlike  Thoma,  we  do 
not  regard  this  ;!s  of  an  inflammatory  natun  (see  p.  ISO). 

.\nioiig  the  consw|uenccs  of  arteriosclerosis  niav  U-  inentioiuHl.  throm- 
lK).sis.  eiiibolism,  ruptu.ie  <.f  the  vessel  wall,  aneurism,  necrosis  from 
ischemia, contracted  kidney,  and  enlargen  ent  o     "  •  heart. 

Ti  T^^^''^*^"*  ''*  *'''*'  institutes  an  anc  .1  authorities  differ, 
the  .siil,|e,  t  ,s  stdl  further  confuse<i  bv  a  midtip..citv  of  terms.  It  is 
perhaps  suuy\vs,  to  define  "ane  .rism,"  with  Ortli,  as  a.:v  circumscribe<l 
iiilataiio!!  of  the  lumen  of  an  arterv. 

If  Mm  MM.urismal  sac  l)e  constitute*!  of  all  or  anv  of  the  coats  of  the 
arterial  «;,||,  ,t   ,.s  ,.all„|  a  "true"  aneurism.     If,"  on  tlu-  other  hand. 

'  Uriii  li  \1,.,1.  Jour  ,  2:  liHXi:  17*17. 

'  Sa|l^  k,.„ ,  (.ent.  f.  I'ath.  .\uat.,  K):  18(18:  321.    Zieplur's  Weitraw,  42;  liMW:  147. 


196 


THE   ARTERIES,  VEINS,  AND  LYMPHATIC  VESSELS 


a  portion  jf  the  sac  be  composed  of  the  surrounding  tissues  or  a  newly. 
formed  fil  irous  investment,  we  speak  of  a  "  false"  aneurism.  In  ad- 
vanced  caies,  however,  it  may  not  be  passible  to  draw  this  distinction. 
In  the  immense  majority  of  cases  aneurisms  are  due  to  the  action  of 
a  normal  or  increasetl  pressure  of  the  bkxxl  upon  an  arterial  wall  weak- 
ened from  disease;  syphilis  ii  Jhe  mast  potent  cause;  tobacco,  alco- 
holism (?),  goi'»,  an  .  lead  poisoning  are  also  effective  in  some  instances. 
Some  cases  are  due  to  muscular  stniiii,  direct  injury,  inflaiiunatorj' 
processes  in  the  vessel,  or  rarely  to  defective  development  of  the  arifrics. 
The  following  classification  is  offered  as  a  convenient  and  fxjmpnln  >ive 
one: 

I.  Aneurism  from  dilatation. 

(a)  Arteriectasis. 

(6)  Cirsoid  or  racemose  aneurism. 

'  )  Serpentine  aneurism. 

(rf)  Cylindrical  aneurism. 

(e)  F'usiforra  aneurism. 

(/)  Sacculated  aneurism. 
TI.  Aneurisms  from  rupture. 

(a)  Dissecting  aneurism. 

(6)  Sacculated  aneurism. 

(c>  Anastomotic  aneurism    |  y»"t-osc  aneurism. 

( Ancunsmal  vari.v. 
III.  Aneurism  from  external  erosion. 
IV.  Aneurism  from  emlwlism. 
(a)  Tearing  of  the  intima. 
(fe)  Mycotic. 
V.  Traumatic  aneurism. 
VI.  Aneurism  from  traction.* 


'  Osier,  in  his  Mcxiem  Me<licinc  (vol.  4,  pp.  4.')0,  4.51,  1008),  Riv«'s  the  following 
as  a  useful  classification  for  practical  purjioses: 

1.  True  anfurixtn  (\.  veriiin.  .\.  spontatieuMi),  in  which  one  or  more  of  tlie  cnais 

of  the  artery  fomi  the  walls  of  the  tiiinor. 
(a)  Dilntntiim  iineiiriKm. 

1.  Limited  to  a  certain  section  of  ii  vessel — fiisifonn  aneiirisni   cvlin- 

(Iroid  aneurism. 

2.  Extending  over  a  whole  artery  and  its  branches — cirsoid  :iii<urism. 

(b)  Circuninrribril  sarcuhir  nnnirixm — the  more  common  form  in  tlir  aorta. 

in  which  there  is  distension  of  two  or  more  t)f  the  coats,  or  di-it  ii.«ionof 
the  adventitia  after  destruction  of  the  intima  and  media. 

(c)  DiKKfrting  (ineiinsni,  with  splitting  of  the  coats  to  a  greater  or  li  ~.--  extent 

and  occasionally  with  the  fonnution  of  a  new  tulic  lined  with  intimal 
endothelium. 

2.  False  nvcurium,  following  wound  or  rupture  of  an  artery,  caiisiii'.:  ;\  diffuse 

or  circumscrilic<l  hematoma. 

3.  Ariiriitvcniiux  amurixm — cominunicaiion  U'lHt-en  artery  and  xciin'.;;  1 1  >1iitct 

— aneurismal  varix — or  with  the  intervention  of  a  sac — varicose  i.r^i'urm. 

4.  Special  formn,  such  as  the  traction  aneurism,  the  erosion       1  pani-iisc  fonw, 

which  have  a  pathological  rather  than  a  clinical  interest. 


ANEURISMS 


197 


Tlif  forms  in  the  Erst  group  are  differentiated  accoHing  to  the  shape 
whicli  the  dilatation  takes. 

iitoieetuia  is  a  tubular,  spindle-formed,  or  nodular  dilatation  of 
an  artt-ry  affecting  a  more  or  less  wnsiderable  extent  of  the  vascular 
tree.  Such  is  commonest  in  the  aorta  or  some  portion  of  it,  as  the 
thoracic  aorta  and  the  arch. 


Flo.  43 


San ulitcil  iiiieurism  of  the  aai'rnilinK  anil  Iransveree  arch  of  toe  ao't*.    (From  the  Patho- 
logical Laboratory  of  Uoyal  Victor  Hoapitii;.) 


Will  II,  in  addition  to  the  dilatation  of  the  vessels,  there  is  great  tortu- 
osity \yiili  free  anastomohis,  we  iTieak  of  cirsoid  aneuiism.  These  are 
found  ■  ,  [lie  large  vessels  of  the  pelvis,  and  on  the  scalp.  Some  of  them 
si'  „ii(!  i).)ssil)ly  lie  classified  with  the  angiomas.  A  sub-variety  is  the 
iwpenune,  characterized  as  its  name  implies. 

Cylindrical  and  fusiform  aneurisms  are  found  commonly  in  the  thoracic 
aorta  ;i;;d  in  the  great  vessels  springing  from  the  arch. 


Hi;-f 


THE  ARTKRIES,  VEINS,  AXD  LYMPHATIC  VESSELS 


r  fi 


if 


i!      ^ 


■i       ! 


Fio.  44 


\m 


A  very  iin|x)rtunt  fonn  is  the  ueeablwl,  in  which,  .sprinj^n);  from  the 
side  <»f  f'le  affeeU-*!  vessel,  is  a  saccular  diverticulum,  often  of  lurjjc  size, 
and  coK.rnuiiicutinK  with  the  lumen  of  the  vessel  by  a  eompiirutivrlv 
narrow  opening;.     Su<'h  art'  the  aneurisms  which  especially  give  rise  tu 

presstire  symptoms,  enxsion,  niptiiri",  and 
the  like. 

Sometimes  the  various  forms  may  be 
combined.  An  aneurismal  sac  usu- 
ally shows  s<jme  variation  in  thicknos,s  in 
its  various  parts,  inasmuch  as  »lic  wall 
is  generally  extensively  dLseastHJ ;  sdme 
|)urts  showing  advancc«i  atlierDiimlou'i 
<lcgcneration,  while  in  others  the  wall 
of  the  sac  may  be  quite  thin,  one  or 
more  coata  being  absent.  Within  the 
sac  one  often  .sees  l<x-al  deposits  of  fihrin 
or  passibly  orgiinize<i  clot  adherent  to 
the  atheromatous  plaqu(>s.  Amy  con- 
siderable amount  of  clot  or  reparative 
change  is  ilistinctly  rare;  in  one  speci- 
men, however,  in  the  museum  of  Mc(iill 
University,  where  complete  cure  took 
place,  the  .sac  was  quite  obliteratetl  liy 
the  organization  of  clot. 

As  will  he  n-adily  understocHJ,  in  a 
diseased  and  weakened  arterial  wall  rup- 
ture very  readily  takes  place. 

If  the  rupture  In-  through  the  intima 
into  the  media,  the  blood  finds  its  wav 
along  the  vessel  lietween  the  layers  of 
media,  and  a  dissaetiiif  aneunsm  is  the 
n'sult.  These  are  foun<l  frc<|iientiy  in 
the  aorta  and  the  vessels  of  the  hraii:. 
I'sually  swiftly  fatal,  they  have  lieen 
known  to  undergo  repair.'  The  excitinj! 
ciiuse  is  usually  some  strain  or  injurv. 
If  all  the  coats  be  ruptured,  there  is 
naturally  hemorrhage  alwut  the  vi-ssel, 
with  the  formation  of  a  heniaionia,  or 
hemorrhage  into  .some  cavity.  In  some 
cases,  where  the  intima  and  media  are 
torn  through,  a  hnal  or  sacculated  dilatation  is  formi-d,  owiiifr  to  the 
distension  of  the  weak  adventitia.  Such  may  Ik-  quite  large,  (pr,  again, 
small  and  multiple  in  distribution.  They  .sometimes  hea!  np,  leaving 
few  tracts. 

'  Adnmi,  On  Arrested  or  liepiiirtMl  Disscctinf;  .^neiirismx,  Montreal  Mi'il.  Jour., 
2<  •  18<J5-!«);  'M',,  and  2',-  lS'J(i:23. 


DJssertiiiK  iiiicuriMii  of  the  unrlii. 
(Knitii  tlif  I'utltitliiKital  Muf«uiii  nf 
Mc(iill   I'liiverNity.) 


AXKURISMS 


100 


In  tlio  outer  wall  of  U..'  sac  swondary  inflninmatory  chaiij;^  i.s  common, 
hwlini;  to  a  development  of  fihrous  tUsue. 

Whtii  rupture  takes  pla«r  into  a  vein,  in  the  cuses  where  the  artery 
ami  vein  have  tiecome  closely  united,  we  get  an  •atuiiiul  Twiz  pro- 
(lureil.  In  other  iiuitances  a  false  aneurism '  *\\e  result,  which  later  breaks 
into  II  vi'iii,  so  that  there  is  an  indirect  eon.  unication  lietween  vein  and 
Brtrry.    'I'his  is  a  yarieoM  annriam. 

AnciirlMiis  fn>m  •itMioa  are  found  chiefly  in  suppurating;  wounds  and 
in  tiilKTciiloiLs  <-avities.  They  an-  ilue  to  the  extension  of  the  necrotic 
prutt'ss  to  the  wall  of  the  vessel,  thas  rt>nderinjj  it  weak  and  unsup- 
portwl.    In  tulH'rcnIous  cavities  one  fr»f|uently  sees  the  vessels  stretch- 


Fi<i.  45 


^"*'""" f  till- ii.irla.      Here   tlip   >'ternum    nml   contui  lUrtiliiKes  wcrp  extensively  rr'nlml,  h 

lar«e  fill-,-  Jilt  iir.sin  iiiilsiitinK  uinler  llie  nkiii  uiid  eventually  iiii<lerK>iiiiKexleniul  nir)tilre.      (Fnim 
llie  M4-.li,  ,1  Cliriir  ,>t  the  Itc.yal  Victiiria  lliispilal,  uniler  the  late  l>r.  J.  Stewart.) 


ill}.' 11(1  uss  willi  small  ancurisnial  dilatations  upon  them  (see  Fijj.  75). 
Tlif  Ik  im.rrliape  so  common  in  cases  of  ulcerative  tulnTciilosis  of  the 
iuiifrs  i>  frctjucntly  due  to  the  rupture  of  one  of  these  minute  am  u- 
n>iiiH.  ill  most  ca-^es.  however,  the  vessel  is  ihromlM)sc<|  .and  flie 
lumen  ..lilitcraftHi  Ix'fore  the  tubercle  liegins  to-soften. 

Embolic  AnAuiisms  are  of  two  forms.      In  the  first,  sharp  calcareoiLs 
partii  I,  -  Krcak  hxxse  from  an  ulcerated  valve  of  the  heart  or  an  athero- 


200         THE  ARTERIES,  VEINS,  AND  LYMPHATIC  VESSELS 


I 


f   '■ 


matoiLs  |Hitoh,  ami  are  carried  along  in  the  blood  stream  to  sunu'  .<iina|| 
ves.<iel,  where  thoy  tear  the  intima,  producing  hemorrhaoe  or  an  tuiciirisig 
from  rupture.  In  the  second  form,  the  mycotic,  inrective  einliuli  w 
up  degeneration  and  inflammation  of  the  arterial  wall  and  thus  brini; 
about  weakening  and  rupture.  Osier  has  drawn  attention  to  iiu'ltiple 
aneurisms  of  this  type  occurring  in  ulcerative  endocarditis.  J.  McCrw 
has  also  recorded  a  ca-se.'  In  the  horse  similar  aneurisms  iin-  pn>. 
duced  by  parasites,  such  as  the  Strongyliis  armatus. 

TnuuDOtie  UMOiliiiii  are  formed  by  the  rupture  of  one  or  all  of  the 
arterial  coats  due  to  external  violence,  particularly  penetrating  wounh. 
Many  of  the  false  aneurisms,  as  well  as  the  anastomotic,  come  utiilcr  thu 
head. 

The  commonest  sites  for  aneurisms  are  the  aorta,  chiefly  tlic  arrh, 
the  abiluniinal  aorta,  the  popliteal,  femoral,  sulx-lavian,  carotid,  innomi- 
nate, and  iliac  arteries,  in  i\"  order  named.  Aneurisms  are  not  nnmm- 
monly  multiple  in  distribution.  Multiple  miliary  aneurisms  arc  often 
fc  und  in  the  arteries  of  the  brain,  particularly  those  supplying  the  letiticulo- 
strinte  region,  and  are  a  fertile  cause  of  cerebral  hemorrhage.  Aneurisms 
of  the  aorta,  according  to  their  size  and  position,  produce  a  variety  of 
effect").  If  large,  they  dislocate  various  organs  ami  produce  collapse  of 
the  lung,  necrosis,  or  form  adhesions.  Aneurisms  of  the  middle  part  of 
the  arch  press  upon  the  left  recurrent  laryngeal  nerve  and  the  u-sophapis. 
The  ribs  or  the  vertebral  column  may  be  enMlwl  and  the  vertelirul  ciitial 
may  be  opened.  Rupture  can  take  place  into  a  right  auricle  of  the 
heart,  as  in  a  case  recorded  by  McPhctlran,'  the  bronchi,  the  (esophagus, 
the  trachea,  the  pleural  cavity,  or  externally. 


PR0ORU8IVK  MITAM0RPH08U. 


1  '.£■ 


*l 


Hypertrophy. — ^I1ie  cause  of  general  arterial  hypertrophy  is  in- 
crease*!  function — due  to  excessive  intravascular  pressure,  ovtraork, 
or  nervous  influences. 

True  hypertrophy  Ls  found  in  certain  organs  or  portions  of  an  orpin 
which  are  the  sites  of  compensatory  hypertrophy.  The  enl;ir);ement 
affects  both  the  thickness  and  the  length  of  the  vessel,  so  that  it  frctiueiitW 
Ijecomes  tortuous.  All  coat«  may  b  affected,  but  particularly  the  mtilia, 
the  latter  condition  being  markwl  m  that  form  _  f  arterial  hypertrophy 
found  in  chronic  Bright's  disease. 

Cirsoid  aneurism,  or  the  angioma  arteriule,  is  by  .some  dasseil  under 
♦his  head. 

Tumors. — Primary  tumors  of  the  arteries  are  very  rare,  liriidowski 
has  recorded  a  case  of  primary  sarcoma  of  the  thoracic  aorta.  .\  verj' 
interesting  form  of  tumor  is  the  perithelioma,  which  may  be  eitlur  l)enijni 
or  malignant.     This  is  found  in  the  suprarensils,  the  prostate,  the  thy- 


'  J.  McCnic,  Jour.  Path,  and  Bact.,  10: 190.5:373. 
>  Canadian  Practitioner,  21:  1896:  578. 


VAJUCOStTY  OF  THE  VEtNS 


201 


roil],  and  in  the  brain.  It  b  a  vascular  tumor,  really  a  9pin<il<-celled 
jarcomu,  which  originateit  in  the  perithelium  of  the  vessels. 

liyoou  are  aho  said  to  occur. 

S«-<>iMlary  tumors  arising  by  direct  extension  or  from  embolism  are 
not  uiK-onimon. 

TBI  OAPXLLAIBS. 

Thrombodi  of  the  capillaries  is  rare,  but  •mbeUam  is  not  uncommon. 

Capillary  UMriuu  are  met  with  frequently,  due  to  active  or  passive 
congestion.  These  re  seen  particularly  well  in  the  lung,  where  in  such 
s  wralitiiin  the  capillaries  of  the  alveolar  wall  assume  a  tortuous  or 
varicose  appearance. 

Ill  exudative  inflammations  the  capillaries  play  an  important  part. 
The  (omponent  cells  show  swelling  of  the  nucleus  and  cell  body,  with 
some  granulation  of  the  protoplasm. 

In  proliferative  inflammation  the  appearances  are  similar,  but  are 
of  a  more  progressive  character.  Owing  to  local  collections  of  granular 
protoplasmic  substance,  small  buds  are  produced  which  ultimateh 
develop  into  new  capillaries.    ITie  same  process  a  seen  in  many  tumors. 

Like  the  arteries,  the  capillaries  are  frequently  affected  by  fattj 
d«t«nantion,  eakarvma  depoiit,  hTalln*  or  colloid  dogtnantioB.  Perhaps 
the  most  important  of  these  is  amyloid  disoaso.  In  the  case  of  the  lymph- 
Klcniis,  the  liver,  spleen,  and  the  kidneys,  amyloid  disease  is  amyloid 
diseas*'  of  the  capillaries. 

Capillary  angiomai,  telaaffiectam,  are  generally  congenital,  but  may 
appear  or  increase  in  size  after  birth.  They  form  usually  flat  tumor- 
like masses  in  the  sulwutancous  tissues  of  soft  consistency,  and  of 
bright  red  color.  They  may  be  combined  with  true  tumor  formation, 
as  snri-onia,  carcinoma,  or  lipoma. 


THE  VEINS. 

The  pathological  changes  in  the  veins  are  very  similar  to  those  of  the 
artenis,  .xcept  that  inflammation  is  distinctly  more  coram  .n,  and  there 
!s  griai.r  tendency  to  tumor  formation. 

Varicosity  (PUebectasia).— Varicosity  is  a  dilatation  of  a  vessel 
(lup  to  a  incfhanical  hindranc-c  to  the  free  return  flow  of  the  blood  to 
local  or  jr.iural  stasis,  to  compression  of  the  veins,  thrombosis,  and 
hf-art  «.,,kiH-.s.s.  Disease  of  the  venous  wall  is  a  predisposing  cause. 
ihe  V. ss,  1  may  be  ddated  cylindrically,  or  become  sacculated,  or  com- 
pUciiinl  I.H)ps  may  be  formed.  Adjacent  loops  may  fuse  so  that  anasto- 
mosm:;  y.-nous  sinuses  are  produced.  The  walls  in  time  become 
tmrK,.|. ,  „r  even  ciikificd,  and  the  vessel  is  usually  both  tortuous  and 
eionpii.Mi.  Varices  are  found  most  frequentlv  in  the  lower  extremities 
pelvi.  s.  ins,  the  broad  ligaments,  spermatic  veins,  prostate,  bladder! 
scrotum,  labia,  and  the  rectum.     In  cases  of  cirrhosis  of  the  liver  the 


I ' 


j        ; 


2()2 


TIIK  ARTKRIKM.  VEISS,  AXD  LYMPHATIC  VK.HSEL'i 


vi'ia'<  of  the  irsoi>lm);u.H,  t\w  pitrtui  vein,  |Im>  vciiM  of  t\w  iilMluiiiiiHl 
wall  HMil  hi'iMitif  lipiiiK-ntH  un>  ofifti  ((rcntly  dilulitl. 

VarHi-s  an-  h  fntpH'tit  c-hujm-  nf  hfmoiTliHKi',  atlrimi,  ititliiiniiMtion, 
ulrcration,  thnHnlMHiM  nilciKmlioii,  iuhI  |NU'hyiU'rtiiiu. 


Ira.  4A 


i   1 

L  1 

V«rir"««-  vi-iii"  I'l  the  If*.      (Krolii  tlie  SiirKiral  (  liiiir  ,,l  i|,p  Munlrrul  (IfiiiTiil  II  -iiilal ) 


PMebitis.  -  Simple  and  Suppurative  Phlebitis.  Tliis  frc<|n('<iilv  tKriiri, 
and  ihe  histoliip'cal  changes  an-  simiia-  to  tliosi-  in  tln'  cii  r  of  the 
arti'rics. 

Proliferative  Thrombophlebitis.—Prolifcrativc  tlironilK>pliKliitis  is  (k- 
qiH'iit  in  the  veins  of  tlie  lt»w<r  extrfmitit-s,  tliv  prlvis,  ami  llu-  ;iiit«fviof 
the  brain.  A.s  in  tlie  ease  of  the  arteries,  it  ean  lea<l  to  parli.il  or  ctra- 
plete  oliliteration  of  the  Jninen.  The  tlm)nil)ii.s  may  ealeif  v .  fomiiiig 
a  phlebolith. 


lYMpnwfiiris 


203 


Tibamloai  FUaMtU.  '1'iiImtc>uIi>ii.s  plilt-hitis  arMi  |N>riphlf>i>ili.*t  u 
•mtof^oii"  ii>  tiilM'n-uloiis  Hrtfritii  iiimI  M>ri-urti'riti.s. 

IjphiUUe  PhtoUtia.  Syohilitic  phlchitU  is  iiuMt  rn>4jiH*nt  in  the  di-ttrict 
of  thr  iMirtuI  vein  and  in  Int'  nuiltilicul  vein  of  th<>  newuMni. 

PhlabotdtfOSif.  — A  <iinilition  of  fihniid  thickrnin^t  ()f  the  intimaaml 
mrdia  of  veins  cliiwly  n-.M-inhlin^  that  sevn  in  arteri<>«'lerw«i.s  is  murh 
mon*  coniinon  than  is  usually  iinufpnnl.  Huch  phlflNMrlenisi.s  afffcts 
more  |Mirticuluriy  veins  that  are  p«M»riy  .sup'  'He«|,  antl  this  even  in 
v(Min);ailMlls:  it  is  unassiH-iuteil  with  any  si^nsot  progressive  inltainma- 
tiiin,  uihI  iks  our  eoileague  Dr.  ('.  F.  Martin'  concluiles,  inu.st  he  plocetl 
in  the  ^;r(>ii|i  of  ".stniin  lil>ro.ses." 


TBI  LTMPHAnO  VI88IL8. 


Afftslioiis  of  the  smuHer  iyninhaties  are  almost  iiivariuhly  n.s.so<-iated 
with  iliMiise  of  the  tissue  in  which  they  lie.  Pathological  eoiHiition.s  of 
the  iurp-r  tnuiks,  in  the  inuin,  i-oncern  us  here.  When  we  remeinln'r, 
howt'vtr,  that  t!ie  pleuru,  the  |)eritoiieuin,  aiul  other  .serous  saes  an>  large 
■span-s  ill  (lose  relationship  with  the  lyinpii-ehannels,  the  .suLject  attaiiM 
importaiil  |)ri>(M>rtions. 

The  l.viiiplmtics  derive  their  ini|M>rtttnc(>  fr«>ni  the  fact  that  they 
affiinl  a  niuiy  means  for  the  invasion  of  the  organism  or  {utrtieular 
npoiis  liy  iiflamnialory  priK-esses,  and  for  the  dissemination  of  malig- 
iiniil  ):n>wtlis.  Further,  hy  their  ohstruetion  they  give  rise  t«»  .several 
rrmarkalilc  condilioiis. 

Lymphar  ^tis.  A  fr(>(|uent  disorder  of  the  lymphuties  is  lympli- 
U|itii  aiiij  perilymphangitii.  It  is  almost  invariai>ly  due  to  the  presenee 
<>f  an  iiifcclive  iiiHammatioii  in  some  part  draintsi  i>y  the  affwted 
\•vss^'U.  iiiftstiv;'  organisms  pass  rapidly  up  the  ehamiels  from  the 
wniiiiil.aiid  may  ultimately  reacii  the  lymph-glunds,  where  they  often  .set 
lip  liy|Kr|>las|ic  aii<'  •veil  suppurative  ihuiigi-s.  Thus,  infection  from  a 
woiiiiil  iif  ihc  f<K>(  :.,ay  reach  the  inguinal  glands.  The  uirectisl  lyin- 
pliat"  >  lire  s»  en  as  nsldish  lines  extending  up  the  limit,  and  are  somewhat 

l^ii. Ill  flic  mildest  form,  the  endothelial  cells  ar«'  swollen  and 

slmw  Mill  Icar  division.  In  more  advancfHl  eases,  they  are  desquamated 
and  till'  liiiricn  of  the  vessel  is  filled  with  dehrls,  lymphoid  cells,  and 
fihriii.  In  the  suppurative  form  the  channels  may  l>e  dilated,  owing  to 
(•tilicctioii  of  the  pus,  and  may  thus  n-semble  a  ntsar}-.  The  inflamma- 
tion s|(ria(ls  to  the  surrounding  tissues,  which  are  a>deinatou.s,  hyperemic, 
anil  iiililinited  with  IcukcK-ytes.  Lymphangitis  may  heal  (-ompletely 
with  iii;i  iicratioii  of  the  di'slroye«l  cells,  aKsw.sses  may  form,  or  indura- 
tion finiii  lil)r()us  hy|M>rplasia  may  result. 

Of  mm  li  iiii|M)rta!ur  are  the  .specific  inflammations,  i>spociallv  the 

tHbrr,-:;!M;,s.  '^ 


I 


'  Tnriw,ii,,„s  \sHiK-.  of  Amor.  1'Iivh.,  2():  liKW:  .'i2.'>. 

Beiir.,:',M;KK):4!»l. 


S<s'  also  Figctior,  Zicfrlor'ii 


I  It  ill: 


8 


'i    i 


ta 


204 


THE  ARTERIES,  VEINS,  AND  LYMPHATIC  VESSELS 


TabercnlOBis. — ^Tuberculosis  attacks  the  various  organs  with  gi«gt 
avidity  through  the  Ij-mphatics.  Tuberculosis  of  the  thoracic  duct  is 
a  frequent  cause  of  miliary  tulierculosis  in  children,  and  tuljorculous 
lymphangitis  is  a  common  method  of  infection  in  the  lungs.  In  tuber- 
culous ulceration  of  the  intestines,  one  can  frequently  see  subserouii 
tubercles  situated  along  the  course  of  the  lymphatic  vessels. 

Sjrphilis. — In  syphilis,  in  addition  to  a  proliferative  lymphangitis, 
gummatous  infiltration  of  the  wall  is  seen.  The  lymphatics  are  also 
affected  in  leprosy  and  glanders. 

Fio.  47 


Cavernous  lympliangioma  of  the  axilla  i>f  cnngenital  urigin.      (Wurreii.) 

DUatation  (L3rmphailgiectasis).-  Dilatation  is  the  result  of  some 
obstruction  to  the  free  outflow  of  lymph.  This  may  be  due  to  pressure 
of  external  tumors,  aneurisms,  cnlargc<l  glands,  metastatic  <;ri)Wths  in 
the  wall,  chronic  inflammation,  impaction  of  filaria,  thrombosis  of  tiie 
left  innominate  vein  or  of  the  duct  itself,  backward  pr«'.ssiirc  in  the 
sulK'lavian  vein  from  tricuspid  insufficiency.  The  condition  is  often  seen 
verj-  prettily  on  the  semsa  of  the  intestine  in  the  neighborho<Ml  ol'  tulwrcu- 
loas  and  typhoid  ulcers,  where  the  chyle  vessels  are  found  n-;  delicate 
transparent  tulK>s  fil^-d  \  Itli  dear  fluid.  As  a  coaseijuencf  "f  overdis- 
tension, or  in  the  course  of  ()|)eriti(>iis,  the  vessel  wall  may  U-  lupturrd 
and  a  condition  of  lymphoirhagia  may  Ix'  the  r«>sult.  The  interesting 
condition  of  chylous  ascites  is  due  to  the  rupture  of  the  lyni))h  chaiinek 


TUMORS 


205 


from  trauinatisra,  erosion,  or  to  rupture  of  the  thorecic  duct  itself  (see 
p.  111).  Similarly  dqrlooi  hjrdrothonx  may  be  produced.  The  allied 
conditions  of  chyliform  and  pseudochylous  ascites  have  already  been 
descriW  (p.  111). 

Parasites.— Among  parasites  found  in  the  lymph-vessels  may  be 
noted  tiie  echinoooccus  and  the  Filaria  sanguinis.  The  latter  is  asso- 
ciated with  certain  cases  of  elephantiasis  found  in  the  tropics  and  the 
condition  known  as  ehyhiria. 

The  retrograde  changes  are  of  little  importance.  Fatty  degeneration 
of  the  endothelium  is  common ;  and  ealeifleation  of  the  thoracic  duct  as 
a  resuh  of  productive  inflammation  has  l)een  oKserved. 

Hypertrophy  of  the  walls  of  the  lymph  channels  has  been  noted  in  cases 
of  ol).striic'tion. 

Fia.  48 


MaiTi(glos«ia.     (I)r.  Shcpherd'u  case,  Muntreal  General  Hospital.) 


More  important  are  the  tnmon.  Oarcinomata  have  a  sp<fial  tendency 
to  spread  hy  means  of  the  lymphatics,  and  often  considerable  portions 
of  a  ves-i.  1  may  Ik;  blocked  by  cancer  cells.  This  occurs  not  merely  in  the 
iKMKhlioiliiMMl  of  the  original  growth,  but  affects  even  distant  parts,  as, 
for  evHiiiplc,  wlien  we  get  metastases  in  the  lymph-vessels  of  the  lungs 
in  caiviiinma  of  the  stomach.  Besides  carc-inomas,  chondromas  seem 
to  ha\<'  a  t<'n(lency  to  grow  into  the  lymphatics.  The  most  important 
and  iiif.  irstiiig  primary  tumor  is  the  endotheUoma,  a  growth  which  has 
som.  .. .,  Hiiilances  both  to  carcinoma  and  sarcoma,  and  hence  has  been 
called  Iv  -ioine,  ill-advisedly,  sarcocarcinoma. 

Tlii>  iM'iiDr  is  found  particularly  in  connection  with  the  larger  serous 


I 


llftl 


Ji 

Mi 


■I  1 


206 


THE  ARTERIES,   \Ef\S.  AXn  LYMPHATIC  VESSELS 


sacs,  but  also  orifriimtes   in   tlu'  vesst-ls.      It   devi'lops,  consiMiiicntlv, 
in  the  pleura,  tlie  peritoneuin,  the  dura  mater,  and  tlie  various  or^puis. 


Kifi.  ^•» 


Elephaiitiuni!!  vf  the  leg.     Kuomious  enlargement  nf  the  Itml),  witli  iclitliyu^is.     i J'.LihulnfiiL'al 
Museum,  ^!c<jiil  I'niversity.) 

The  jjrowth  forms  citluT  iiuihiple  small  ntMlulcs  on  (lie  scions  iiicni- 
hrane,  only  .slij;hfly  elevatetl  aiiove  the  f;eneral  level  ami  often  -d  iiiiiiutc 
as  toJ>e  easily  overl(M)kitl,  or  extensive  slurt-like  masses.     Mi'  idscopic- 


ELEPHANTIASIS 


207 


ally,  it  <'<)iisists  in  matwes  of  wlls,  not  unlikf  epithelial  cells,  having  an 
alveolar  iirraiij^ment,  which  are  really  only  lymphatic  channels  with 
thickeiK'il  and  pmliferated  endothelium.     The  gnjwth  is  malignant. 

.\  second  primary  tumor  is  the  lymphangiomk,  which  presents  itself 
either  as  a  diffuse  enlargement  of  the  part  with  preservation  of  its  out- 
ward contour,  or  as  a  definite  tumor  mass.  It  iK-curs  chiefly  in  the 
coiiiifctivc  and  submucous  tissues  in  the  throat,  neck,  tongue,  and  lips 
lmacrm/liiKnla,  marrocheilia),  the  extri'mities,  mesentery,  an<l  kidneys. 
Most  of  these  are  more  accurately  conditicms  of  congenital  lymphangiec- 
tasis  (vol.  i,  p.  754),  although  the  true  lymphangicmia  does  occur. 

.\lli('d  to  this  is  tlie  condition  known  as  eleplumtiasis  lympbangiecUtica, 
wliieh  is  seen  most  frtHjuently  in  the  extremities,  the  scrotum,  and  the 
vulvn. 


■*•*[•  I 


li 


I  ii 


CHAPTER    X. 

THE  HLOOD-FOHMING  OHGANS. 

THE  LTMPHATIO  GLANDS.' 

Lymphau.  void  t-ssiie  is  widely  distributed  throughout  the  Ixxlv, 
being  found  in  almost  all  the  organs  in  the  form  of  follicli's  or  scattered 
lymphoid  cells.  More  important  than  this,  it  is  agjr'cgated  in  certain 
regions  into  definite  glands,  which  form  an  integral  part  of  the  lymph- 
vascular  system. 

The  structure  of  a  lymph-node  is  fairly  simple.  It  is  coni|H)se(l  of 
a  fibrous  capsule  sending  in  trabecula?,  which  break  up  into  iiiniimerahle 
fine  ramifications,  so  as  to  form  a  reticulated  stroma.  On  tlic  walls 
of  the  spaces  thus  produced  are  situated  large  mononuclear  (clls  with 
clear  pnitoplasm-  '"^e  endotli<Iioid  plates.  The  remaining  portion  of 
the  cavities  is  fiilcu  iip  with  small,  round  cells,  which  contain  a  single, 
relatively  large,  and  deeply  staining  nucleus,  in  all  respects  resembling 
the  lymphocyte  of  the  blootl.  In  the  outer  zone  the  lymphoid  clcmenls 
are  grouped  into  follicles  tt)  form  the  cortex  of  the  node.  In  the  central 
portion,  or  medulla,  wavy  strands  of  connective  tissue,  lined  with 
endothelioid  cells,  are  found,  constituting  the  sinuses,  which  are  directly 
continuous  with  the  lymphatic  vessels.  The  cells  of  the  medulla  are  lari.w 
and  stain  more  feebly  than  those  of  the  cortex,  and  the  nuclei  frc(|iienliy 
show  cMdences  of  mitosis,  proving  that  this  portion  is  the  frerminai 
centre  of  the  node.  A  striking  point  in  connection  with  the  lymphatic 
glands  is  that  they  possess  tlx'  embryonal  characteristic  of  active  };rowtli, 
so  that  the  cells,  under  tlu  influence  of  a  very  slight  stimulus,  rapidly 
undergo  nuclear  division  and  proliferation.  This  is  the  feature  that 
dominates  the  picture  in  all  the  imjiortant  pathological  prtK-esses  atFcctinj; 
these  structures. 

The  function  of  the  lymphatic  glands  is  to  act  as  a  .sort  of  filter  for 
the  lymph,  which  enters  the  sinuses  in  the  medulla  and  graiiiially  per- 
colates into  the  cortex,  where  it  is  taken  up  by  the  efferent  ly  nipliaties. 
In  this  way,  should  the  lymph  contain  any  foreign  substance  or  toxic 
material,  these  tend  to  l>e  stopped  within  the  gland,  and  thus,  not  only 
on  account  of  the  anatomical  j)eculiarities  of  the  structure,  Iml  also  of 
the  cellular  hyperplasia  that  results  from  the  irritation,  this  ban  irr  action, 
as  will  readily  be  understood,  is  a  most  important  one.     The  1  niphatic 

'  While  strongly  olijecting  ti>  tliis  desigiiiition,  on  the  groiiiiil  thai.  -i<akiii(!  o: 
these  as  ghinds,  the  student  becomes  ronfusc<l  in  his  conception  of  glaiidi;'  ii;ctivily. 
we  realize  that  the  term  is  8o  lirmly  establislieU  that  it  would  lie  I'lanlicto 
change  it. 


CONOENITAL  ASOMALIES 


209 


glands  arc  set  iike  st-ntinels  to  j,'uar(l  all  the  orifiw.s  and  channels  of  the 
Ixxlv.  ami  frft|uently  prt  vent  systemie  infection.  This  function  of  the 
j;iaiiti.s  has  l)een  clearly  demonstrated  by  the  rescan-hes  of  Bizzozero, 
Riiffer,  anil  llihlnTt,  who  have  shown  that  the  glands  in  the  pharynx, 
neck,  root  of  the  lungs,  and  mesi'ntery  :n  healthy  animals  contain 
Iwctcria.  A  further  imjMJrtant  funcMon  is  said  to  lie  the  formation 
of  leukocytes,  whij-h  is  especially  active  under  most  conditions  of 
infection. 

Lvniph-iuHles  uK  of  two  kinds — (ordinary  lymph-noiles  and  hemo- 
lympli-ncnhs.  The  latter  were  first  discovered  by  (Jibbes,'  and  more 
fully  (IcscrilHtl  by  Robertson^  and  .Swale  Vincent.'  They  have  been 
found  in  the  shwp,  ox,  \i\y,  horse,  and  inan.  The  most  recent  and 
comprtluMisive  study  of  these  structures  is  that  of  Warthin,*  who  divides 
them  into  two  varieticf  ,splenolymph-n(Hles  and  marrow  lymph-mxles,  with 
ri.inien)us  transitional  forms.  lie  has  shown  that  there  Is  a  close  relation- 
ship iHtwccii  the  lymph-nodes,  the  spleen,  and  bone-marrow,  aud  that 
the  lu'inolyinph-noiles  can  take  on  more  or  less  completely  the  structure 
and  function  of  the  spleen  or  marrow  when  either  of  these  i.s  incapacitated 
Ihrou^tli  <iis<ase.  Tnder  normal  conditions  the  hemolymph-nodes  are 
(wcerncd  chiefly  in  hemolysis  and  leukwyte  priKluctioii.  The  spleno- 
lymph-iiodes  are  fomid  chiefly  in  the  neighlK)rho(Kl  of  the  .solar  plexus, 
adnnal  and  renal  vessels,  omentum,  mesentery,  epiploica,  thymus  ami 
thyroid  fjlaiids.  The  marrow  lymph-mxles  are  found  only  in'the  retro- 
[xritoneal  tissues,  near  the  great  ves.sels.  particularly  tlie  vena  cava, 
aorta,  and  eonunon  iliacs.  rnlike  the  ordinary  lym|)h"-iio<les,  the  hemo- 
mnph-n(Hles,  exce])t  the  transitional  forms,  contain  bkyxl-sinuses  but 
no  iyinph-siiiuses.  Hemolymph-niMles  are  dark  red  or  biiiisl  in  color, 
possess  a  liilus  into  y  Inch  a  large  vessel  enters,  and  are  usuallv  surrounded 
hy  a  plexus  of  veins.  On  section  t  ley  resemble  spleen  pulp.  Thev 
have  a  particular  importance  in  connection  with  the  various  forms  of 
anemia. 

.Vs  will  readily  be  inferred,  the  most  imp;)rtant  affections  of  the  Ivmph- 
iiiKJes  ar<'  the  inflammatory,  and  this  from  a  clinical  as  well  as  a  "patho- 
lo^'ieal  point  e  view.  They  ar(\  however,  rarely  affwtcd  as  a  svstem, 
e\  pt  in  the  possible  ca.sr  of  leukemia  and  lymphosarcoma.  As  a  rule, 
I"     'lie  ;;lands  be-longing  to  a  certain  anatomical  district  are  involved.' 


Ik 


OONOBNITAL  ANOMALIES. 

The  r  ;iie  not  important,  with  the  exception  of  that  excessive  pnxluc- 
'II  ot    lymphoid   ti.ssue    tl    -"ghout   the    Ixxly   characteristic  of  the 

'CJiiiir     Iniir.   Mirr.  .S,-ioiic(.s,  24:  1S,S4:  ISli;  and  Amcr.  Jour,  of  the  Med    .Sci 

2Mvi:!:i|i, 

■'  I-ii ijuuidii,  I.S!H):ii:ll,52. 

'•'"iir    \!Mi.  aihl  I'hysiol.,  M  ■  ls<t7:17(>. 

'   \  Iwitrjlmtin,,  t<,  111,.  Nomial  Histology  ami   I'athologv  of  (he  Ilernolymph 
l.hiii.|-.  l.i.r  „r  Mclical  licscarch,  (i:  1<K)1  -3 

II 


210 


THU  LYMPHATIC  GLANDS 


.so-«\  ted  " itatni  lymptastieiu."  It  may,  perhaps,  be  notetl  lure  that 
in  infancy  and  childhood  the  lymph-glandular  system  is  very  prominent, 
and  as  puberty  is  reached  it  becomes  relatively  less  important. 


OIBOTJLATORT  DUTVBBAITOIS. 

Anemia. — ^The  circulatorj'  disturl)anees  are  also  of  no  spetiiil  inttresi. 
The  lymph-glands  normally  contain  but  little  blood,  and  in  (general 
anemia  even  this  may  disappear. 

Hj^eremia. — Hyperemia  is  almost  iaseparably  assotiatiti  with 
inflammation.    The  glamls  are  reddened,  enlarged,  and  sutcnlt-nt. 

HemORhages. — Hemorrhages  in  such  cases  readily  oc<iir,  which 
may  also  be  due  to  minute  emboli  in  the  cortical  vessels  ifaiiinjj  to 
rupture. 

(Edema. — (Edema  may  be  inflammatorj*  or  part  of  a  general  aiia.sami. 

Varices. — A  curious  occurrence  is  the  formation  of  varices  or  cyiti 
in  the  centre  of  the  nodes  owing  to  obstruction  of  the  efferent  lymphatics, 
which  is  generally  brought  about  by  inflammation.  In  seven-  cases  the 
dilate<l  and  tortuoas  sinuses  may  coalesce  and  the  lUKle-siihstaiice  he 
disten<le<l  into  a  large  cystic  space  {adenatymphocele),^  varyiiij;  in  size 
from  that  of  a  nut  to  that  of  one's  head.  The  inguinal  glan<l.s  arc  those 
usually  invc!ve«l,  and  young  people  are  particularly  liable  to  be  atfwted. 
The  disease  is  endemic  in  some  tropical  countries. 


i 


INFLIMBIATIONS. 

Lymphadenitis. — Inflammation  of  the  lymph-glands-  lymphaden- 
itis—is  one  of  the  commonest  of  comlitions.  It  is  usually  l>roiij;ht 
al)out  by  infective  agents  or  toxins  reaching  them  thn)tigli  the  afferent 
Ivmphat'ics.  Not  infrequently,  also,  the  process  arises  by  extension  of 
inflammation  from  the  adjacent  structures;  more  rarely  the  atftttion  is 
hematogenic.  Lymphadenitis  is  invariably  secondary  to  infection  t■ls^ 
where.  The  glands  nearest  the  point  of  entrance  of  the  otfendirij; 
bacteria  are  chiefly  affecte<l,  but  those  at  some  distanc-e  arc  (piite  com- 
monly involved,  owing  to  the  action  of  diffusible  toxins.  In  inanv 
diseases,  such  as  diphtheria  and  variola,  lymphadenitis  is  a  inarkeii 
feature,  and  in  one— plague— it  may  give  the  character  to  the  clinical 
tv|M>  (bulwnic  plague).  In  certain  other  diseases,  such  as  Icnkeniia 
and  Ho<lgkin's  disea.se,  the  involvement  of  the  glands  is  striking:.  The 
relationship  of  chronic  inflammatory  change  to  the  latter  comlilion  has 
l)een  di.sciisse<l  in  our  first  volume  (p.  (Wli). 

Acute  Lymphadenitis. — Acute  lymphadenitis  is  ximplc  or  xiijipuml.it 
Both  fonns  have  much  in  conunon,  for  the  suppurative  varicn  itvnmh 


'   Auger,    l)es  Tumcurs  i'-rcctilcs    hmphatiques  (adenolymphoceli 
Paris,  1867. 


These  'it 


ACUTE  LYMPHADENITIS 


211 


supemncs  upon  the  other.  Suppurative  lymphadenitis  is  due  to  infer- 
tion  witli  pyogenic  microoixanlsms.  and  may  result  from  septie  wounds 
puerperal  nietritis  and  emlometrltis,  gonorrhfea,  chancroid,  diphtheria! 
and  .s<arlii(ina.  When  inflamed,  the  jjiands  are  enlarKetl.  hyperemi.  \ 
ami  soft  (hul)o).  On  section,  they  vary  in  color  from  grav  or  Kravish- 
whi(e  to  pink,  and  are  succulent,  so  that  a  milkv  juice  can  Jie  scraped 
from  the  surface.  In  the  early  stages  the  congestion  is  confinwl  to 
the  cort<x,  but  .sooner  or  later  it  becomes  imp<»ssible  to  differentiate 
between  tiie  cortex  and  me<lulla.  In  some  cases,  as  of  diphtheria  ami 
typhoid,  one  can  make  out  dull,  opaque,  necrotic  areas,  an<l,  in  the  most 
severe  forms,  softening,  with  the  formation  of  thick,  grecnish-vellow  pus 
in  many  instances  the  fibrous  capsule  of  the  glands  and  the  nciglilwring 
tissues  arc  ntlematous,  infiltrate*!,  and  congeste«l  {perihimphudenHh). 


Via.  SO 


.\ 


Zfiv.  ,.llj, 

'  ni\pr-it\ 


if  mrM.„leri,„|a„,l  in  ty„h«id  fever,  -hnwing  the  enlanre-l  ei..l.,ll,elial  and 
.."U  nnmerMun,   without  ocular.      (Frc.m   the   Pall..,l,«ical   Latx.ratc.ry 


Kiatit  cell.... 
(•f   .Mi'diU 


Ml  r  .>..,,  Kally.  the  enlargement  of  the  glands  is  foun.l,  in  the  m^u'i., 
^^  ^^'ii>H  ot  u  i.y,H-r,,lasm  of  the  cellular  elements,  as  evi.lenctHl  hy 
»'<lt"r  .hvisK.n  and  mcrease  in  the  numln'r  of  cells.  \ot  onlv  arc  th'c 
»n.ph  .Icin.nts  afftTted  in  this  way,  but  the  endothelial  plates  prolifer- 
ate an.  ;,r..  found  ui  great  numln-rs,  often  with  .several  nuclei  more 
ar,^  ,,H,  .„  tin.  lymph-channels.     This  "catarrh"  of  the ^lat.^ 

,  fT'    '    ^^'"'"■-'■'    ''  ''  P'^"'""'-nt  feature  i ,.  nle.senti.ric 

Ma-i.l>  .M,|,  to  ..onie  extent,  ni  others,  in  tjphoi.l  fever,  where  in  many 

'  Jour.  Exper.  Med.,  3: 1898: (ill. 


i 


^i 


212 


THE  LYMPHATIC  OLASDS 


caws  they  fuse  into  jfiant  eells  liavinj?  phiigooytic  propertit-t.  Thf 
tmlieculw  uml  the  capsule  may  lie  UHleiiiatoiLs  and  iiiKhratnl  with  irlk 
Not  infrequently  the  lymph- sinuses  are  ililatetl  with  an  exudate  con. 
tainiu);  but  few  cells.  In  the severiT  forms  of  inflammation  tin- txiidaif 
may  Im-  fibrinous  or  hemorrhagic,  or  lx>th.  Fibrinous  (iep«)sit  is  stin 
chiefly  in  the  sinus»<s,  and  is  especially  prominent  in  lobar  putii. 
monia  and  fliphtheria.  Occasionally  spots  of  nwrosls  may  1h'  mvw 
where  the  lymphoitl  cells  and  tVo  •  of  the  stroma  lose  tlu-ir  >iiiiiiin^. 
power,  become  granular,  and  finally  disintegrate.  This  cliaiip-  is 
r>n>ught  alwut  by  the  direct  action  of  the  toxin,  but  also,  n<»  (i«Hil!t,  In 
the  olxstruction  to  the  circulation  cause*!  by  the  cellular  pruiiftraiidii 
and  accinnulation  o(  debris.  Should  suppuration  occur,  thi-rc  is  an 
abiuidant  aggregation  of  ptilyniorphomiclear  leukocytes  in  tlic  lyrnpli- 
spai-es,  together  with  nwrosis  and,  ultimately,  litpiefaction.  Winn 
this  event  «loes  not  (x-cur,  it  is  p)ssibl-  for  the  inflammation  tu  ri'solw. 
The  nnlundant  cells  ami  fibrin  undergo  fatty  degenemtion,  and  Himllv 
disintegrate  and  dissolve,  the  debris  l)eiiig  carried  off  in  the  lyni|)li->treiiiii 
or  taken  up  by  the  phagocytes.  In  cases  where  hyperemia  lias  Ikhh 
markeil,  or  where  hemorrhage  has  taken  platv,  it  is  common  for  \>i)i\m\{ 
to  Ik?  (leposited.  In  the  severer  forms  it  is  usual  for  the  gland  l<>  remain 
somewhat  enlargetl  and  firm,  owing  to  fibrous  hyperplasia.  Whert 
necrosis  or  suppuration  has  occurred,  a  <lefinite  scar  may  Ik-  the  result, 
or,  if  the  ne<Tose<l  substance  Ik*  not  absorlxnl,  the  gland  may  iiiiil(>r};ii 
calcification.  In  some  cases,  where  the  gland  has  burst  externally,  a 
sinus  discharging  lymph  has  persiste<l  for  some  time. 

Obronie  Lymphtdenltia.  ("hronic  lymphacU'nitis  cK-curs  as  a  sf(|iiil 
to  the  acute  form,  but  may  arise  in<lejM'ndently.  In  the  latter  ease  it  i> 
due  to  the  action  of  mild  or  repeated  irritation.  Apart  fn)iii  sypliili< 
or  tulR're.iiosis,  the  most  common  cause  is  the  presence  of  dust  orotlur 
foreij;.!  material.  The  pnK-ess  is  .seen  most  comnionly  in  the  peri- 
bronchial glands,  where  large  amounts  of  coal,  stone,  stwl,  or  oilioniu-i 
inav  Ix'  deposite<i,  and  in  the  axillary  glands  after  tattooing. 

The  affected  ihkIcs  are  eidargtnl,  firm,  and  variously  ])i;:ineiiitil. 
acconling  to  the  nature  of  the  offending  mat-  rial.  In  the  earlier  sta;;c> 
the  enlargement  is  due  to  simple  cellular  hyperplasia,  Imi  mhhi  thf 
capsule  and  stroma  InHome  noticeably  thickeninl,  cncroaeliinj:  p-nl- 
iially  upon  the  lymphoid  cells,  until,  eventually,  there  is  atrn|iliy()f  the 
Ivinphoid  elements,  and  the  ikhIc  is  converted  into  a  fibrous  ikkIuK  ur 
tMicapsuiati'd  mass  of  pigment.  In  other  cases  the  necn)sis  i-  sd  ra|iiJ 
that  the  ikhIc  softens  and  its  contents  may  l)e  dischar^ie.  1  into  tlit 
nearest  hollow  viscns. 

Tuberculosis. — TulnTctilosis  of  the  lymph-glands,  in  nm  t  eases,  L- 
brought  alMMit  by  bacilli  that  reach  them  through  the  atlVn  it  lymiili- 
vessels;  more  rarely  from  the  bliMxl-stream.  The  glands  (■lii(  tiy  atftrtd 
an-  the  i-ervii-al,  penltronchial,  and  mest-ntrric 

In  exce|)tional  cases  the  disease  is  widespread,  involvini;  li  axilliin. 
inguinal,  and  retroperitoneal  regions  as  well.  Often  the  (  :.:ims  fmni 
whic-h  the  infecti-d  lymph  is  derive<l  show  evidences  of  tu!Mrcul(>>i-. 


TUBERCUUJSIS 


213 


but  thi-  is  liy  no  meaas  ncwisan-.  In  the  ca.M«  of  the  lunjp.  for  iastance, 
wliilf  utFi  ction  of  the  perilironc-hial  glamis  Is  attributable  in  .some  cases 
ti>  a  priiiiarv  pulmonary  lesion,  yet,  as  Uibliert  ami  Baumgarten  have 
shown,  the  reverse  procfs.s  is  frefjuently  at  work,  and,  in  tuljerrulosis  ttt 
the  (rrviciil  glunds,  where  infection  takes  place  fhr(»u>;h  the  toasils, 
i;tiiiis,  aiKJ  nasopharynx,  it  is  rare  for  the  latter  structures  to  show 
the  loioiis  of  the  disease.  Similarly,  in  tuberculosis  of  the  mesenteric 
(.'luiiils,  ilic  mucous  membrane  of  the  intestines  may  entirelv  escape. 

The  iiffttte<l  glands  are  noticeably,  and  in  some  cases'  enormously, 
Milurv'f<l.  presenting  all  the  sigas  of  a"  more  or  less  intense  inflammation. 
hi  the  ("arlier  stages  section  reveals  a  homogeneous,  traaslucent  infil- 
tration r,f  jrruyish  color,  a»f«ting  either  the  greater  portion  of  the  gland 
or  tntrcly  scatferetl  areas.     Ijjter,  this  Ijecomes  opaque,  granular  look- 
\\%  and  nmy  finally  caseate.  m)  that  the  mass  becomes  vellowish-white 
in  color,  gruiiiilar.  and  friable.     In  some  cases,  p«.ssiblv  from  secondary 
infit  tion.  the  glands  suppurate  and  may  discharge  their'contents  into  the 
ntanst  cavity.     Rupture  into  a  v^-in  or  into  the  thoracic  duct  is  the  most 
|x)tiiit  cause  of  systemic  miliary  infection  with  tul)erculasis.     Rupture 
may  alM,  taki-  place  into  the  pericanliuni,  me«Jiastinum,  oesophagus, 
ami  intotiiial  tract.     In  long-stamling  cases  the  glands  liecome  shrunken. 
more  or  hss  filmxsed.  anil  destniveil,  and  may  c-ontain  calcareous  spicules.' 
Mi(nK((.pically.  there  is  an  increase  in 'the  number  of  round  cells! 
[wrily  from  the  proliferation  of  the  lymphoid  elements  and  partlv  froni 
the  (lia|M.lesis  from  the  vessels.     With  this,  there  is  more  or  less'hvper- 
phoia  of  the  eiidothelioid  cells.     In  the  more  advanced  stages  the  «>ntr<' 
IS  (K'<M|)i.il  l,y  isolatcfl  or  confluent  areas  of  caseation,  the  tissue  in  the 
rieiKhliorlMHKl  showing  evideiic-es  of  cellular  disintegration  and  nuclear 
I  estriK  tion.     In  chronic  cases  giant  cells  make  their  appearance  about 
the  [Mripiiery  of  the  tulx-rcle.  and  in  still  more  chronic  foruLS  there  is  an 
atteni|)t  at  wallmg  off  the  «lead  material  with  fibrous  tissue.     Calcifi- 
•  atioM  rnav  also  l)e  noted.    True  bone  has  occasionally  been  okse^^■ed  ■ 

A  iM|(  iiliar  form,  which  desenes  special  mention'  on  account  of  its 
nsein  .lance  to  Hodgkin's  disease,^  is  chronic  hyperplutic  taberenloiit. 
Ins  .liscase  has  l)ecn  descril)ed  in  connec-tion  with  the  intestinal  tract 
the  ser,Hb  membranes,  and  the  lymphatic  glands.  The  glands  are  con- 
si.leral.iv  ,„larged.  and  are  hard,  showing  no  striking  evidence  of 
i'tnt,-  inllanimatory  action.  On  section,  thev  are  firm,  gravish.  ami 
tran>l„c,„t  „,  appearance,  or  present  small  gravish  dots.  Caseation  is 
aiisciit.  (,r  at  least  rwhicetl  to  a  minimum. 

Mi<n,Mu,,ically.the  chief  feature  is  a  proliferation  of  the  emiothclial 
l^at. .,  u„|,  l,„|e  or  no  leukoc-ytosis.  The  endothelial  cells  at  first  form 
smal  n...s,s  ,vluch  .iltimately  c-oalesce  and  encroach  upon  the  lymphoid 

mono,',',?  I        '  t;  ""''•■'"  ""*'  ^^^  h.vperplastic  tissue  is  ma.le  up  of  large 
mono,,,,,  |,,,r  cells,  either  n«.nd.  stellate,  or  .spi.ulk-shapcd.  with  pale 

'  I. Ill  Mich,  \ircli.  Arch..  177- 1904:, 371. 
l^uir,/!;  Ti.  sir'lj™'''''  ''""''■•  ^■'-  "*"-«-2-"»-^':  «"'l  »"nnet.  .lour,  dc  Phvs.  .-.ml 


214 


THE  U'MPllATir  (ILASDS 


I    I 


iHM-loi  UII.I  n-liitivi'ly  nliiiiMiHiit  pniloplaMin.  Wry  ofU-ti  jIks,.  „.|l 
iH)ll«<«ti<>i)>  iiixK-rKii  hyuliiu-  «'Iihii){i'  ttiui  urr  citiivrrtiii  into  tniiisliuvni, 
.siniftun'Kiw  iiiuxHt-s.  ( 'H.H<>ution  is  m-vu  only  in  wry  lonj<-stttiMiiii>r  (u<«n. 
'I'liis  iitTcction  is  Hp|>nn'ntly  t\w  lM>ni)(n  fonn  of  tulNTi'tiiosis.  l>iiva|' 
has  n-pnHiiutMi  •'  n  »Im'  rttl»l»it  l»y  injwtions  of  uttentiutnl  tiilirn'lf 
iHicilli. 

ByphUil.     Tlu"  iniJial  l»»sion  of  sy|.  followiil  hy  a  slow,  |>ninll^■l 

<>tilarp-ni<'nt  of  tlu-  nnin-st  lyinph-jjlu  lus  (inili)lrnf  hnlxi),  'I'hc  iiipiiml, 
axillary,  and  q)i»nK'liloar.  «rr>iml  iiml  pri'Vfrli'hnil  ft^amU  have  Ixrn 
founil  alT«fl«>«l.  'I'iir  glands  art'  imxU'ratrly  onlarjjitl  and  firm.  Mirni- 
.s<-opically,  iIm"  j-oiMliliitn  Is  found  to  Ih'  due  to  thickeninjj  of  llu-  capMilc 
ami  .s»>pt'a.  with  hy|M«q»lasiu lK»tli  <»f  tin-  lymphoid  an«l  t'nd«>th(lial  cvlU 
'i'ho  iMidolhclial  plates  lini'ijj  thf  lyniph-spacrs  an>  the  oius  ihifflv 
involvf«i.  TIm-  SpirtK-luta  |Mllida  may  oftt-n  Ik-  ck'twti-tl  hy  ai>pn)|)riaif 
staining.'  Tlu-  condition  may  |M'rsi.st  f<»r  months  or  ewn  y»'ar>.  When 
hoaling  takc-s  pUur,  th»'  «rlls  und(>rp>  fatty  tU-gi-neration,  tlu-  swcllim; 
snlisidcs.  and  fiu*  >;land.s  Ihhvh'  more  or  U'ss  indurated,  tlnmnu 
formati«>n  iHturs  in  tertian.-  .syphilis,  and  uffe<'t.s  usually  tlu  iiiciiiial, 
siilimaxillarh',  anti  (fr\i(id  );lands.  \s  a  rule,  oidy  one  or  xwu  arv 
atTii'te<l. 

Plague. —In  one  f«mn  of  plague,  "pestis  hulmniea,"  the  iiunlvr- 
nient  of  the  iympli-glaiuls  is  .striking.  In  alKiut  one-half  of  the  ray- 
the  inguinal  glands  are  those  first  attneke<l,  and  in  aUiut  2.'»  [kt crm 
the  axillary.  While  the  chain  of  glands  next  the  site  of  the  iiiiKtilati .' 
is  chiefly  invtjivitl,  thase  elsewhere,  notably  of  the  pharynx,  tlic  nmi  .f 
the  huigs,  and  the  mesentery-,  an'  iLsually  (piickly  attacked.  Tlu-  ii(«lr. 
first  infwted  are  gn-atly  enlarged,  riMldene*!,  and  hemorrhajiic.  aiui  tl-y 
tissues  in  the  neighlwrluKHl  .show  hemorrhagic  nwlema.  In  tlic  rarl 
stages,  or  ii  the  iiif»Htit)n  1h>  not  ver}-  virulent,  they  are  <juite  tirm.  I>m  i:; 
other  cases  they  are  softenwl  anil  even  li(|uefie«i.  On  scM-tioii.  ilif  wie- 
an>  of  a  gniyish-riHl  color,  with  areas  of  hemorrhage,  or  the  i mire  «i- 
staiMV  may  Ih'  densely  infiltrateil  with  hUxxl.  In  the  severot  form  v.r 
undergo  colli(|uative  nwrosis  and  contain  a  semifluid  giuniny  inaitri, 
or  a  sulistance  not  unlike  lard.  The  distinction  iK'twirii  ..>rit\  u,: 
medulla  is  usually  lost.  In  the  mori'  remote  mxles  hemorrhajn  »!"»■> ••■ 
(Kcur  except  in  ca.ses  of  relapse. 

Microscopically,  the  hl(HKlve.s.sel.s  and  the  lymphatics  an  tncri-. 
with  cells  and  contain  abundant  pest  bacilli.  There  is  |.nilifrr»;i  • 
lM)th  of  the  lymphoid  and  tlie  emlolheliul  crlls,  and  the  latter  (vMx:: 
large  numln-rs  »)f  Ixuilli  within  their  pmtoplasm.  An  unii-iiil  nun.!'^' 
of  " Mast-zellen"  is  also  iH)ticeal  le.  Almost  the  whole  glai.i  raa'  » 
convertiil  into  finely  granular  mi  terial,  consisting  of  a  few  (tlL-  ^~ 
al.undant  cellular  debris  and  hosts  of  Imcteria.  A  few  |. la-ma  (rfe 
niav  also  1)»>  s»HMi,  but  polymorphonuclear  cells  rv  ((uite  -  .ir-.r.  Ij '^ 
incorrect,  however,  to  call  the  softening  "suppuration,"  a-  >  x^  "^•'- 


'  .l(.iir.  of  K\p.  M<h1..  11   1!K)<»:40U. 

■  Tchlftihoff.  KoiiNsky  Vmfch,  .liine  IS,  KXl.".,  ronfiniiiiiK  H.t^ 


KKTROHRKSSIVK  MKTA  MORPHWIES 


215 


i|(>w.  lU"  terial  thnnnJii  may  lie  fouml  in  the  hliKMlvi-4.s«>U  anii  Ivinph- 
aiics,  »liirh  ai*  jfTwitlv  ilLstriKlnl  ami  <how  pp>liferaiion  and  (icvenrni* 
tion  of  th'  ir  enlirthflium.  Fairly  nunM-n>iu  ami  WFll>pm«n-r<l  rvd  wlU 
ran  a^tially  In-  -wen  within  the  necrotic  an>a.s.  The  tlwues  surrouniiint; 
thr  inftt  t>il  ({Untk  .<ihow  inflammatory  rrviema,  the  hloodvesieU  are 
iIIUikI,  atnl  there  Ls  an  exmlate  of  lymphoi<l  celU  and  erythrocvies  into  the 
lvmph"f>ii<t^.  The  liKioilvesseU  it>ntain  numeroas  liacilli.  The  lymph- 
^'larxi>  ai  '»mv  ili-tance  from  the  main  lesion.*  are  somewhat  enlan;e<l  and 
»f  a  ilarker  ciilor  than  normal,  hut  show  nierely  con||:e:«tion  ami  hyper- 
pia-'ia. 

L«proty.— In  leprosy,  chanjces  in  the  axillary,  ii^ruinal.  and  me^nteric 
iHatidi  an-  sonu-timcM  met  with.  The  affected  structures  are  enlargnl, 
M>h,  ami  <if  yellow  color. 

Miini-xiipically.  all  the  sijfns  of  h^-perpla-stic  inflammation  may  lie 
sn-n.  Katiy  chani^es  in  the  lymphoid  ceILt  and  reticulum  have  also  Iteen 
oWntil.  as  Well  as  phagm-ytes  rontainin);  pi^ent  ami  hItKMi  cells. 
'ITie  ^[)t•<•iri<•  liacilli  may  lie  <lemon.strate«l  within  the  no<les. 

Pwasitei.— Filarije.  Trichimv.  ("ysticerci.  aiul  IVntastoma  have  U-en 

I.lt'I  will). 


KITROOUMin  mr  AMORPHOUS. 


Simple  Atrophy. — Simple  atrophy  occurs  as  an  involution  process 
in  old  iii;f.  The  atrophy  affects  chiefly  the  lymphoid  elements,  although 
llir  >tn>iiia  is  r»-laiively  or  even  absolutely  increaseii.  The  glands  are 
^mail.  iiHTj-asetl  in  consistency,  and  contain  but  little  juice.  An  inter- 
esting.' varitty  is  the  .so-calle»l  "lipomutous"  atrophy.  Here  the  lymphoid 
wIN  of  th«'  nuiliilla  gradually  disappt^ar  ami  the  fibn>us  stroma  under- 
(.iifs  fatty  nictani()q>liosis.  The  proces.s  gradually  extends  to  the  c-ortij-al 
ixirtioii  atid  the  original  follicular  structure  may  in  time  lie  utterly 
ile^trovni.  'I'he  atf«xtion  is  said  to  occur  chiefly  in  the  glamis  of  the 
nu'vnttn .  cs{)e<-ially  in  cases  of  chronic  alcoholism. 

Amyloid  Disease. — The  lymph-glands,  particularly  those  of  the 
alxiointii,  may  l»e  affecteti  in  ca.se  of  widespread  amyloid  change. 
(>c(a^ii>iially.  especially  where  there  is  chronic  Iwne  disetise,  they 
mav  U  early  or  alone  involve*!.  In  advanced  cases  the  nodes  aiv 
tniar;.'id.  hard,  and  of  a  grayish-white  .-emitransluwnt  appearance. 
llif  iliMax-  Ugins  in  the  walls  of  the  arteries  and  capillaries  o'  the 
(orttA  ,iiiii  in  the  filmnis  septa,  where  it  leads  to  the  pnnluction  of  small 
flatttiinl  ii.hIuIcs  that  gradually  encroach  upon  the  lymphoid  «-lls.  anil 
in  time  l.riiig  alMHit  complete  atmphy.  In  rarer  cases  the  walls  of  the 
IviMiili-imises  ill  the  medulla  are  chiefly  or  alone  affecteil. 

Hyaline  Degeneration.— This  is  foumi  particularly  as  a  seciimlari- 
maiiit  ;  ;!iii!i  iii  tiiUrculous  mules.  Generally,  the  reticulum  and  the 
Ivinphi  i  I  ells  an>  swollen,  hemorrhagic,  and  transparent,  and  are  fuseti 
into  in  -iilar  ina.s.ses.  Such  hyaline  degeneration  is  apt  to  l)e  the 
prtrni.  ,  ,,f  (ascation,  though  it  is  not  invariahlv  associt.  eil  with  tul>er- 


210 


TIIK  LYMPHATIC  V.I.ANItS 


I    .■ 


I 


(■ul(Mi.<«.  lifw  frpqiicntl}-  tlic  dtyencration  atfifU  the  walU  of  »lir  y\m\\rr 
vi'jwel.s. 

Oaldfleatioil.  Cuk-ifiration  M  iMUttlly  nu-t  with  in  foiiiHtiiiM)  with 
c-hn>nii-  tulKTiMiloHin  t)f  the  Klaiidit,  but  nmv  lie  fouiul  iti  previuiislv  ht-althv 
kIhimIm,  a!4  in  iMleonialai-ia. 

Mterotil. — \e<'nwi!i  Ls  fairly  cnmmon  in  cases  of  inftuniniutiori.i^tiir- 
riii^',  for  iiwtaiK-e,  in  diphtheria,  typhoid,  tiilien-uIiMis,  liulKinii  |>lu)(ii,' 
uikI  si-pticemia.  It  m  asnaliy due  to  blixkin); of  ve.<Mel.s, owiri^  in livMr- 
phtsiu  of  their  eiulotliHial  li»inj{.  Extensive  glandular  ne'.'n)s«'s  have  Iktm 
ile^-rilKHl  in  iitruH-ilion  with  severe  burns  of  the  skin.  J.  .Mi(  rat'  has 
pnMJiieetl  a  careful  study  of  thia  funn.' 


PROOtlUIYl  BOTAliOEPBOSU. 


n  t 


1 1   i 

a 


In  the  present  transitionni  state  of  our  ideas  it  is  inipossilili'  top 
a  thoroughly  si-itntifie  description  of  the  progn-ssive  «'lmn^'es  alftr 
the  lyiiipli-);lands. 

Hyperplasia.  II\-peq>lasia  is  one  of  tlic  commonest  of  these  clinnps. 
and  arises  from  a  numU-r  of  ditTen>nt  causes.  It  is  fre(|uently  iiii|N)ssililt' 
to  draw  a  liarti  and  fast  line  iK'twtTU  what  are  men-ly  c()iii|Hiisaturv 
or  iiiHanunatory  hy|M'q)lasia.s  and  true  tumor  formation.  'I'lic  wholi- 
sulijjtt  of  ovi'rjjrowth  of  the  lymphatic  j;lan»ls  at  the  pn-seiit  time  i> 
in  such  almost  ho|M-less  confusion  that  at  this  point  we  have  ilioiijjlii 
it  ix'tter  to  deal  chieHy,  and  that  in  a  very  sketchy  way,  with  the  iiiu- 
toniical  conditions  of  the  glands,  h-avinj;  (lie  fuller  consideraiioii  of  tin 
sul>je<'t  to  another  place  (see  vol.  i,  p.  (iSO). 

Many  oliservers,  notably  \Vinoj;railow,  Pio  Foa,  and   M(»ltr,  hau 

noted  comi>e>milorij  hi/iMrjlldnlii  of  llie  lymph-elands  after  exiHriiiicntil 

xdrjwitiiiii  ;^f  the  spleen  in  the  lower  animals.     A  similar  cniulition 

lias  iH-en  observe<l  (xcasionalh  in  man.     The  compensation,  huHivtr. 

apjHars  to  Ix-  tem|)orary. 

Lymphadenia.  I'lKhr  the  term  lymphadenia,  or  "|)rii;;r*'ssivf 
hy{)erplasia  «)f  the  lymph-elands,"  we  may  include  a  niimlK  r  of  allifil 
conditions  in  which  then'  is  an  i  rease  in  the  lymph  'id  miu!  other 
elements  of  the  glands,  whereby  tin     l)ecome  notably  enlarged. 

I  iider  this  caption  we  may  conveniently  deal  with  the  conditiniis  known 
as  chr^oic  hyperplasia,  Hodgldn'i  disease,  leukemia,  typical  or  btnip 
lymphoma,  atypical  or  malignant  lymphoma  (lymphosarcoma!. 

The  dislinclions  U'twcH-n  these  various  affections  have  not  in  (lie  [wsi 
In-en  by  any  means  clearly  define<l,  nor  even  yet  is  their  p;ill)iiL:iiiv  fiillv 
understood.  The  confusion  that  has  existi-*!  in  this  regard  is  id  In- seen. 
to  take  a  single  j'xample,  in  the  numerous  synonyms  that  ha\r  Iktii  pni- 
posed  for  Hixljikin's  di.sea.se,  namely,  simple  adenia  <  rioiisseaiii. 
lynip!i<is4ircoma  ; \'ircfii>w),  malijinant  Iym{>homa  {Billroth^  an  !  [«!k!ii- 


'  Till'  Niitiin-  ol'    Internal    [.esiions  in   l»<'ath  fnini  ."su|K>rficial  Hiir 
.Medieini',  2: 1!H)1 :7:{.-.. 


Nincncan 


LYMPIIADKSIA 


217 


liMikcmi«  (rf>hnheira).     More  retrnt  .stiKJi«>»  havr  <loiu>  sutncthing  to 
hriii^'  onlcr  out  of  ehiuM. 

'IV  iH^rjii  with,  it  Is  iHiw  lievoiui  c|ut>.<4tiun  that  we  can  j{i't  a  rrlatively 
I'lioriiious  i-nlargt-inent  «if  the  regional  Ij'inph-imdes  at  a  result  of  infi'tm- 
niatixii,  The  majority  of  »u«-h  eases  are  prolNii>ly  ilue  to  tuberculoMi.s, 
whidi  >;ives  rwe  to  tw«»  typ^  of  lesiorw,  the  onii'iiar}-  granuloma  witli 
(UMiition.  and  a  mo-e  chronic  hyper{>ia.stie  form  without  caseation. 
In  llw  latter  the  fibroas  tissue  is  inen-astnl,  largi-  etxlotheliul  cills  are 
nimn-n)iis,  aiul  the  lymphoid  elements  an-  diniinishtHl.     (  asj-ation  is 


Flo.  SI 


H'nIltklJl 


Hot  |)rc 

siii"il,it 
tioiis  I 

tliNlr. 

);ri'jt|v 
tlic  a\i 


■li-ea*  in  «  y,.u.„  girl.     (From  Dr.  F.  Ci.  Ki.,l..y'»  .  linio,  .Montreal  (icn.ral  Hon-ital.) 


"lit  here,  aiul  the  sjiecific  bacilli  can  l)e  detettitl  with  <liffi(ultv 

iiv  (lie  ra.se.s  whieh.  as  Hilton  Faggc  wa.s  the  first  to  iK>int  out.' 

ll<),lKkin.s  di.sea.se  very  olosely,  and  no  doubt  the  two  affec- 

>  '  •    '  f«-<iuently  confused.     In  Hodgkin's  di.sease  the  cervical 

iv^  tie   hrst   to    Ix-   noticeably  involved,  »)ecomiiig  gradiiallv 

":>!-Ki'.  and  cottsulidating  into  deii.se  nia.sses.     Suh.s(H|ucntlv 

..  mgumal,  retroperitoneal,  peribronchial,  mediastinal,  and' 


Puth.  Trans.,  London,  25:  1874:  2.^i. 


21S 


THE  LYMPHATIC  (ILASDS 


inesenteric  >;lainl.s  presi'iit  a  similar  fhaiigc,  and  finally  the  sphcn  and 
liver  iHH'ome  enlarj;e<l. 

Histol()j;ically,  the  pnKess  apparently  In-gins  with  the  proliferation 
of  the  endothelial  plates  of  the  lymph-sinuses  and  the  larj;e  cflis  in 
the  germinal  centres.  I^ter,  the  lympli-sinuses  and  reticular  s|)Uf«s 
are  fillc>d  with  proliferating  lymphoid  and  endothelial  cells,  '^'iiiiicnnis 
giant  cells  and  plasma  cells  are  also  to  1k'  seen.  (loldmnnn  I'ni  ix:rin7' 
|H)inted  out  the  great  abundance  of  the  eosinophile  ee.'i  in  the  imiio 
in  this  disease,  a  fact  that  has  been  emphasize<l  by  .some  tiu>u;;ii.  In  oi,' 
judgment,  err()iuH)Usly,  as  a  diagnostic  point  between  Hi  Itrl  mi-  liiscu  c 
and  tulKTculous  adenitis  (Dietrich,  Fischer,  UeetP).  /•  ;l>  o  i..  ,si' 
advances,  the  fibrous  septa  of  the  nodes  increase  in  size,  dividing  them  into 
coarse  h>l)ules,  and  graciually  bring  almut  a  degeneration  of  the  lyiiipiioid 
and  other  cellular  elements.  This  connective  tissue  may  show  iiyaliiie 
metamorphosis,  and  large  areas  resemblitig  ischemic  ni-crosis  are  frc- 
(piently  .swn.  The  histological  appearances  in  Hcxlgkin's  (jiseasf 
suggest  undoubtedly  an  inflammatory  and  probably  an  infectious  orijfin. 

In  leukemia  (of  the  lymphatic  type)  the  lynipli-ntxles  all  omt  the 
Ixxly  are  enlarged.  Lymphoid  tissue  everywhere  is  increased,  and 
the  splc-en  reaches  truly  colossal  proportions.  Histologically,  all  tlic 
elements  of  the  ntxles  are  incrt-ased,  and,  unlike  Hodgkiii's  (iiseibc, 
there  is  no  sfx'cial  increase  of  fil)n)us  tissue.  A  striking  and  character- 
istic feature  is  the  alteration  in  the  bhxxl  (excessive  lymphocytosis). 

Henign  lymphoma  is  extremely  rare,  but  its  occurrence  is  recojiiiized 
by  Ih'  ("omit'  and  Knndrat. 

Lymphosarcoma,  histologically  sp«'aking.  is  a  small  rouiKi-eelJHl 
.sarcoma,  originating  in  the  proliferation  of  the  lymphoid  elements  of 
the  lymph-nixles.  The  ntxles  enlarge,  fuse  together,  and  iiifiltriitc 
liK'ally,  so  that  enormous  solid  masses  of  new-growth  are  produced,  it 
is  found  commonly  in  the  thorax,  involving  the  mtHliastimnii  and  llu' 
structures  in  that  region;  and  has  also  Ix-en  note<l  as  iH'giniiinj;  in  the 
subinucosa  of  the  intestine.  It  d(H's  not  form  distant  metasta.M'-.  The 
reliitionsliip  of  thi-;  condition  to  diffuse  lymphomatosis  has  alre;i<ly  limi 
discussed  (vol.  i,  p.  (iS4). 

Tumors. — The  only  primary  growths  are  lymphoma,  sarcoiii.i.  liliro- 
sarcoma,  eiichondroma,  and  carcinoma. 

.\cconling  to  histological  structure,  the  .sarcomas  may  Ix'  dividnl  into 
round-celled,  spindle-celltnl,  and  alveolar.  The  growth  nmy  ()riL;iiial<'  in 
the  perithelium  of  tin-  vessels  (angiosarc(mia),  the  endothelial  lining' of 
the  lymj)h-sinuses  (endothelioma),  from  the  lymphoid  cells  (lyiMphosar- 
<'onia),and  from  the  connective-tissue  stroma  (sarcoma).  'I'he  I nic  round- 
celled  sarcoma  is  hard  to  distinguish  from  tlu'  lympho-sjirconia  |i!iviously 


'  (VMtrall)l.  f.  allp.  I'litli.,  r,:  ISiM:  2<t<t. 

'  Si-d  Dortithy  M.  Ui'i'il.  On  thi-  I'.ithnhijripnl  Clvmgru  in  H<>i|j;k;':  Di-a-as-. 
with  Sjiccial  Heferi'iice  In  Itn  IJelationsliip  tci  'rulHTPiiliisis,  .Iiihns  Iliipkin-  Hospital 
ItepnrtH,  111-  1!KI2  :i:«. 

'  .l.oir.  (if  F,\|MT.  Med.,  I:  IS'MI:  .V)!!. 


iamphadenia 

Fro.  S2 


219 


I..vni|,li-n.Hle  iti  Hc..l«kin'»  disease.  The  wrtion  shows  a  |.,irti<in  ()f  Ihe  lortex  of  a  node  with 
llii-  lap-iilo.  The  liorse-clicstnut-like  rails  are  eosinophiles  which  were  numerous  in  this  reni.in. 
Zeis"  ..hj.  ,';.  nil  immersion,  ocular  No.  1.  (Kn.m  the  Pathological  Lalxiralory  of  the  Montreai 
(General  llDsjiilal.) 


Kl.i.  5.-? 


Mill  1.  „    1.   ,„  II.Klgkin's  disease,  showiug  Ihe  extensive  fibrosis  orcurrinn  in  the  later  stage. 
"        ■■     I'J.  Tu,  without  <Kular.      (1-nmi  the  pollection  of  the  Montreal  Ceneral  Hospital.) 


t. 


I 


5      ' 


220 


I.ympli.i-'an.iina.      I.rilz  i.hj.  N.i.  7.  without  .icular.      (1  n.m  lliv  i  ulli-iti.in  i.t  l)i    \{.   \i,\ 


■      1 


Secondary  cnliimnar-<-elleil  caniiiomB  of  lym|>)i-niHlp.     Zeiss  obj.  1)1),  without  i 
the  rollerlion  of  the  Hc.yal  Viiloria  Ilonpital.) 


THE  SPLEES 


221 


nffiT-il  ?".  It,  however,  urijonates  in  a  sinjrie  >;laiul  ami  rjiies  not  tend 
to  iMv.lvf  the  neighU)riri>j  jrlands.  It  rather  invades  tiie  capsule  and 
othtr  ti--iits.  and  pnxlufes  dL-<tant  frxi  of  metastatic  depasit. 

prhinrij  mrrinomn  ha.s  Jjeen  descrihe<l.'  This  should  proUhlv  Ije 
c]p-i;:narfi|  alveolar  endothelioma .. 

Ttv  -M-ondarj-  growths  are  c-arcinorna,  -arcoma,  chondroma,  and 
mvxoiKi.  In  secondare  sarcoma  the  glands  irest  the  primarj-  gitjwth 
UfDiiif  Kr-t  involved.  Thev  are  en!arge«l  ami  infiltrate«J  with  a  new- 
foniiatii  III  more  or  les.s  perfe<tK  reseinblinj:  the  priman."  growth.  The  cflLs 
i>f  t!i>  -tfundarv  growth  are  formeil  into  dusters  or  liands  surrounded 
l)V(uiiim  tivf  iksue  derived  from  the  prrjliferation  of  the  strt>ma. 


THE  SPLEEN. 

Tli>-  ixact  function  of  the  sple«'n  is  still  in  douht.  but,  from  the  ana- 
ti.mi<al  >tnictuo>  of  the  organ  and  from  experiment,  we  can  deduce 
nrraiii  comlusions  that  an-  im[>ortanf.  so  far  as  thev  go.  In  general 
tirin>,  tlif  >p|tfn  tnay  U-  d»-.  rilieil  as  an  organ  comj^)s.-d  of  numerous 
hh«).|v."tl-  wliidi  discharge  their  cotitciits  into  a  j)eculiarlv  arrangt-d 
Iviiijihailttiuid  tis^iif.  The  organ,  which  weighs  on  an  average  170 
LTaiib.  i-  l>ounrlf<l  \>\  a  capMile  of  Hl>n>us  and  elastic  tivsue  which  sends 
|)rnli)iigation>  or  traU-JuLe  into  the  sut>stanr .  .if  the  gland.  In  the  crntral 
iKrlinii  tliese  traU-(iil:e  hrt-ak  up  into  finer  ramification-,  so  as  to  fonn 
a  -[Hiiiiry  matrix.  From  the  hiius  p:!>-es  in  the  artery-,  whose  Itranch^s 
fnlluu  iliec.mnective-ti-.>iie  septa.  The  .Malpighian  corjf)iiscles  art-  seen 
nil  -.  rtioti  as  whitish  dots  that  <-<i:itnist  with  the  re<l  of  the  spleen  pulp. 
Up  (iiiiNi..t  in  small  (t)llections  of  lymphoi<l  c-ells,  either  encircling  or 
-itiiati.i  to  (jiie  side  of  the  afferent  arterioles,  together  with  rrticulateil 
ii"ii.  lit  rive<l  fnmi  the  advciititia  of  the  ves>t  1>.  Thev  generallv,  though 
not  iiivarialiiy.  contain  capillario  that  empty  into  thespjeen  pulp.  The 
lin  Illation  i>  very  fr.f.  The  liUxl  entcr-'at  the  hilus  hy  the  splenic 
iirti  I .,  whence  it  diffuses  through  to  tiie  mrtex.  Thert>  is  no  iloiiht  now 
ihat  ihr  Mmrinlc-.  ending  in  small  dilatation-,  (he  ampullie  of  Thoma, 
ili-(h:ir-r  directly  into  the  pulp,  white  at  the  s;,,ne  time  thev  communicate 
<l  imI\  uith  the  veins. 

lli(  |iiilp  is  com|)osed  of  a  n-ticulated  fihnuis-tissue  stnmia  in  which 
Ik'  innn.niiis  lymphoid  cells.  The  walls  of  the  spaces  art-  lin.nl  l.y 
lari:.'  iiioiiMiuKleat.Ml  cells,  or  endothelial  elements,  similar  to  tho.se  lining 
thr  liloodv.  -.-ei-  of  the  lymph-siimses.  Bi^ides  this  we  mav  see  red  blood 
(tll~  111  various  -tagi-s  of  degeneration,  blotxl  pigment,  and  phagix-vte.s 
(imt.Miiii,-  cellular  debris  ami  pigment.  From  thi.s  it  mav  U-  infemnl 
■  )v  IS  a  close  relationship  liotween  the  spleen  and'the  va.scular 
;-y-iriii  ri„.  lymphoid  character  of  the  pulp  cells  suggi-sts  that  one  of 
IN  tuM.  n,,„>  ,s  to  produce  I;. mphocytes,  and  this  is  |M)ssiblv  correct, 
11  II  I  I  lo  U-  taught  that  the  large  mononuclear  and  transitional  cells 
of  111.  i,„„d  were  forme<l  in  the  spUvn,  hence  they  were  callwl  "spleno- 

'  V.  WillTmnn,  Inaug.  Diss,  Munch.,  1!»04. 


tl 


il 


'  1    !l 


•>•>•> 


THE  SPLEEX 


f 


I 

1 

I  : 

I  I 


I  I 


cytes."  But  we  know  now  thiit  the  .spleen  is  not  at  l«'a.st  the  onl\  source 
of  orijjin,  for  the  splemx-ytes  may  still  In*  found  in  fhe  blood  after  n- 
periinental  e.\tir|>atiun  of  the  organ.  The  main  function  of  the  s|)lwn, 
therefore,  seems  to  Ite  the  destruction  of  the  nil  hUNxl-eells  wliicli  are 
found  in  all  stages  .f  disintegration  in  the  pulp.  For  it  has  Ihimi  found 
that  when  red  hiocHl-corpuscies  in  exce.ss  are  introduc-ed  into  the  eircu- 
lation,  there  is  a  great  incri'ase  in  the  amount  of  the  eiythnnvtes  and 
pigment  in  the  .spleen.  It  is  now  practically  .settle<l  that  the  spleen  is 
not  normally  concernetl  in  the  formation  of  re<l  cells,  e.xtrpt  (hirini! 
fn'tal  life  and  in  the  first  year  after  birth.  In  cases  of  destnietion  of 
lM)ne-marrow,  it  may  resume  this  function.'  The  hyperplasia  of  the 
spleen,  which  is  .so  common  a  feature  in  many  infective  fevers,  sufijjests 
also  that  this  organ  may  play  a  part  in  the  neutnili/.ittion  of  toxins. 
As  demonstrate*!  by  Roy,  the  organ  exhibits  a  |H>riiKlic  eontn.itioii  and 
expansion  (through  the  agency  of  the  plain  muscle  fibers  present  in  its 
capsule).  By  this  means  the  contents  of  the  sinuses  undergo  renewal. 
( )wing  to  this  and  the  close  coimection  with  the  vascular  .system,  which  has 
suggestwl  the  name  "alxloininal  heart"  for  the  spleen,  we  can  uiidetNtand 
readil}  how  it  is  that  the  spleen  is  especially  liable  to  1k>  involved  in 
changes  in  the  bloml,  either  from  fon'ign  substances  reachin/i;  it,  from  ilic 
action  of  .soluble  toxins,  or  from  alterations  in  blcKxl  pressure,  .\piin, 
as  the  splenic  vein  forms  part  of  the  portal  .system,  the  patliolojjica! 
conditions  in  the  liver  react  upon  the  spleen,  and  vice  irraa. 


OONOENITAL  ANOMALIES. 

The  nirt'st  anomaly  is  complete  absence  of  the  spleen.  This  is  miM 
often  found  in  association  with  other  grave  defects  of  (Ievelii|iMitni. 
The  splenic  arterj-  is  usually  wanting  in  such  ca.ses.  A1h)iiI  tliirtcen 
cases  are  on  record,'  but  only  one,  that  of  Birch-Hirschfeld,^  is  Invond 
cavil. 

More  often  the  place  of  the  spleen  is  taken  by  scattercil  iiodides  (if 
.splenic  ti.ssue  in  various  parts  {.ipleniDiciili).  H.  Albnclit'  has  recorded 
a  rem«rk;it)le  case  'a  which  nearly  4(K)  of  these  spleniiin  idi  wer>' 
found  .scattennl  throughout  the  alxlominal  cavity.  Proliablv  the  nnot 
coimnon  anoniaK  is  the  wcurrence  of  accessory  spleens.  Tin  ^c  iKdir 
in  our  »'X|K'rieiice  in  1 1  pvr  cent,  of  all  autopsies.  They  vary  in  iiiinilier 
from  one  to  twenty,  and  may  In-  scarcely  ret-ognizable  or  as  kf^v  as  a 
wahrit.  Care  .should  Ih'  taken  not  to  mistake  hemolymplT-noilcs  fur 
accessory  spleens.  The  latter  an-  found  usually  on  the  umler  side  (if 
the  gastrosplenic  omentum,  the  mesentery,  the  wall  of  the  iiilotine.  and 

'  Meyer  ii.  Heiiieke.  Verlmiidl.  d.  dent.  Path.  Gesell.schaft,  i»  :  l!K).i  :  I'.M    .Mornv 
,|ohns  Hopkins  Hospital  Hull.,  1«;  lt»»7;2()0. 
'.Sh"  Hodenpyl,  .Med.  Keconl,  .54: 1  SOS: ((9.5. 

'  IK'fect  ilcr  Milz  liei  « ineni  Xeugeborenen,  .Arch.  f.  Heilk.,  I^^ipzig,  1:'.  l*^71:  ISO. 
•  Ziegler's  Heitriige,  20:1890:513 


tSFARCTIOS 


223 


in  the  tail  of  the  pancrca-s.  Irregularities  in  shape  arul  position  are 
ratl«r  .omrnon.  Uolleston  has  reconled  a  lernarkable  case  in  which 
there  was  a  tonjjue-like  prtx-es-s  extending?  into  the  scrotum 

OongenitAl  dislocation  of  tha  spleen  ha.s  l)een  olwervwi  in  ra.ses  of 
iiml.ilual  atid  diaphragmatic  hernia.  The  so-called  "  wanderinq  spleen" 
is  in  part  due  to  c-ongenital  laxity  of  the  tissues  at  the  hilas,  hm  perhaps 
more  iiiii)<)rtant  ts  increa.sed  weight  of  the  spleen,  such  as  may  be 
l)rou>;lit  alxHit  by  malaria.  In  these  cases  the  spleen  mav  lie  found  in 
the  l^'lvis.  In  Irumposition  of  the  viscera,  the  spleen  mav  l,e  found  on 
the  r\\im  side. 

Alteratians  in  P08ition.-The  spleen  may  Ik;  found  in  almost  any 
nart  of  tlie  alxlommal  c-avity.  This  may  be  due  in  part  to  congenital 
iHxness  of  Its  attachments,  but  increase  in  the  weight  of  the  organ  is 
the  chief  cause.  In  other  cases  the  orgjin  mav  Ik-  dragged  down  a.s  in 
pistroptosis  and  enteroptosis.  Occasionally,  inf^ammator^•  adlit-sions 
n.\  It  in  the  ajiiormal  {wsition. 


OIBOULATOKT  DISTURB-iNOES. 

Aneinia.-Anemia  of  the  spleen  is  found  in  all  forms  of  generali^.sl 
aiieima  and  in  compressio:,  of  the  organ  from  anv  cause.  The  orjmn  is 
siiiall,  the  capsule  somewhat  wriiiklwl,  and  on  section  the  tis.Viie  is 
pale,  {.'ravish-rwl.  ari.l  less  pulpy  than  usual,  while  the  traU-cuhe  stand 

out  proinineiuly. 

ayperemia. -Active  or  congestive  hj-perc-mia  is  foun.l  in  cases  of 
infclum  or  intoxication,  an.l  is  closely  allie.1  to  acute  inflammation, 
of  winch  It  forms  the  fiiNt  stage.  It  leads  to  rapi.i  swelling  of  tin-  oruan 
|v.th  .hstension  of  ,hc  bloodvessels,  so  that  the  part  contains  more  bLj 
han  norinai.  The  spleen  is  usually  greatly  enlarg,-,!,  the  capsule  is 
tense  and  thin,  and  thn.ugh  it  can  In-  seen  the  congested  pulp  The 
swelhnjr  may  Ik;  so  great  that  spontaneous  rupture  of  the  organ  mav 
-Konr.  On  s«ti„n.  ,t  ,s  soft,  pulpy,  an.l  intensely  red.lene«l,  so  that  the 
corpiiMles  and  tial)eculie  are  «|uite  indistinct. 

Passive  Hyperemis.- Passive  hypert-mia  is  a  common  con.lition  and 
i>  Iron.!,,  alKHit  bv  olxstructi.m  t..  the  f«-eexit  of  blocxl  fn,m  the  spleen 
Mi-h  as  n.ay  resiilt  fr,mi  valvular  disea.se  of  the  heart,  defective  pulmonary 
;;«"i ''-.M.  cirrhosis  of  the  liver,  and  thn,mlK.sis  of  the  spLiic  vd^u 

';■  ""''ted  organ  is  somewhat  enlarge.1,  the  capsule  tense,  opaque. 
an.  soMietinies  thickened.  The  consistcncv  is  also  inc^-a.;.!  ^On 
Motion  .he  tissue  IS  as  a  rule,  dark  purple-r«l  in  clor.  firm  and  dry,  and 
the  tral «.,„!„.  an.l  blcKxIvcssels  are  thickene.1 

is  m' li'iv"'I,ff:!"- ■;  '\r''^"  "r  «"!«*'■•*'«'•  *'^»'"  '-"vemous.  and  the  pulp 

talH,,.!,..  ,n„l  r..t,cu!um  g.M.erally  are  tliickcnci.  aiui  tl  e  vcvsels  mav 

iic  ion"*'k-'''^'-^  T""?""  '■''  ™"«'  cy-otic  induration  " 

todu"     ?h'7,      '  ."  •*  ^""■'•''  r*""™""  *""'"*   '■"   "i*-   Tlt-en.  owing 
"1.  t .,  t  that  the  .splenic  artery  is  a  lai^e  ves,sel  that  breaks  up  ,,uickly 


i 


I  f ' 


.l? 


k 


224 


r//A,'  SPLKES 


into  limiu'hcs  forn.!.ij{  n-lutivdy  small  end-iirtcrifs.  The  usual  ciiiisi-of 
cinltolism  is  the  disicMlpneiit  <if  hue  particles  from  the  heart-valves  or 
aorta.  An  (xx'asit>nal  eniise  is  thn)inl)(>sis  of  the  splenic  arterv,  mori' 
rarely  of  the  splenic  vein.  Osier  has  reeortled  infarction  in  a  niovahle 
spleen  due  to  twisting  of  the  jwliele.  Kinlxilie  infarcts  are  .sirijjje  or 
multiple,  an(  an-  <>f  small  siw,  or,  a^iin,  may  involve  the  whole  thick- 
ness of  the  oipm.  The  smaller  infarcts  are  mon-  or  less  we«lj{i'-sliiipc(l, 
with  the  ajH'X  towanl  the  hihis.     Ue<-ent  infarcts  form  a  firm  proiniiiencc 


I'm.  50 


White  infarct  of  ttio    !>|tleeii.      Section  waa    made  through  the    infarct,  the  organ    lirin,;  thereby 
laiil  open.      (From  the  Pathological  Laboratory  of  McOill  eniversily.) 

on  the  surface  of  the  orjiaii.  (*n  .section,  the  affectwl  area  i.s  ivnrv-whiic 
in  "olor,  less  commonly  somewhat  iieinorrhaf;ic,  and  sharjilv  iletincil 
from  the  rest  of  the  splenic  ti.s.sue.  Mi.xinl  forms  also  wciir,  wliere  the 
centre  is  pale  and  tlie  |H'riphery  iiiKltratetl  with  bloo<l.  Acccirdini.'  to 
Orth,  all  infarcts  at  first  are  white,  hut  later  some  may  la'coinc  hemor- 
rhagic. Beattie  ami  Dixon  claim  on  the  other  hand  that  all  iiifani> 
exhibit  a  preliminarA-  congestive  stage,  which  may  pa.ss  on  eitlitr  to  tlif 
white  or  the  hemorrhagic  stage. 

Microscopically,  the  anemic  n'gion  shows  coagulation-nei  lo-is,  the 
cells  an'  swollen  and  granular  and  their  nuclei  indistinct.  In  .idvanwl 
conditions,  the  nuclei  have  di.sai)peartHl  and  the  ti.ssue  is  coiivt  nui  int" 
a  granular,  slightly  rcfractile,  fthrinoid  material.  In  parts.  •  -pecialK 
al)out  the  periphery,  the  cills  show  a  certain  amount  of  fatty  .!■  j.Tnera- 
tioii.  As  a  rule,  surrounding  the  infarct  there  is  a  zone  of  reactive 
inflammation.     As  'lie  infarct  ages,  the  necrotic  material  i.-  .railuallv 


SPLEXITIS 


225 


softennl  and  absorbed,  while  vascular  jrranulation  tissue  develops  at 
th-  penf.herj-  and  gradually  substitutes  the  damaged  area,  until  finally 
uni/  a  pi;.'niented  scar  ninaias.  In  the  red  infarct  the  vessels  are  greatly 
distendnl  and  the  pulp  is  densely  infiltrated  with  blood.  \Mien  the 
r.boli  are  infective  the  infareU  rapidly  soften  and  are  converted  into 
abscessc-'.  Rarely,  these  heal  and  may  cause  local  adhesive  perisplenitis 
Or  again,  they  may  burst  into  the  peritoneal  cavitv  and  set  up  a  fatal 
penwnitis.  '  '^ 

Hemorrhage.-Hemorrhage  into  the  spleen  is  of  frequent  occurrence 
b«t  It  IS  .,f?cn  difficult  to  be  sure  of  the  condition,  since  the  spleen  pulp 
normally  .-ontaiiw  such  gnat  numbers  of  red  cells.  Apart  from  traumatism 
m\  mfar.  tiori.  the  usual  causes  are  malaria,  tj-phoid,  variola,  leukemia 
ami  purpura  haemorrhagica;  in  fact,  any  condition  that  mavset  up  acute 
spleniti-.  1  he  hemorrhages  are  rew^ized  as  dark  red  siiots  or  streaks 
in  the  parenchjina. 

OTXAMMATIOm. 

Splenitis.-Acat.    SplenitU.-Acute    splenitis    is  closely   associated 
with  ioiigr.tive  hyperemia,  ami,  indeed,  can  harfllv  be  considered  apart 

mm  It.  Ihe  condition  arises  in  the  course  of  'a  varietv  of  infective 
fevers,  such  as  typhoid,  pneumonia,  scarlatina,  diphtheria,  septicemia 
malaria,  ami  relapsing  fever,  and  is  characterized  in  the  main  bv  h%-per- 
plasia.  1  lie  spleen  is  enlarged,  sometimes  to  several  times  its  usual' size 
^oft.aml  the  nipsule  is  tease.  On  section,  the  organ  in  the  eariier  stages' 
IS  intensely  hvperemic  and  firm.  Later,  it  becomes  pulpv,  almost 
.liffluent,  ami  of  a  grayish-rcl  color.  The  follicles  are  usiiallv  not  prom- 
went,  l„„  may  \^  imticeably  enlarged  in  scariatina.  \ot  {nfr«,uentlv 
on  tHMapM.le  is  a  fibrinous  or  fibrinopurulent  exudation  iperis2nith) 

Mieroseopieallv.  there  is  a  numerical  increase  chieflvof  The  l^inphoid 
(ells,  nmny  „f  which  show  fatty  change,  while  large  multinucleated  cells 

Z2L  :7\U  '"S"""''  P'r"" '•  ^'"''^*'"-*'»-"  blood-corpuscles,  and 
mphoH    ,ells     The  vascular  sinases  ami  hmphatics  are  dilated  and 

their  en.l..theluun  shows  sigas  of  proliferation  Ld  fattv  degenerate  n 
nail    eniorHiages  into  the  splenic  suhstance  are  common.  "Fn  "ta  in 

a>e>  tl,..  follu  les  also  participate  in  the  acute  h%-perplasia.      In  connec- 

;-. -.1.  ^^^^^^^^  Klein-  has  described  hyaC  Vneratlon  o?  the 

Besi,|,.<  the  appearances  just  described,  there  are  certain  others  that 
serve  mention  Harely.  the  follicles  are  found  to  l^  of  a  ve  loTcJo 
"•  !"■  -  .N.re  a.„l  s„ften«l,  having  undergone,  not  suppurative  but  raThel 
-ll..|Matne.  necrt«is.  This  has  been  described  particulariv'in  Jomie^ 
:;;;  '  7'r  -"^hematicus  and  relapsing  Cer.  \L  ZZn 
IX  ■  ^"-^  ^'t'"}"  ""•'■  ^  ""^"^h-  of  microscopic  size,  but 
Jhi      ,.,,,,,,  reach  that  of  a  cherry.'    These  are  found  chiefly 

foil..  Ir  .     I  he  affected  cells  are  found  in  all  stages  of  disintegraSon 


10 


'  Trans.  Path.  Soc.  Lond.,  28: 1877:430. 


226 


THE  SPLEEN 


I        ■ 


I 


St)  tliat  in  the  ufft-j-ttxl  urt'a  wc  find  frapnonta  of  nurUn  nml  cclliilnr 
tifhris.  Al)uut  the  fHTiphfry  is  an  extnivosation  of  !ciik<K'_vt<s.  The 
condition  Ls  duo,  in  |>«rt,  t«)  the  direi-t  action  of  bacterial  toxins,  Imt 
chiefly  to  anemia  hroii(»ht  alwiit  by  the  olxstniction  of  the  blixHlviNsjls 
and  lymphatics  throu^ih  cell  proliferation  and  the  accumulation  of  dcliris. 
The  iarj^T  necrol"  •  fcx-i  may  soften  or  suppunitc  and  may  burst  through 
the  capsule,  thns  .ettinn  up  purulent  ju'ritonitis. 

The  results  of  acute  splenitis  are  various.  Commonly,  tlic  pnniss 
suKsitles,  the  h\-p«-«'mia  ffratlually  disap|H'ars,  the  hy|HTplastic  ttHs  are 
(lisintegrattHl  and  .*'  -.orlKNl,  and  complete  resolution  takes  place.  Uartly, 
the  simple  .splenitis  may  Infome  suppurative,  or  the  pnxx-.ss  niiiy  lieconie 
chronic. 

Suppurative  Splenitii.-  In  this  fonn  the  whole  spKcn  may  \h-  <liiTiL«('lv 
infiltmtc«l  with  pus,  but  it  is  mor»'  c<immon  to  find  multiple  alisctssei. 
The  condition  is  usually  due  to  a  hematojtenic  infwtion  with  |)yo)r!>nic 
niicroorpmisms,  such  as  (K-curs  in  ulcerative  endocanlitis  and  s<'|)tioemia. 
Here  the  pnnv.ss  is  frt'quently  combined  with  hemorrha>;ic  infamion. 
In  other  cases  the  inflanunation  may  extemi  from  neij;lilK)riii);  [wn-, 
lis,  for  instance,  in  ulcenitinj;  carcinoma  of  the  st«)ma<'li,  abscess  of  thr 
pancreas,  {x-riivpliritic  abs<r.ss,  and  purulent  peritonitis.  Tin-  iilisd^irs 
may  rupture  nto  the  jieritoneal  cavity,  the  left  pleura,  left  lun;;.  stomadi. 
or  intestines.  Should  the  patient  live,  the  absc«\s.ses,  when  small,  may  lie 
absorbtnl  and  lH>come  fibroid;  the  larger  ones  finally  l)econif  tiidiotni 
in  a  fibmus  capsule,  while  the  contents  l)ecome  inspissated  or  i  altannuv 
(^allin);  to  mind  the  relative  frequency  of  pyemic  and  bacteric'iiic  statfv 
the  rarity  of  supiHimtive  disturlwnces  in  the  .spleen  is  very  ninarkallf 
It  can  only  l)e  explainetl  on  the  a.ssumption  of  strong  bictericiilai  pni[>- 
erties  on  the  part  of  this  organ. 

Chronic  Indurative  Splenitis. ^Tliis  may  l)e  the  result  of  acuic  splenitis 
or  mav  Ik-  an  insi<lioiis  pnx^ss  from  the  first.  It  is  found  chiffly  in 
malaria,  cirrhosis  of  the  liver,  rickets,  and  late  .syphilis.  In  malaria 
the  pnK-e.ss  may,  f  >r  a  time,  run  an  acute  course,  just  as  in  otlicr  iiifwtiv. 
fevers,  but,  .as  a  rule,  the  splwu,  in  addition  to  the  signs  of  active  intiam- 
mation,  contains  yellow,  browni.sh,  or  black  pignicrf  in  the  |)nlp  and  in 
the  centre  of  the  follicles.  In  relapsing  ciises  and  hronic  malarial 
cachexia,  the  spleen  l)ecomes  permanently  enlarge*]  and  firm  in  cen-i-i- 
ence,  owing  to  the  overgniwth  of  fibrous  connective  tissue  i  ague  c»ke 
The  capsule  is  usually  thickene<l  and  the  organ  is  mor(>  or  1>  -<  ^;m!'i 
attached  to  the  diaphragm.  The  enlargement  may  be  so  };n  at  that  the 
spleen  may  lxH.-oine  dlslocatwl,  or  grow  until  it  reaches  the  \x-U'\<.  In  m 
malarial  spleen  it  is  not  uncommon  to  find  amyloid  chaiigi-.  Ttie  nver- 
growih  of  fibrous  tissue  is  permanent,  but  the  malarial  - 
(Ktasionally  diminish  in  size,  owing  to  the  lestruction  of  tin 
elements. 

Another  f»)rm  of  i^plenomcgaly  that  has  been  confounded  « ; 
a-s-scx^iati-d   with  febrile  disturl)ance,  is  found  in   kala-azar. 
parasites  are  end  .se<l  in  the  smaller  endothelial  cells.    '11 
enlarged  and  firm,  but  friable  and  not  sclerotic. 


;il(rn  ma" 
lymphi'i: 

Here  ti* 
1   splffn  I- 


TUBERCULOSIS 


237 


111  cirrli.wLs  of  the  liver  the  spleen  is  often  noticeably  enlarml  and 
this  l-.th  in  the  portal  a'id  the  biliarj-  forms  fllanot's  tvpe),  the  enlarve- 
meiit  Uing  more  ir,arked  in  the  former.  It  L.sed  to  be  thought  that 
this  wa>  due  to  stasis  in  the  portal  circulation,  but  this  is  undoubtedly 
not  th.  whole  explanation,  for  the  spleen  may  be  enlarged  and  hjper- 
phi>ti(  in  rases  where  portal  obstruction  is  not  present,  while  its  substance 
mav  U  |)iile  red  and  soft,  quite  unlike  the  hard  cyanotic  spleen  of  passive 
(Dnp.  ion.  It  is  more  probable  that  infective  micnKirganisms,  orcircu- 
latm;;  toxins,  are  at  work  here  as  well.  The  h>-perplasia  affects  the  pulp 
«hif  h  nintaias  numerotts  red  and  white  cells  without  any  special  change 
m  stni.  tiir.-.  Later,  the  arrangement  of  the  pulp  i.e^roes  confus«l 
aixl  thtrc  IS  a  cellular  transformation  of  the  reticular  connective  tissue. 

Fio.  S7 


(■a*,u-  ,:,l„.r,ul„.i,  of  ,he  ,,.!«„  (miliary  ty,»).      l^»^  „hj.  x,,  7,  „i,|„,„,  „.„,^^ 
Ihe  Cdlle.tion  i>f  I)r.  A.  G.  Ni.li.ill,  ) 


( From 


Tubercul0S18.~Th.s  ,s  rarely  primary  in  the  spU-en.     Acute  nntian, 

«rn^..v,.,  occurs  m  system.c  dt.ssemination  of  the  t..lH-r..ulous  i„f.<.- 

Z\\,I  '^r'  "  r''*'^''  •  *^^  P^'-'^'^vma on  sec-ti.,„  is  .soft. swollen, 

Mi. TO.  .,,,ioaIly  the  miliary  nodules  mav  be  purely  lymphoid  in  type, 
s    ,'""   "•'™'""V'^-  ^ndothelioid.  and  giant  cells  are  present  a.s  S\ 

>iU.t  r,,s,;iti<)n   1.S  often  olxser\ed. 

Tll''''::'';;T/r\^Ar"'r-t^  >»«>•  ^  f^^-^r,  rarer,  and  caseous. 
T  i  ,  ",  '"  "  -V«'P'^'}'«"  ^^^  «"'!  ahout  the  bloodvessels. 
iwr.  I.  ani  to  \ye  more  or  less  adhesive  perisplenitis. 


228 


THE  SPLKKS 


I  r 


■  t 


STpUUl.  J//7/>ir//  ijummiii'  an-  nm-,  luiJ  an-  met  willi  in  Imili 
inherihHl  himI  Hci|iiirc4l  svpliilis.  |jirj{«'  Kiiiiiiims,  vuryinn  in  >!/.■  fnnii 
tlmt  of  a  jK'a  to  tlint  of  hii  I'f^;.  have  Ut-ii  (li-HcrilK-*!. 

Diffme  hijpt'rplaniit  is  l»_v  far  tlic  most  coinmoi'  atul  iin|M>rlant  ^vphiliti, 
inuiiifcstation.  Tlu' fonditioii  may  In-  acnt*',  atfiH-tiiif;  tin-  lympliuid (tl|<, 
or  may  l«>a<l  to  c-hronic  tliickciiing  of  tin-  n-tifiiliim  iiinl  IralMHulii'.  In 
loii);-stuiuiiiig  disease  amyloiil  clmnj:*'  is  also  nu-t  with,  in  s.-nc  (use, 
of  old  lues  the  .spleen  coiituiiis  ahundnnt  pigment. 

LeprOiy.  The  ."pUrn  is  eiilarptl  and  pn-seiits  iiiimenMis  j;raniiliiiiiii>, 
whieh  (s>iitain  the  s|)«H'iHe  imeilhis. 

Olanders.  The  orpm  is  eiilarKisI,  .soft,  >;reatly  nsldtiicii,  unil 
stiidde«i  with  iniiltipic  ah.s<v.sses,  containing  thii-k  yellow,  rMtlicr  \\^%\ 
pas,  in  which  the  .sin-ciHc  Uicilhis  may  U-  demonstratiHl.  In  timiim 
ca.s«'s  amyloi<l  de|K>sit  may  also  In-  oliservtsl. 

Actinomycosis. -  'lliis  is  rare  in  the  splet-n  and  j;enendly  a  x'niiMlarv 
manifestation.  It  leads  to  the  formation  of  isolatisl  aiwci'sscs  fillnl  v.iiii 
jjlairy  pns,  in  which  lan  Ik-  nvo^niz*^!  the  actinomycosis  j;r»iii> 

Parasites.-  Kchin<H(K«iis,  ( 'ysticcrcus,  and  the  IVnlasli»ni 
ticulatcm  have  Ijeen  met  with. 


niiMii  dm- 


RETROGRESSIVE  METAMORPHOSES. 

Atrophy.— .Vtn>|)hy  of  the  spleen  is  found  in  old  |M'(>plc  ami  in  iIhn' 
sntTerinj;  from  lon>;-st«ndinjc  disease.  It  may  follow  acute  >|iltMiti> 
an<l  mav  Ik-  prcxhu-t-fl  by  >;eneral  anenii-  or  hy  any  ohstrucliuM  of  tin 
splenic  artery  leading  to  hnal  anemia.  'I'he  spU-eii  is  small,  (inn.  iiiid 
the  capsule  wrinkle*!.  On  section,  the  pulp  is  noticeably  (liniiiiislitil 
the  tralKK'uhv  are  pnMiiiiient,  and  the  orpin  con'ains  hut  liiilc  Hi*»\. 

Hyaline  Degeneration.— Hyaline  defeneration  has  l)een  idiMmiliii 
the  vessels  and  reticulum.    It  is  so.nctimes  sujHTaddi'cl  to  amyl< liil  (listav 

Amyloid  Infiltration. This  is  a  fairly  conunon  (K-cnrrencc.  I'licrparr 
two  main  tvjx's,  the  ".sa>;o"  spUt-n  and  the  ditfuse  amyloid  or  "Ipadnn 
spleen,  lnit  these  forms  are  frequently  combined.  In  the  fivM  tv]M,  i!ii 
splwu  is  not  enlarj;e<l  to  any  extent  and  its  consistency  is  but  liiilr  ulitrtil. 
On  strtion,  the  pulp  is  red  and  thickly  studded  with  firm,  iiaii-liKriii 
m'latiiu)us-I<K)kinf;  ImxHcs,  varyinj;  in  size  from  a  millet  seed  in  a  |iiii- 
head  or  somewhat  larger.  These  are  the  amyloid  Malpi;:lii  hi  IkkIu-, 
and  they  l)ear  a  clo.se  resemblanir  to  grains  of  lM)iled  sajro,  wlirnnilr 
name.  Microseopically,  the  amyloid  material  is  laid  down  iii  ilii- wall- 
of  the  smaller  arterioles  and  capillaries,  chiefly  in  the  iiiterm.  ,liato  zi)!f 
)f  the  Malpijjhian  IxHiies,  so  that  the  ap|M'arance  preseiitisi  i-  iliaH'fa 
rin>;  of  amyloid  material.  In  more  advanced  ci  litions, 
corpu.scle  may  Ik-  thus  transfornw-d.  'ITie  ve.s.sels  an  i-f  cour-r 
and  the  lymphoid  eiemenis  teml  to  atrophy.  It  may  liappi  : 
that  the  vessels  are  not  particidarly  involved. 

In  the  diffuse  form,  which  is  less  common,  the  orjian  i-  ' 
enlarged,  the  capsule  distended,  and  the  itlges  n)undeil. 


1 1  If  will  tie 
■  il'ickflicl 

:.    i.-irWt'Vi-f 

itiKlcniifl}' 
i'he  ti-'siK 


RE(iESKR.\TI\K  HYPERPLASIA  229 

is  firm  Ilk.'  riihU-r  an<]  is  »  nHliKfiu  whin  u  thin  section  U  held  up 
lo  ih.  Iij.t.  On  s«Ht,..n.  '  .,H.-<i.-,l  li^rht,  the  si.rfatt?  fa  of  a  peculiar 
„mitn.ii,[.arrnt.  r,-.|.ii,h  .w^r,  «s  if  ,„ver.-,I  with  a  thin  cwVinjr  of 
H«'iN,  vvli.iKf  It  hu^  lit-.-n  c.infwn-.l  to  ham  or  Iwc-on  (Sw-ikmilz) 

Ml,  r.,M„|ii(ullv,  the  amvloi.l  charip-  utf.vts  tlie  walls  of  the  venous 
r,,.l..l..  .n.l  the  retie.ilum  of  the  pulp.  'H...  endothelial  lining  of  the 
M-i,M'U  i>  unuff.-ct.-.]  ami  the  lymphoid  rejis  slu.w  merely  the  eff«t.s 
..f  [.ro-un.    The  .Malpijchiau  U«lies,  as  a  ruh-,  .-scape  in  thb  form 

II..  .aiis^s  of  amyloid  .li-Ka-s.-  an-  the  usual  on<-.,  rhnmie  wsting 
i.tre.ti.,n,  an.  (•achexia.s.  mt.-.miyelitis.  suppuration,  .-pticemia  tul^-r- 
.uln-K  >yp„l,s.  uifermittent  fev.  r,  .hnHiie  glanders.  earein.Hna.  and 
the  Ilk. .  AsMKiate.!  with  the  disease-,  and  de,,«.mling  equally  upon 
ti,.jnm,.l  <a.ise  ar.-  pigmentation,  iiifantion.  ami  film.us  h>pe'rpla.sia 
Pigmentary  Infiltration.     Ihis  is  met  with  in  cuses  of  fL^siy^ 

...iipMi,,,,.  i!  ,;.  ,.x,as.  leukemia,  and  all  diseases  a.s.s.K-iateJj  with 
l.l.--l.l..~tni.tion.  It  IS  well  mark«-.l  in  malaria  an.l  in  hemoehromat.xsis; 
r,.r..|v.  ,,„r,„|,.s  of  e,«d  ,l„st  may  n-a.h  the  spl,..,,.  Aeeorrline  to  its 
nanir...  rlu-  p.pnent  is  ^.,lden.  ml.li,),.  r,.,ldish.l,rown.  through  all 
-Im, .  >  „f  l,r..« ,.  to  l.la.k.  It  is  lai.l  duwi.  ,  hiVHy  aUnit  the  bloodyes.sel.s 
iM  til.'  in.U.iila.,  hut  may  lie  (nt-  or  \viihin  |>lia>;.KVtic  c-ell.s 

Necrosis     N.^rosis   may  imoUe  tlu-  ,p|een  h.-eaM-s  in  which   the 
l>li««l  'iil>|ily  IS  sudijeiily  cut  off. 


PROORUSIVE  MZTAM0RPH08K8. 


R  generative   Hyperpla.H,a.-Hepeneratiye   hy,Krpla.sia   has  been 

iWh    1,..  MaipiKl.ian  Ihh!„.s  and  the  p„|p  part.Vipate  in  the  pnxWs. 

«l     ,   1„.  .lasx.!  with  the  tumors.  !,,  ,„,,  with  in  .logs  and  has  occa- 
1  ,rMll>  i,.  ,„  s..,.,,  m  „,a„      1,  forms  a  lunlular  mass  the  size  of  a  cherry 

l.Z!'u'    h"      ^'^''>';''-'-,7'  ••"'•"••  f"i'-lv  well  defiiud  fn,m  the  re.st  of 
"•'  >|>i'M,.     It    s  .Kvasionally  surr..mMle<l  l,v  a  Hhrous  capsule 

i.-i::;rlL,ri':,i'"-''''' '""■'  ■"  '"*■  '•""•""■■"  "■"- 

A«  in  th.  ,  a>,.  of  the  lymph-n.Hles.  it  is  difficult  to  draw  the  line  l)etween 
Ha  ,,,,...„.  hyperplasia  of  the  spleen  and  tum.r  formation  andTlier; 

Nk,  Mu„  ,  ,„1  1  .Hi,kn,  s  disease,  whi.h  U^long  ,.,  this  del«tahle  iro"i.d. 

t    i!l.l  l!".l     'x>   *'  ''''"■"  '"  '''"''''"''"  "'"'  P^^-U'Joleukemia  arc 
.      '       <a.     Ihe  organ  may  U-  greatly  enlargi^l.  so  that  i. 

..  l^  ttiukciu.!  .„  pia.vs  and  ,„v.n-,l  with  numerous  shaggy 

•   .'■""li"«  't  to  the  .haphiagm  and  the  neighlwring  struotums" 

'.mi>  are  rm.gnii«»l,le :  the  first  in  which  the  hNTX-rpla-sia  is 

■  •".'    >plttn  pulp,  and   the  secon.l   where  the  Malpighian 

"-   "'v,.lv„l.     In  ,he  first,  the  par^-nchvina  Ls  .soft  and  Wgh" 


Til,' . 
priictic-i 
r("a,|it> 
TIic  i"i| 
a,i|ic>iiii 

TW,.   Ill; I 

nmHiiiil 


11 


V: 


ii 


i       i 


230 


THE  SPLKKS 


ntl  or  mhlLsh-ftnty,  while  tlie  corptuc-les  show  little  ur  ihi  rluttit>r 
Hftiiorrhugic  infarcts  of  roruick-nihle  size  are  not  iineorninoii.  Mim^ 
Mi>|iically,  one  stfs  hyjiercmia  with  hypt'rplasia  U»th  of  thrl  vrnplm*! 
iriU  ami  the  «inn«'tiv«>-tk«(iie  stninia.  In  the  stHi»nd  vari«'ty,  the  Ma|. 
pi^liian  iMMlies  are  ((reatly  enlar)(etl,  forming  whitish,  tumor-liki'  tiiiiv>n 
arrunf{e«|  in  iHMliiles  or  Imiuls.    They  vary  in  size  from  that  of  a  pii 


Kl..    SN 


The  ^plffn  in  tliret*  ilillt>rent  conditiiiiiH,  to  iUiiHtrat«  variatiitrm  in  »ise.  Iron)  l<-it  t>>  nilii 
'I,  nnnnul  aiilren;  '',  typbuidkl  (iilcciii  c,  leukemic  upleen.  (From  the  ralhuhi^iral  Muwiimi 
Mriiill  UniverHly.) 

to  that  of  1'.  walnut.  In  long-standing  cases,  owing  to  the  ovcr^'niwth  uf 
fihroiis  tisiue,  the  organ  iK-conies  fimi  and  the  c-oior  gray,  oftrii  ^trcaktii 
with  brown  or  hrowni.sh-l>lack  pigment.  In  tlie.se  tiiscHSfs  ilif  .-.[ilftii 
nuiy  i)e  tiie  first  and  only  organ  to  lie  afftxted,  but,  as  a  rule.  :iii!ili>pia> 
cliangcs  are  to  Ix-  found  in  the  iyniph-iuHJes  and  l)one-niarr<tw. 

Tlimors. — Tumors  do  not  commonly  involve  the  spletn.  \mm\f 
the  primary  benign  growths  may  be  mentioned  fibroma  and  lymphisgi- 
oma.  Langhans'  has  recorded  a  curious  case  of  angioma  cavemoica 
( angiosarcoma  ?)  in  which  small  secondary  masses  were  present  in  the  liver. 
Dermoid  cyits  are  rare.  Simple  eyits,  containing  clear  or  MoiHl-staiiit^l 
Huid,  may  arise  from  degeneration  of  the  pan-nchynia,  the  iJilutation  »i 
the  lymph-spaces  (Fink  and  Aschoff),  or  from  the  inclusion  "i  inritoiifal 
endothelium  (llengghi'). 

Sarcoma.'-- -Sarcoma  cx-curs  occasionally  as  a  primary  ^.Kiwth,  1  ■! 
is  usually  secondan.-.     A  form  arising  from  the  endolheliiil  plates  ha- 


>  Virch.  Archiv.  fWi:  1879-  273;  see  also  Thiele,  Virch.  Arch.,  17^:  IIKM. 

'  Inaiig.  Diss  Zurich,  1.S94. 

'  t?ee  Jepson  and  AU>ert,  -AnnaU  of  Surgeo',  40:1904:80. 


THE  BONE-MARROW 


231 


Irtn .!« M  rilK!«l."    Mtluotie  Mreom*  not  unromraonly  Uwli  to  mettutases 
in  ilif  -|>Ufn,  which,  however,  are  not  necestsarily  pigmented. 

Otrtinoott.  -rarcinoma  U  invariably  sccomlary  and  arises  either  by 
iiieta.st;i-is  or  tlirect  extension  from  the'stoinach. 


TBI  BONI  MAKEOW. 

Atmtoinicallv  sfn-akinj;,  the  marrow  formi  an  intefjral  portion  of  the 
Ikmics,  m.  thiit  it  is  clittieuit  to  conceive  of  it  as  deUK-hcd  from  tliis  aiscK-ia- 
lion.  Nevertheless,  the  marrow  can  hanlly  Wi  regarded  as  fonnin^  a 
Y&n  of  the  supportinj{  structure  of  the  Uxiy," except  in  s<i  far  as  it  contril>- 
iilcs  t.)  (lie  nourishment  of  lK)ne.  Histolojjically,  its  structure  is  closi-iy 
ukin  Ic  that  of  the  spleen  and  lymph-mMles,  aiid  as  its  main  functi«m 
miiioiil.ttslly  is  to  pnj«luce  certain  types  of  l>l(M»d-cells.  it  seems  mon- 
loKiiiii  to  coasider  it  in  its  physiofogical  rather  than  its  anatomitid 
rt-iutiiiiisiiips. 

IV  Lone-marrow  is  in  its  young  state  soft,  cellular,  and  well  supplietl 
with  lilcMxivfssels.  The  stroma  is  composed  of  branching  coniiective- 
ikstic  .  lis  forming  a  fine  reticulum,  in  the  meshes  of  which  lie  a  great 
variety  of  cells,  namely,  red  blood-cells,  hematoblasts,  lymphocytes, 
ttwiH.j.liiles.  pigmented  cells,  and  multinucleated  giant  cells  (myeloplaxes; 
nrt;»«  i".v(H\  tes ).  The  bloodyes,sel.s  aiv  wide,  thiii-wallc<l,  and  arranged  so 
ihiit  ( nllapse  cannot  (K-ciir.  On  account  of  its  appearance  and  structure, 
this  form  is  called  tiie  rc<l  or  lymphoid  bone-marrow.  He<l  lK)ne-marn)W 
h  prcMiit  in  all  the  Immics  at  birth,  but  gradually  changes  its  character, 
the  ((lis  of  the  stip|M)rting  stnima  l)eing  transform«l  into  fat  {UtMil 
iilwjtiiii  I.  The  color  thus  chang«'s  from  reii  to  vellow,  hence  the  term 
•yellow"  iK.Mc-marrow.  At  aU>ut  the  age  of  puberty  all  the  long  bones 
(■(mtaiM  tins  yellow  morrow.  The  nil  marrow,  however,  persists  into 
a.ivaiK  ( ,!  life  in  the  sternum,  rilw,  vertebrre,  and  skull.  With  old  age  the 
yehmv  fiitty  mar ow  exhibits  serous  atrophy. 

The  fuiietion  of  the  bone-marrow  is  to  produce  blood-corpuscles  and 
to  ahsorli  or  otherwise  render  harmless  foreign  substances  in  the  blood, 
the  jjiaiit  cell.',  just  referred  to  can  also  on  occasion  act  as  osteoclasts. 


OntOTTLATORT  DISTURBAMOIS. 

Anemia.— Anemia  occurs,  out  is  so  claselv  associated  with  regenera- 
tion nt  the  medulla  that  it  is  better  dealt  with  under  the  Progressive 

-Metai:iorpii()ses. 

Hyperemia.— In  hyperemia  the  yellow  marrow  assumes  a  reddish- 
yellow  coldr. 

Hemorrhage.    Hemorrhage  into  the  metluila  occurs  from  trauma- 
tiMH  ai„!  iwni  obstruction  to  the  free  exit  of  blooil  from  the  part. 

'  Hunting,  Univ.  of  Tenna.  Med.  Bull.,  10: 1903: 188. 


232 


THE  BLOOD-FORMINO  ORGANS 


rniMMtuxion. 


Inflammatoiy  infections  so  commonly  involve  the  bone  as  well,  that 
they  are  better  considered  under  affections  of  the  bones  (see  p.  1019). 
The  usual  forms  are  ottMinjeUtii,  meteitetie  abscMiet,  taberenlosii, 
■TpliiUi,  and  leproiy.  Litten  and  Orth'  have  pointed  out  that  in  mam- 
infer  tious  diseases  associated  with  acute  splenic  tumors,  such  as  sepsis, 
typhoid  fever,  fibrinous  pneumonia,  an  analogous  hyperplasia  is  present 
in  the  bone-marrow.  This  has  been  confirmed  for  acute  endocarditis 
by  Ponfick,  and  for  variola  by  Golgi.  In  addition  to  hyperplasia,  fattv 
degeneration  of  the  vessels  has  been  noted,  an  well  as  the  presence  of 
numerous  cells  containing  broken-down  blood-corpuscles  and  jjipnent. 

Mstastatie  Abscesses. — Metastatic  alxscesses  are  found  in  the 
marrow  not  uncommonly  in  septicemia  and  certain  other  iiifectioas 
fevers,  notably  variola. 

Tabercnlosis.— Tuberculosis  arises  as  a  hematogenic  infection  in 
most  c  «s,  and  usually  begins  in  the  cancellous  part  of  the  JKjne.  It 
occurs  also  in  tiie  miliary  form,  in  general  systemic  tul)erculous  infection. 

Sjrphilis. — Syphilis  takes  the  form  of  gummas.  It  is  nm>  in  the 
marrow. 

Leprosy. — Granulomas  containing  the  characteristic  bacillus  have 
been  found. 

RKTROORB88IVX  BIETAMORPHOSU. 

Atrophy. — Atrophy  of  the  bone-marrow  occurs  in  old  age,  in  chronic 
pulmonary  emphysema,  chronic  pulmonary  tul)ereulosis,  chronic  nephritis, 
and  in  death  from  star\-ation.  The  fat  cells  are  gradually  al)sorlH'(i 
and  the  tissue  shrinks.  Its  plaoe  is  taken  by  a  mucinous  fluid,  so  that 
the  marrow  becomes  gelatinous,  translucent,  and  somewhat  hrownLsh 
(Gallertmark).  The  condition  is  identical  with  the  serom  ulrophy  of 
fat  that  occurs  elsewhere. 

Fatty  Degeneration.— Patty  degeneration  of  the  capillaries  and 
medullarj'  cells  is  met  with  in  certain  of  the  infectious  fevers,  nolahlv 
t^vphoid,  typhus,  and  relapsing  fever. 

Focal  Necroses. — Focal  necroses  may  occur  under  similar  circum- 
stances. 


i 


PR00BU8IVE  METAMORPHOSES. 

H]rperplasia.— Hv-perplasia  of  the  fatty  tissue  of  the  marrow  is 
met  with  in  the  generalized  atrophy  of  the  skeleton  that  imi  nrs  in  old 
age.  Not  only  are  the  medullary  canals  enlarge',  but  the  I -one  itself 
l)ecomes  rarefied,  cancollcis,  and  infiltrated  with  fat.     Not  iii'Vtinienilv 

'  Ueber  Vertinderungen  des  Marks  in  Kdhrcnknochen  unter  verRchiiili  urn  patho- 
logischen  Verhijltniggen,  lierl.  kliii.  Woch.,  14: 1877: 743. 


f   ; 


TUMORS 


233 


the  fat  gradually  disappears  and  there  is  a  hyperplasia  of  the  marrow, 
so  that  it  reverts  to  the  more  primitive  form  of  red  or  lymphoid  marrow. 
This  ocuiirs  in  anemia,  leukemia,  chronic  pulmonary  tul)erculasis,  sup- 
purative l)one  disease,  and  cancerous  cachexia.  It  has  also  been  found 
in  many  of  the  infectious  diseases,  such  as  typhoid,  pneumonia,  septi- 
cemia, acute  endocarditis,  and  variola,  also  in  cases  where  death  has 
occurred  after  prolonged  illness.  The  process  begins  first  in  the  long 
bones  and  involves  the  epiphyses  of  the  upper  part  of  the  bones,  grad- 
ually spreading  to  the  whole  medulla.  The  fatty  tissue  is  gradually 
reduced  and  replaced  by  lymphoid  cells  until  the  metlulla  assumes  a 
reddish-gray  or  dark  red  color  and,  in  severe  cases,  the  appearance  of 
raspberry  jelly. 

Microscopically,  there  is  a  great  increase  in  the  numl)er  of  all  the 
marrow  ci-Us,  but  particularly  the  nucleated  red  corpuscles,  suggesting 
that  tiie  process  is  a  regenerative  one.  The  lymphoid  cells  are  often 
fatty,  and  there  are  numerous  phagocytic  and  pigment-bearing  cells. 
Besides  these,  there  may  be  seen  numbers  of  small  octahedral  crystals, 
the  so-called  Charcot-Neumann  crystals. 

Neumann'  was  the  first  to  draw  attention  to  that  form  of  leukemia 
in  which  the  Iwne-marrow  was  first  and  chiefly  affected,  hence  called 
mednUtry  or  myelogenic  leukemia.  The  changes  in  the  marrow  have 
lieen  ngarde<l  as  the  cause  of  the  altered  blood  condition.  Pure 
myelojrenic  leukemia,  that  is,  leukemia  apart  from  marked  i  hanges  in  the 
spleen  and  lymph-glands,  is  certainly  rare,  but  one  instance  has  come 
under  our  notice  at  the  Royal  Victoria  Hospital.  This  occurred  in  a  man, 
aged  sixty-eight  years.  The  bone-marrow  presented  a  marked  rasp- 
herrv-jelly  appearance,  while  the  spleen  was  small.  The  retroperitoneal 
glands  were  somewhat  enlarged,  but  not  more  so  than  in  many  cases 
of  other  forms  of  disease.  The  bone-marrow  is  not  always  soft,  juicv 
and  f.'ciatinous  in  myelogenic  leukemia,  but,  as  Ponfick^' pointed  ou't! 
may  assume  a  grayish-yellow  or  even  green  color,  owing  to  the  great 
increase  m  the  numbers  of  the  colorless  cells  (pyoid  marrow).  Not 
oii^y  this,  but  the  marrow  is  anemic  from  compression  of  the  vessels  and 
mflanimafion  ol  their  walls.  lied  blood-cells  normal  and  nudeatetl, 
fattily  d.generated  leukocytes,  and  Charcot-Neumann  crystals  are  here 
found  IN  vtirynig  amounts.  The  two  forms,  therefore,  s'eem  to  be  but 
variations  of  the  same  condition. 

Ill  pBeudolenkemin  the  changes  in  the  bone-marrow  are  also  variable. 
At  (,ii.'  lime  there  is  hyperplasia  such  as  is  found  in  anemias,  at  another 
lyniphiiniatoiis  nmlules. 

Tumors. -Tumors  of  the  medulla  may  arise  from  the  cellular 
ekimnts  „r  from  the  fibrous  stroma.  Many  of  these  lead  to  rarefaction 
'«  ni«;  l.;.iie  through  pressure  or  the  action  of  osteoclasts.  With  this 
mere  i,  lrr,|uently  a  new  formation  of  bone  from  the  periosteum.  This 
'•>  parii.i.iaily  well  seen  in  the  giant-celled  or  "myeloid"  sareoma,  or  more 
accnn.i.  Iv  myeloma  (see  vol.  i,  676),  which  mav  start  from  the  medulla 


'  llirl   kliii.  Woch.,  14:1877:685. 


'  Viroh.  .\rch.,  56:1 872 :.5.'>0. 


2:{4 


THE  BONE-MARROW 


iiiul  form  a  liirjjp  titinur.  On  tlie  siirfiKr  of  tlir  growth  can  1h'  lilt  thin 
pltitos  of  Iwni'  tliut  give  on  pressure  ii  |N><-uliur  sensation  n-sfinlJini; 
the  cnK  kling  of  an  epg sliell.  Tlierc  is  in  tumors  «)f  tills  kind  a  ttiiilencv 
to  develop  lH>ne  in  their  interior.  Among  the  malignant  growths,  beside 
the  sureoniius,  carcinomH  are  sometimes  met  with. 

.\mong  U'nign  growths  niuy  In-  mentioned  fibroma,  chondroma,  myx- 
oma, and  flbromyxoma.  \"irehow  has  descrilM'«l  a  mvelogenons  angiomt 
of  the  vrrtehne. 


Sarcoma  n(  the  ^huft  uf  the  hiinieni!*.       (Fruin  the  Pathological  Museum  of  Mn.iii  Iiu^frfitv 

Of  these  various  tumors,  sarcomas  are  hy  far  the  most  coininci!i.  .">everal 
forms  are  descrilKtl.  The  most  usual  site  for  their  develoijiiniii  L-  i:; 
the  maxillae  and  the  epiphyses  of  the  long  bones,  especially  ilit  luimrru- 
and  tibia.  They  may,  however,  start  in  the  diaphysis.  In  iln'  farlj 
stag»'s  they  produce  a  gradual  caries  of  the  bone,  so  that  sp^nianei  i- 
fractures  are  not  rart>,  and  eventually  lead  to  great  expaiisioi!  ;!!!'!  n^ 
factir»n  of  the  Iwne.  The  softer  growths  are  round-cellwl,  '^^liile  ^ 
firmer  are  spindle-celletl,  but  mixed  forms  occur.  Of  the  mixed  t}7ie. 
the  most  interesting  is  the  giant-celled  myeloma  (tunuur  ii  /  ,./<i/)/iw.' 


MYELOMA 


23.7 


of  N. JttifiH.  Here  in  the  ground  substance  are  njund,  spimlle.  or 
railed  r.l!>.  with  a  vamng  amount  of  connective  tLisue  and  numerous 
Urjy.  miihiiuicieateiJ  cells.  These  tumors  are  often  ven.-  vascular. 
owin.:  to  the  presence  of  wiile  vessels.  'ITiese  may  give  way,  s<j  that 
heinorrhai.f  and  degeneration  are  not  infref|uent  occurrences.  The 
presem  I  uf  so  much  blood  gives  them  a  bright  r>^l  appearance  that  is 
yjmf'-vh.it  characteristic.  They  are  relatively  lests  malignant  than  other 
form-  "f  -arcomas  in  that  they  clo  not  tend  to  form  meta.sta.se?.  Not 
infrfi|UfiitIy.  masses  and  lian<Ls  of  f*steoid  ti-^iic  or  evt-n  true  lione  are 
frtrni"!  ii-tffjid  sarcoma,  osteosarcoma  >.  Hctn>gn's>ive  changes  are 
not  imroiamon  in  this  fonu  of  tumor,  and  we  meet  with  fatty  degi-neration 
hfiiinrrliiige.  pigmentation,  liquefaction,  and  cyst  formation.  (Xt-asion- 
allv,  till'  gn'iiter  {xirtion  of  the  tumor  may  l»e  tlestroyeil.  Another  form 
i-  tilt-  alveolar  sarcoma,  in  which  the  stroma  isarrangeil  in  alveoli  ct^ntain- 
iiy  m-i-  I  if  relatively  large  celU.  so  that  an  appearance  not  unlike 
r.in'ii!<>:n  i  is  pro<lii(-ed.  An  alveolar  endothelioma  has  l^een  de.scril>e<l 
liv  Uillriith.'  Hill  let  inuid.-  and  Driessen.'  .^^ome,  at  least,  of  these  and  of 
the  iiJM-iilar  ^arciiina-i  «>f  tone  would  seem  to  l,e  secondary  adrenal 
L'rowtli-. 

.\ti  iiitiTe-.ting  form  to  which  much  attention  has  been  p»aid  recently 
i«  mil-  n-i'inliliiig  a  small  round-celleil  or  lymphosarcoma,  the  so-calleil 
myelt-ia.  Tlu'  exact  etiology  of  this  growth  U  yet  a  matter  of  doubt. 
ii'  i-  |inivt-ii  \<y  the  great  numl>er  of  names  that  have  Iteen  proposed 
for  it,  iiainrly,  angiosarcoma.  lytnpho<ari-i>ma.  lymphadenia  ossium 
Niitliii;ii;tl' '.  general  lyinphadetiomatosis  of  Imhic  iWelien.  myeloma 
V,  Ku-tizky.  Kleb-;.  Herrick  and  Hektoen'  .  and  plasmoma. 

Tlir  ].»(uliaritie>  of  this  growth  an'  that  it  develops  usually  in  oM 
|xr-.cii!«.  fiirnis  multiple  apparently  individual  growths  in  different  por- 
liiiii-  lit"  the  Ixmy  skeleton,  and  takes  the  sluijie  of  no»Jule.s  or  ditfust> 
iiitiitniti(iii>  of  soft  consistency.  The  skull,  vertebral  colimin,  and  ribs 
arc  tlir  >ites  of  elwtion.  Multiple  spontaiu-H)!!-;  fractures  of  the  Ixine 
fr(i|iii  iitly  iH'-ult.  .\.s  a  rule,  but  little  new  Ume  is  formetl.  yet  excep- 
tion- u<  this  statement  oirur.  Microsct)pically.  there  is  a  delicate  con- 
iif<(iM.ii,,ue  stroma  inclosing  ma.v^e.s  of  jinall  round  cells  and  present- 
iii!.'  imuurous  large  and  imperfectly  definetl  blmxlvessels.  Wright* 
lia-  |i(>ii;ti(l  out  that  most  of  the  cells  clo'«ely  resemble  "pla.sma"  cells. 
A  I  iiii..u-  point  asstK'iated  with  this  growth  is  the  excretion  of  albumose 
III  i!ii  uiim.'  .Vs  we  have  pointed  out  in  the  first  volume,  the  multiple 
iid  cliardcteristics  of  this  form  of  growth  place  it  among  the 
toiil  formations,  as  a  myelomatosis  rather  than  a  myeloma. 


iialiir 
lihi-r, 


•  I.aiiBiiil  eck's  .Vrthiv..  11:1S69:244. 

■  li<'\itsclie  Zeitsohr.  I.  I'hir..  "1 :  IWU  :2(.;{. 
/.iipler's  I^itr..  12:  lS9.3:t;.i. 

'  i;;t--rnat.  Ikitr.  Fv«t5chr,  :.  Virch^^w.  IVii. 

MtJical  .\e« s,  (w :  1S04 :  239. 
'  15i>st(.n  :s,)c.  of  Med.  Soi..  4- 1900: 19.">. 

■  >i'  IViicc-Joncs.  I'hil.  Trans.  I'.oval  Sk-    1s|s  •  Tart  I  ;  .V). 


236 


THE  BONE-MARROW 


Carcinoma  of  the  bone-marrow  is  invaiiably  sec-oiulary  am]  .-rises  bv 
direct  infection  or  by  metastasis.  Nodular  and  ditfuse  for-....  i.rc  met 
with. 


.'  -I 


i 


i 


Fio.  80 

Jl 

Jls^ 

-T 

ESS? 

^«9MV^'XP!Piii)' 

ri, 

■A 

1 

f% 

1 

Ihe  "ternuin  sud  ribs,  showing  the  location  of  niyeloiiiutous  gtowthn.      (Herri,  k  un.l 
Hektoen'a  caw.) 


FiQ.  CI 


Section  of  myeloma  of  vertebra.      X  600.     (.S.  .Saltykow.) 


SECTION  II. 
THE    RESPIRATORY  SYSTEM. 


CHAPTER    XI. 

TflK  KESPIKATOKY  FrXfTION  AND  ITS  niSTnUJA.\CE.S. 

Ix  (liscussinj;  tlip  broad  pathology,  as  distinct  frt)m  the  pathological 
histolojiy,  of  the  mspiratory  system,  we  have  to  keep  constantly  before 
us  the  |)rimary  function  of  that  system,  namely,  the  intake  of  oxygen 
ami  the  discharge  of  carlwn  dioxide  for  the  benefit  of  the  economy.  All 
other  fiiiH'tions  are  in  comparison  of  minor  importance.  Strictly  speak- 
in};,  r(s|)iration  is  concerned  with  the  whole  problem  of  gaseous  inter- 
change, not  merely  l)etween  the  system  and  the  external  medium,  but 
also  iM'twfcn  the  bi(KKl,  the  internal  vehicle,  and  the  tissue  cells. 

Internal  Respiration.— This  latter,  the  internal  respiralion,  we 
can  l)ut  glance  at  incidentally,  although  it  is  the  process  to  which  the 
otiur  is  subservient.  The  data  regarding  the  conditions  in  which  oxygen 
exists  ill  the  blood,  the  avidity  for  it  exhibited  by  the  hemoglobin  of  the 
entlinKvtes,  its  entrance  into  combination  with  the  same,  are  known 
to  even  first  year  student  of  me<licine.  But  of  the  processes  occurring 
in  the  capillaries  governing  the  discharge  of  the  oxygen,  of  its  entraiuv 
into  the  tissues  and  into  the  crlls,  and  of  the  changes  undergone  in  these 
cells  \v(  know  singularly  little. 

The  arterial  bloo<l,  we  know,  is  almost  saturated,  but  not  quite,  with 
oxvjrcii,  i,„r  is  this  wholly  uswl  up  in  the  circulation  through  the  tissues; 
even  in  the  last  stages  of  asphyxia  some  oxygen  can  still  be  gained  from 
the  lildiMJ.  In  other  words,  the  blo<Kl  carries  more  oxygen  than  is  neetled 
hy  the  tissues.  Some  of  this  oxygen,  but  only  a  small  portion,  would  .seem 
to  1111(1, !;;()  direct  reduction  in  the  ml  corpuscles,  with  production  of 
earlxm  .lioxide.  This,  however,  is  but  an  inconsidemble  fraction  of 
the  caseous  interchange.  We  possess  abundant  evidence  that  the  active 
interelia!ii;e  occurs  in  the  tissue  cells.  These  have  an  inten.se  aviditv 
for  oxy-eii,  and  take  it  up  from  the  surrounding  blood  and  Ivmph— 
nav,  iiini, ,  are  capable  of  storing  it  to  some  extent,  for  it  has  been  shown 
that  MiiHcie  and  oiher  tissues  are  capable  of  active  metabolism  for  some 
little  jM  iiixi,  ill  an  atmosphere  deprived  of  o.xygen,  or  when  transfused 
with  owm  ii-free  saline  solution,  and  during  this  metabolism  they  dis- 


238     THE  RESPIRATORY  FUNCTION  AND  ITS  DISTURBANCHS 

charge  abundant  CO,.  The  appearance  of  ^hicu^e,  lactic  aciil,  ttc. 
in  the  urine  of  animals  kept  upon  an  insufficient  oxyp-n  .su,)|)l\,  indi- 
cates  tliat  the  oxygen  thus  taken  into  the  cell  in  excess  enters  there  into 
loase  chemical  combinations,  and  that  when  this  store  of  oxygen  is  neeiird, 
and  there  is  continued  discharge  of  CO,,  these  IxNlies  also  iHtninc 
dischargtHl  from  the  cells.  I'ltiraately  the  amount  of  oxygen  removed 
from,  ami  of  CO,  afforded  to  the  capillary  blood,  depends  upon  (lie  rela- 
tive  tension  of  the  two  gases  in  the  blood  and  tissue  cells  res|)eetivilv; 
but  of  the  stages  whereby  the  combine<l  oxygen  of  the  erytlmKviis 
Ix-comes  lil)erati-d  into  the  surn)unding  plasma,  and  thence  passes  tii  ilie 
lymph,  and  thence  to  the  tissue  cells,  our  knowledge  is  minimal.' 

Ixtemal  Respiration. — In  connection  with  this  we  have  tn  puss 
in  review:  (1)  ] )isturl)ances  in  the  mechanism  when-by  jiir  pins 
entrance  into  the  lungs,  and  their  effects.  (2)  I  >isturl>ances  in  tlic  air 
sacs  of  the  lungs,  the  medium  of  gaseous  interchange  between  ilie  air 
ami  the  bloo<l,  and  their  effects.  (3)  Disturbances  in  the  coni[)()sitioii 
of  the  air  entering  the  lungs. 


THE  RESPIRATORY  ME0HAHI8M. 

This  may  lie  dividetl  into  four  parts:  (1)  The  air  psissages;  u')  the 
muscles  of  respiration;  (.})  the  pleural  cavities;  and  (4)  the  m'r\ous 
mechanism. 

The  Air  Passages.— I'n<ler  these  are  to  be  included  the  wliole 
tract  from  the  external  nares  to  the  terminal  brou'  n  oles.  Tlicso,  it 
will  l)e  recogniztnl,  are  of  considerable  length,  and  their  effect  upon  the 
air  passing  down  them  is  that  with  normal  respiration  it  enters  the  air 
sacs  (a)  at  the  bo<ly  temperature  instead  of  at  that  of  the  exteriiul  air; 
{!>)  impregnatcfl,  if  not  saturated  with  moisture;  and  (r)  devoid  of  dust 
ancl  foreign  particles,  ami,  as  a  consequence,  sterile. 

A  multiplicity  of  mechanisms  brinj;  about  these  results,  and  distiirli- 
ances  of  any  one  of  tiiem  tends  to  modify  the  (piulity  of  the  air  >:ainiii}; 
entranj'e  to  the  air  sacs.  The  nasal  passages  are  factors  of  liij:li  iiii[M)r- 
tance;  the  wide  surfaces  of  the  turbinatt"*!  lH)nes  are  of  {M'culiiir  >(  niee, 
lx)th  in  warming  the  iiispinnl  air  after  the  manner  of  radiator^,  and  in 
imparting  moisture  to  the  same.  To  a  considerable  extent,  uUk  these 
moistened,  somewhat  glairy  surfaces  detain  foreign  particles  present  in 
the  air  passing  over  them.  It  cannot  be  tcK)  strongly  emplia>i/i't|  tbt 
persistent  mouth-breathing  is  harmful  in  that  it  favors  the  air  interinf; 
the  air  sacs  l)eing  defi<-ieiit  in  each  of  these  respects.  Ifenec.  it  favors 
irritation  of  the  lower  air  passages  and  of  the  lungs,  with  resultant  iiiHam- 
mation.  Such  mouth-i)reathing  results  from  n.isal  obstruction  nt  >evi:al 
onlers — congenital  narrowness  of  the  nares,  ae(|uired  .stenosi--  nf  these 
passages,   fn>tn    trauma,   ehnmic   syphilitic   and   other   inH;ii!:ii:atiom, 


'  For  tlic  main  data  liearing  upon  the  internal  n'spirution,  see  PcmiI>' 
on  Kespiration,  in  Scliafcr's  Physiology,  vol.  1 :  p.  7H0. 


'<  article 


THE  PHARYNX 


239 


acute  ati<l  subacute  catarrh  with  excretion  of  abundant  thick  mucus, 
the  presence  of  overgrowths  and  tumors  within  the  nasal  passages,  most 
commonly  of  mucous  polj-ps  in  the  posterior  nares  and  of  adenoids 
in  the  imsopharynx.  These  last,  occurring  in  childhood  and  arresting 
the  function  of  the  nose,  arrest  also  its  due  development,  so  that  even 
after  ninoval  it  may  happen  that  the  passages  remain  abnormally  small, 
and  nasal  respiration  is  not  as  free  as  it  should  be.  The  result  in  alj 
these  cases  is  a  peculiar  liability  to  inflammation  of  the  throat  and  lower 
respiratory  passages,  increased  susceptibility  to  infection,  and  in  children 
a  distinct  delay  in  bodily  and  even  in  mental  development.  Your 
mouth-l.reathing  child  not  only  looks,  but  actually  is,  more  stupid  than 
the  average  of  normal-breathing  children. 

The  condition  of  the  inspired  air  may  also  affect  the  nasal  passages 
and,  intliiencing  their  function,  adversely  affect  the  lower  respiratory 
passages  and  the  lungs.  The  nasal  mucosa  is  distinctiv  sensitive,  with 
abundant  vascular  supply  and  rich  supply  of  mucoas  gUnds.  Extremes 
of  tem|)erature  of  the  air.  the  presence  of  irritant  gases  and  particles 
induce  congestion  and  inflammation  with  relative  facility,  an  inflamma- 
tion ciiaracterizetl  by  abundant  mucous  discharge.  That  discharge 
would  appear  to  have  several  fimctions;  it  protects  the  underlving  epi- 
thelium; washes  off  and  dilutes  irritant  substances,  and  is  to  some  extent 
bactcnculal,  addwl  to  which,  by  its  physical  constitution,  it  am-sts  the 
pjusape  and  spread  of  bacteria. 

If  chronic  and  long-t-oiitinued,  catarrh  is  apt  to  be  followed  bv  atn-phv 
of  the  nasal  mucosa.  .Such  alrophir  rhinlt!.-,  being  acc«)mpaiiie(l  b"v 
reduction  of  discharge  and  direct  lodgement  of  irritant  particles  on  liic 
nasal  mucosa,  favors  ulceration  and  deep  inflammation,  and  as  reganis 
the  lower  respiratory  passages,  from  pressure  of  irritant  IkkHcs  in  the 
inhakxl  air,  and  from  relative  lack  of  moistening  of  that  air,  tends  to  pro- 
duce nsnlts  similar  to  those  brought  alx)ut  bv  mouth-breathing. 

The  Pharynx.  -The  moist  surface  of  the  pharvnx,  together  with  the 
sudden  Innd  ni  the  direction  of  the  stream  of  inhalwl  air,  converts  this 
mw  particularly  into  an  adjuvant  apparatus  for  removal  of  dust  an,i 
0  licr  ijarticles.  It  can  be  demonstrate<l  experimcntallv  that  if  a  current 
of  air  impinges  upon  a  moist  surface  at  an  angle  of  45°  or  thereabout 
;  'leiiv.rs  up  to  that  surface  the  majority  of  its  contained  solid  particles' 
he  nnuous  glan.ls  of  the  pharyngeal  mucasa  provide  a  m^hanisni 
•nl.v  this  surface  is  kept  continually  moisteneil.  and  the  abundant 
i}n.pl,-j:h,n.ls  of  the  tonsils  and  pharyngeal  roof  constitute  a  further 
jmmrtiv,.  nmhanism.  That  they  function  in  arresting  pathogenic 
l«i<t.rm  is  „„l„.ate.J  by  the  acute  tonsillitis  which  is  the  first  active 
sympto.n  .1,  so  many  diseases  which  we  regaitl  as  air-l«rne.  notablv  the 
ant,"  ,A,,„th,.mata  Although  the  diphtherial  membrane  mav  ihow 
"sut  primarily  m  the  nasal  pas.sages,  or  upon  the  back  of  the  pharvnx 
'•'-r  iLe  tonsils  that  it  most  often  makes  its  first  app«'arancc 
raatorv  "i"  .  .K^^'^hs  of  the  upper  part  of  the  pharvnx,  inflam- 
^m  a  ul  neoplastic  growth  of  the  tonsils,  of  neces.sitv  obstruct  the 
passap  „t  :.,r  to  a  greater  or  less  extent. 


It  l,s 
.\deni  pji 


24()     THE  RESPIRATORY  FUNCTION  AND  ITS  DISTURBANCf:S 


} 


I 


Steitor. — Yet  another  form  of  obstructed  breathing  is  brouf;lit  about 
hv  '.OSS  of  tone  or  actual  paralysis  of  the  muscles  of  the  soft  paliitc-  that 
I'orm  of  stcrtor  known  as  atutring.  As  the  reader  may  detenniiif  for 
liiiaself,  three  factors  are  necessary  to  produce  this,  namely,  a  flaccid 
soft  palate,  a  combination  of  mouth-  and  nose-breathing,  and  rclativelv 
deep  inspiratiutis. 

'1  he  other  forms  of  stertor  may  here  be  noted  in  passing.  They  ut: 
(2)  N(u»l  stertor,  seen  in  apoplexy,  with  paralysis  of  the  muscles  of 
the  aid*  nasi,  the  inhaled  air,  as  in  sniffing,  drawing  the  aln>  a^i  °  ist  the 
septum.  (.3)  Buccitl  stertor,  or  puffing  out  and  flapping  of  the  cheeks. 
This  may  (Krur  in  ca.ses  of  paralysis  of  the  facial  nerves,  or  again,  an  in 
the  snoring  sleeper,  from  flaccidity  of  the  mu.scles  with  partial  closuir 
of  the  mouth.  (4)  Pharyngeal  stertor,  flue  to  falling  back  of  the  \me  of 
the  tongue  with  obstruction  to  the  laryngeal  entrance.  (5)  Lurifngral 
stertor,  heard  most  commonly,  according  to  Lister,  during  ciih)rofonn 
inhalation,  and  also  in  paralysis  of  some  of  the  muscles  influciiciii);  the 
v(X'al  conls;  and  lastly,  (G)  Mucous  stertor,  due  to  the  bubbliri);  of  air 
through  mucoid  fluid  in  the  larger  air  tubes.  Of  this  nature  is  the 
"death  rattle."  As  pointed  out  by  B<iwles,  most  of  these  can  Ik'  pre- 
vented by  altering  the  posture  of  ihe  individual. 

The  Luynz. — Two  main  functions  are  to  be  ascril»ed  t»)  the  lartax— 
phonation  and  the  provision  of  a  firm  base  for  attachment  of  the  epi- 
glottis and  control  of  its  movements  in  the  act  of  swallowing;.    As 
rcganis  the  former,  it  has  to  be  admitted  that  thephysiolog^yand  patliologj- 
of  voice  pnMluction  lead  us  so  far  I'rom  the  main  object  of  this  chapter 
— that  of  discussing  the  disturbances  of  respiration  and  their  naliire— 
and  constitute  in  themselves  .so  large  a  subject,  that  here  we  can  at  most 
call  attention  to  them  parenthetically.     We  would  recall  that  the  larvnx, 
essential  for  the  singing  voice,  is  not  essential  for  speech;  that  .s|)ee(h 
is  possible  after  the  complete  extirpation  of  the  larjnx,  aItlion(jh  then 
it  is  hollow,  and  little  more  than  a  whisper;  that  variation  in  the  "note" 
of  the  voice  is  determined  by  the  tension  and  con.sef|Uent  rate  of  vil)rdtion 
of  the  vocal  cords  and  communication  of  the  waves  thus  set  up  to  the 
issuing  air;  that  thus  to  this  extent  the  voice  is  affecteil  by  patholopVal 
conditions  of  the  vocal  cords;  that  the.se  pathological  conditions  ranj.'e 
tlicniselves  into  two  groups:    (1)  The  nervous,  excessive  stimuli  leading 
to  spasmodic  contraction  of  the  intrinsic  laryngeal  mu.scles,  with  ciosurp 
of  the  laryngeal  aperture;  defective  or  arrestetl  stimuli,  leading  to  Haccidit} 
and  paralysis  of  the  vocal  cords  with  lack  of  the  finer  vibrations;  ami 
(2)  intrinsic  disturlmnces  of  the  cords,  either  diffu.se  or  locali/cil  inflam- 
matory thickening  of  the  same,  or  the  development  of  tumors  upon  them; 
by  each  of  these  disturbances  the  cords  become  "muted;"  that  the 
"timbre"  of  the  voice  depends  upon  the  various  resonatiiii.'  cavities 
communicating  with  the  main  air  .stream,  upon  their  size  and  tiir  freedom 
of  communication,  upon  the  lungs  and  thoracic  cavity,  the  lar)neeal 
.sacculi,  the  sphenoidal,  frontal,  ethmoidal,  and  antral  sinust  >,  etc.,  as 
also  upon  the  extent  of  development  of  the  palatal  arch;  that  variation 
in  the  development  of  these,  obstruction  of  their  orifices,  iiiliniimatoir 


J 


Tin:  TRACHKA  AM)  BROSCHt 


241 


and  otiiir  conilitioas  leailinK  to  the  a<fiiiniilation  of  lic|ui<l  or  solkl  matter 
ttithin  the  cavities,  materially  affett  t\w  resonance  of  the  voire;  that 
nrtmdntmn  is  dependent  upon  the  lips,  teeth,  palate,  and  tongue,  and 
this  Ls  niiiterially  affeetwl  either  hy  eonjfenital  or  acfjuired  defects  in  these 
orpms.  or  hy  paralysis  of  the  muJwIes  of  the  lips,  tongue, and  lower  jaw. 
We  an-  apt,  on  first  thought,  to  rife  the  cros.sing  of  the  respiratory  an<i 
alimentary  tracts  as  an  example  of  evolutionary  imperfection  "  Un- 
(loul)tc<lly  it  has  its  «li.sa<lvantages.  With  imperfi-ct  action  of  the 
lamix  or  ilisease  <»f  the  epiglottis,  foo<lstuffs  mav  gain  entrance  into  the 
trachea  and  lungs;  with  paralysis  of  the  soft  palate,  such  as  is  apt  to  occur 
after  (liplithcria,  fluitis,  instead  of  In-ing  swallowetl,  mav  pour  into  and 
throiicii  the  naifs;  the  infant  suffering  from  obstructive  nasal  catarrh 
(anni)t  suckle.  But  this  same  infant,  under  the  same  conditions,  were 
there  m  alternative  respiratorj-  channel  through  the  mouth,  could  not 
lireathe;  and  when  we  come  to  consiiler  the  se<-ondarv  employment 
of  the  orpins  of  mastication,  of  the  mouth  and  mouth  parts  for  articula- 
tion and  .s|K'«rh,  it  may  lie  regarded  as  at  least  doubtful  whether  man. 
as  a  coininiiMicative  animal,  does  not  to  a  ver\-  great  extent  owe  his  posi- 
tion ill  nature  to  the  utilisation  of  this  apparent  imp«>rfection. 

Tlie  iiHW  «-<rnt  studies  u[M)n  deglutition  indicate  that  the  epiglottis 
IS  to  Ik-  rcgimle«l  as  an  adjuvant  rather  than  the  essential  organ  in  prc- 
yentiii;:  the  entrance  of  fixMlstuffs  into  the  larvnx  during  the  act  of  swallow- 
mi!.  Tins  view  issup|K)rted  by  the  fact  that  in  tertian-  svphilis  more 
iwrticulariy,  as  agam  after  extensive  tul)erculous  ulceration,  there  mav  lie 
niost  extensive  erosion  and  destruction  of  the  epiglottis,  ami  this  evidentiv 
of  biv-slaiKling,  and  without  <.Kser\wl  suffcK-ative  attacks.  During 
>wail()«in;r,  that  is,  the  laryngeal  entrance  is  raised  uiuler  the  liackward 
|m.j,rtin;;  root  of  the  tongue,  so  that  the  IkjIus  of  food  or  stream  of 
HukI  passes  well  U'liind  it. 

r-astiy,  it  has  to  Ix-  noted  that  the  passage  through  the  vocal  conis 
constitutes  the  region  of  gn-atest  narrowing  of  the  main  respiratorv 
passap..  Here,  therefore,  the  slightest  grade  of  narrowing  bv  anv  caii.si- 
--spasnuHhc  contraction,  inflamnmtorv  dejxisits,  new-gn)"wth  '  etc  — 
pro,  ue.s  r.!ativcly  the  most  obstruction  to  the  respiratorv  act.  Hut 
tiM-  Ian  MX  as  a  whole  is  a  n'gion  of  narrowing  of  the  passaLre,  ami  thus 
arnvtmiis  of  the  glottis  in  p-neral  an-  liable  to  induce  grave  obstruction. 
■uorc  es,„.,.,a||y  the  I.kwc  attachment  of  the  muco-sa  (save  over  the  vcK'al 
"WM  renders  conp-stion  aiul  ,edenui  a  not  uncommon  event,  cither 
•'>  tiie  ivsnit  of  trauma  or  other  irritation,  of  infection,  or  rarelv  of 
.•iiKionrm„t„.  ty|H-,  as  one  manifestation  of  the  tendencv  to  local  cwlenia 
Ml.  ,le,,  .jevelopment  and  unknown  causation  which  mav  attack 
'""vuiual  portions  of  the  <Iigestive  an.l  respiratorv  tracts.     In 'all  these 

S',,'  ;'»•  'IT'  °^""I*^  °^  ^''^  '"'^■"•^'  "'*•  »"P'Kl"ttic  an<I  arvteno- 
S,!  '  tV'"^  ""''  ^rxvo\s-^\,  an.l  may  by  their  swelling  caus^  such 
f,.r,n  i'"^  '  ■  '  P'''"*''*K*'  ''"if.  unless  intulmtion  or  tracheotomv  \k  per- 
'"nn...|.  ,|,,„h  may  ensue  from  asphvxia.  ' 

The  Trachea  and  Bronchl.-Heyon.i  the  larynx  the  respiratorv  pa.^sage 
«'"«>>i^  ;.:.nM  ,„t„  ,|u.  tra<-hea.  which,  it  may  Ik"  noted,  i.s  not  of  imiform 


242     TIIK  RKSPIRATOHY  FUNCTION  AND  ITS  DIHTVHfiASi  ts 


\ 


if 


(liamrtor,  but  armrilinK  to  thr  meaHiirrtncnt^  of  Rniiinp  an<i  Siahrl' 
M  at  iti  broadest  about  half-wav  Itetwei-n  the  larynx  and  the  |M>in(  of 
bif urcatior. ,  slowly  narrowing  below  this.  The  transverse  section  of  thr 
larger  bron  'hi  is  again  greater  than  that  of  the  Itiwer  emi  of  lh<-  Imchra, 
arol  greater  than  that  of  the  combined  smaller  bronchi.  The  result  of 
these  variatioat,  both  in  the  shape  and  the  transverse  section  voliimrnf 
the  respiratory  pa.ssages,  must  necessarily  be  to  intermingle  tiic  (litfercnt 
portions  of  the  inspired  air-stream,  and  so  favor  all  [Mirtions  of  tluit  stn'am 
coming  into  contact  at  oi  e  or  other  point  with  the  walls  of  the  clmnnt-l. 
There  are,  indt>ed,  indit*ations  that  the  stream  eventually  ac(|uin\s  n  spiral 
iikstead  of  a  direct  motion.  The  moist  ciliated  surface  which  rxtrixis 
from  the  larynx  to  me  terminal  bronchioles  thus  temls  to  arn>.si  siKh 
.solid  particles  as  have  munageii  to  pass  the  upp<>r  respirators-  |>ii.s.sa)!(^, 
and  through  the  action  of  the  cilia  these  arv  pH.s.sed  iipwurd  to  Ik-  exptlltij 
through  the  larynx  by  an  act  of  coughing.  An  adjuvant  in  tlu>  removal 
of  matter  are  leukocytes  which  migrate  on  to  the  free  surfai-e,  und  either 
become  expectorated  or  wander  liack  into  the  lymph-glands,  notablv 
into  the  group  Ix-low  the  bifurcation  of  the  trachea. 

Despite  the  mechanism  of  cartilaginous  Imrs,  by  means  of  which  thr 
trachea  and  bronchi  are  kept  patent  and  at  the  same  time  inoMlc.  there 
may  be  hindrance  to  pa.ssage  of  air  thnnigh  them  either  from  1 1 1  the 
entrance  of  foreign  bodies,  (2)  inflammatory  deposits  or  contraction, 
(3)  new-growths,  or  (4)  pressure  fn)m  without.  The  l.ist  may  lie 
variously  pnxluced  by  aneurism,  goitre,  mediastinal  tumors,  piilargnl 
tuberculous  lymph-giands,  and,  very  passibly,  by  the  eiila''ir«tl  th,vtnii<. 
Regarding  the  capacity  of  the  enlarged  thymus  to  prodix  linnt  ctmi- 
pres.sion  of  the  trachea  in  the  striking  and  fatal  con<litii>..  known  a> 
thymic  aithma,  there  is  still  deltate.  The  sudden  on-set  of  the  (Ivspncra 
and  the  stridor  suggest  spa.sm  of  the  glottis,  and  although  in  these  (uses 
postmortem  exitinination  reveals  an  enlarged  thymus,  then-  is  no  sipi 
of  narrowing  or  distortion  of  the  trachea.  Nevertheless,  it  may  lie 
urgt-d  that  the  thymus  of  young  children  Is  a  very  vascular  orpin:  thai 
a  sudden  congestion  may  greatly  increase  its  size  and  the  pressure  thai 
it  exerts  upon  the  trachea  where  this  passes  through  the  narrow  orifice 
of  the  chest;  and  that  such  sudden  compression  cannot  U-  ex|i«'cteil 
to  show  permanent  effects  upon  the  tracheal  tube.  Crrtain  it  is  thai 
recent  cases  are  on  reconl  in  which  the  operative  removal  of  t'n'  thynm- 
during  paroxysms  of  this  form  of  spasmo<iic  dyspnoea  have  Ihi  n  fnlloweil 
by  marked  disappearance  of  symptoms.  We  have  encoiinliTtd  similar 
paroxysmal  attacks  of  dyspnoea  in  cases  of  goitrous  enlargement  of  the 
middi.'^  lolje  of  the  thyroid  which  could  only  lie  ascrilietl  to  i  nnpe^tion 
and  accompanying  increase  in  size  and  pressure  of  the  goitnui-  inas>. 

Of  peculiar  interest  are  those  forms  of  obstruction,  win  iitr  of  the 
larynx,  trachea,  or  bronchi,  which  assume  a  valvular  natiin  [Krraittiiii' 
free  iaspiration  or  expiration,  hut  not  Iwth.  Thii«,  "•■!•  ':i  of  the 
glottis  or  a  polypoid  tumor  in  the  glottis  will  ot>struct  in-iiralion.  as 


'  Herichte  d.  K.  .Siichs.  Gesell.  d.  Wins.,  Math.  Thys.  ("I.,  Iv^' 


ASTHMA 


243 


.ill  «...  a  Knm-  h  of  th..  wall,  projecting  (mcu  a  smaller  i„U,  a  laric-r 

MW:M  l>elow  the  VfKP..  ronl,.  ^ilj  permit  inspiration.  I.ut  a.t  as  i  vi.f 
vuUr  ,,!,.«  preventmK  expiration  a,  may  also  an  enlarx^l  an.|  ,«.rtlv 
.iet«-  n  tulH-rculoas  (ihrnl  or  other  tumor  in  this  re^on  proje^tinL  in  I. 
one  of  rli.larjter  bronchi  at  the  root  of  the  lunjts  '"k  mm 

V.-.  aiM.iher  f..rm  of  obstnirtion  is  as.sociat«l  with  brr,nchial  narrow- 
u^f.  na-mly.  uthin..  Fhe  symptoms  hen-  point  verv  .lefini.elv  to  a 
.pasm..h,.  nurrowms  o  ,he  l.ronrhi;  the  extreme  jfrnde  of  distension 
of  th.-  lunuN  .levelop«i  „unnK  the  attack  indicate  that  through  the  act  v" 
,..p.ra„.ry  efforts  «,r  «  suckcJ  into  the  alveoli,  but  with  expimth  n 
«nn..  U.  expelU.1  to  the  same  extent.  Evidently,  also,  the'^  wh I 
l.n.n.l,.a  tree  is  simultaneously  involve,!,  for  all  the  lobe,  of  l«th  lunj. 
m  s„„,.l.aneoasly  expamled.  The  sudden  oaset  of  the  condition  a^ 
^».Mh,  .leparture  in. hcate  a  nenous  ori,nn.  that  the  coalition  i^[Zu^ 
'h;an.l.asa  ina  tero  fact,  it  has  fx^n  ol^er^ed  that  in  manv  s»s"vp,  S^ 
>uhje...s  partKular  .xlojs  and  surroundings  in.luc*  the  condi  on  wh  le 
h.«.  .s  ,„  some  a  small  area  of  the  po^teric-  and  upp-r  portio"  o    the 

lirri'"'.  ""'*"!?  "'i'*'^"''  .'"•''"•-^  ""  asthmatic  attack.     vJriZ 

.yn  .  lune  iKH-n  adduced  to  explain  the  development  of  -'     .on.liti. ,.  - 

hat  I,  „  ,|„e  ,o  spasm  of  the  bronchi . I  muscle  sheath:  tl,.a  it"  ' Z  ,.. 

&i..r'  r    r  "'  ''"■  ^'"""•'''"'  "~  membrane  n-ni:  I 
1    i         I  • '.      l!  '  ""*"•'■  ""^"^  "  '^  «  ^P«'«'  '«™  of  inflaminatiot 

IT,.,  /  ,V  "'■*'':^"'">r  «^  'he  lu.^^s.  rurs«hmann's  theon' 
.Ki,  ..,,1  ),v,„  have  brought  for^tanl  stroi^r  evi.iencr  in  favor  of 
ml     .„.  Mccr,  that  the  vagas  ..ontains  motor  fiU-rs  for  the  br.  nch    i 

n     !  ?  are  of  serx-K^  in  a.sthma  are  just  those  which  bv  cxp.T 

'       ■■    '  H.-nnme.l  cause  paralysis  of  the  ner^•c  endin,..  and  T'l  t 

Rss  „.„  i-       r,S.;Z'";"*'i  ""  the  .s>-mptoms  of  all  c„s,.s.     Thcv 
ihel. ,;    X   ;;: '^  ''■''•'"'^  ^f"^'''-  ^-^le  not  primary,  ncvc^- 

kn.m„  ,1,       I  has  b«-n  no  attack  for  a  lonp  peri.Hl.     .^s  is  well 

nh   of  the  bronchial  mucous  membrane.     But,  as  every 
'  Trana.  Path.  Soc.  I^nUon.  .V»:  l!Kt3:ir. 


the 


vaxi 


241     TIIH  RKSPIRATOKV  FiSCTIOS  AND  ITS  hUrrdHHASt'lM 


n 


iki     I 


I! 


oiH'  kiKiwH  who  has  .Htu«lir«l  s«rtiofts  of  tlw  liinip  in  m-iitp  hmncfiirH, 
thill  iiiuctiiit  meinhrHiH*  i^  highly  vuM-iilHr.  AtiinittiiiK  fnn>ly  iluit  i\w 
(iimlitioii  is  l)rou){ht  aUmt  hy  n-fU'K  iwhoim  .H(imiiliitif>ii,  u>  uImi  tin 
vitliM"  of  HnMiie  inri  Pixoa's  olw«Tviili«M>.s,  wf  Nlill  caiiiiut  l)ui  (<iii,i,|,.r 
tli:it,  ill  one  onlrr  of  vaaen  at  fcvi^t.  the  alxintlniit  exuilatiMiml  thf  >iiiiiliii'. 
ity  of  tlM'  caiisHtivi'  fwton  to  iIhisw  wtii  )i|)«Tutin);  in  hiiy-f«'v<r  ^ii^gpsi 
(hf  nn'MtfMi'  of  n  MniilMr  iitiKtoiifiirotic  iisicina. 
Tb«  Q«B«ral  Iflsets  of  Obttniction  to  the  Air  PMMgei.    it  ;> 

■si-ant'  iMK-t'S-sary  to  .statf  that  c-«>tii|>U>t«>  olMtruction  of  tin*  air  [mssinj., 
for  iiHHt*  than  n  few  niiniilfs  i-iids  in  ilratii  hy  asphyxia.  If  ihi'  olt^iriK  lion 
Im  iiH-<irii|>l«'t«-,  th«-ii  aw'onlinj'  to  its  natim*  do  w<-  KimI  ••ithcr  iii-ipiraiiirv 
or  «'\|Mrtt«<>ry  ilyspim'a,  <>r  Ixitli,  ami  iHfonlinj;  to  it<  «li'j;rp»'  do  wv  lm\f 
citht-r  dc  ith  l>y  pn>)^'s.sivi-  slow  .siitT(M*atii>ii,  or  a  rcMiiirkuMc  iiilii|itiitiiiii 
of  tlu-  rispiration  and  of  the  JMNlily  activities  in  f(fiH-nii  to  ihr  Ir-Miml 
supply  of  oxygiMi.  With  obstruction  to  inspin«tion,  the  n-spiriilon  art- 
Iwcomc  slow  and  InlMjnHl,  and  not  only  art'  tli«-  diaphrajj'"'"'''  "'nlrac- 
tions  d«t'|H'r,  imt  also  the  accessory  inHs<'lcs  of  respiration  m-  ("allnl 
into  play,  so  as  to  secure  the  jjn'atest  extent  of  tlionn  U-  etil  riiciimii 
In  inarktHi  contrast,  the  expirations  an  short  and  not  lalxm-d.  I'lu  >Mift 
|)as.sa)^'  of  the  air  through  a  narrowed  jmssap;  leads  to  iii^|>iratiir>  ?Ti4or, 
The  n>verse  is  the  case  in  expinitoi>  olwtniction.  Here  it  i-  the  v\\,i  mn 
that  Is  slow  and  labored;  the  acievsory  innsc-les  calletl  into  play  arc  hiw 
which  most  nxluce  the  thoracic  capacit  ,  iiotaMy  the  alxloiniiial  iiniylf« 
and  those  liending  the  vetiebral  cohiniu,  briiifnng  the  ribs  inure  ( lity  m 
i-ach  other. 

Wierc  only  one  main  l.ronchus  is  dI.  riK'ttsI  the  n-siilts  arc  ilitWiit: 
a  }MTiod  of  rapid,  not  to  say  tumultuous  respiration,  is  fdll.ivvtt!  In 
itHJiiutions  of  ailaptation,  the  one  luiij;  Ikmiij;  ca[Hd>le  of  |HTt'onni]!;' 
the  functions  of  both.  The  rapid  irrepilar  respiration  may  U'  axrilitii 
to  the  differi'nt  peritxis  at  which  the  va^ds  inspiratory  ami  i  \i)initiin 
stimuli  an'  initiated  in  the  t\=ii  lunj»s  (s«'e  p.  24N  et  seq.). 


THE  MUSOLEI  Or  REIPIBATIOM. 


'       i 
i 


In  onliii.iry  <piict  lireathin^  the  expansion  of  th«'  IntiKs  in 
is  iin  active  priKcss,  expinitioii   iH-inj;  larj^-iy,  if  i        eiilir. 
dm-  to  relaxation  of  the  diaphrapn,  and  pressiin-  iipwani     I 
iiial   visceni    under  tlie   normal   alMlominal   tension,   and  to 
rti-.ictioii  of  the  distended  lunjr-  and  of  the  tlioracic  mnsciiht 
ill  cliildn-n  of  txith  sexts.  ami  in  tlie  adult  male,  the  ilistt  i 
hint's  ill  inspiration  is  in  tiie  main  liroii^'st  about  '  ■  coiitr 
iiiaphr,tt;m.      i'he  ine  of  corsets,  and  that  onl;. ,  would  seti 
tile  diaphra<;ii  iitic  activity  and   cans*-    inspiration  of  tlie  ■ 
Woiiieii  who  do  not  employ  corsets  are    .lund  to  exhiiiit  li 
mail*   ty|H'  of  inspiration  iiHlistiiipiislialtk-  fMim  that  of  men 

Hut  while  the  contraction  of  the  iliaphra^rtnatie  muscle,  !• 
tlie  1  ircuinfereiitial  portion  of  tliis  septum  from  the  o^tai 


II  -innitHin 
IMls-ivr, 

iiMiffli- 

I  he  rla.»tii' 
iiir''.  Anii 
•111  of '  •■ 
■  m  of ! 
Ill  tviu" 
-tal  tv 
liiap: 

•'•{lar.r 

all.  i 


Tin:  PLKVRM.  c.wnits 


24.*) 


riuiin  f ..,.,r  in  imrj-asiri^'  ihi-  ihora. ir  .-aviiv.  it  rniisl  Im-  k..pt  in  miiHl 
lUt  II,  ,M,,.irufion  thf  Ihontx  ^wuhms  in  .v.ry  .lirwtion     in  lateral  mihI 
fof,.  Hi-I  aft  .lianiH.TH. a.H  *,.|l  a.i  in  the  v.rtic-al.     It  U  thus  ol.vioas  that 
.hj-...>t..l  ,nas«ul«tur..  w  «!>..  «  factor  even  in  pr.,rH.urK-,Hl  »-a.s«.,  „f  dia- 
phriii'inatic  hnalhin^.     AcrunliiiK  t»  M,^^,,  ,|„rinK  natural  s|,^.„  ,his 
ihorur..   .r.«|hinK  w  |he  tK.rmal  i-otnlition.    (Jf  the miml«. raasinc elev«. 
tion  of  tlie  nlw  and  lattral  arnJ  anterior  expaa.ion  of  the  thonirie  cnife 
the  «t.  nml  mterci^tah  are  the  nj,»*t  im|H,rtai.t.     In  forcr,!  iaspiration  a 
laV'  .,uinl..r  ..f  other  inus<lt^  are  ralle,!  into  plav;  the  hea.l.  shoukler 
aiKl  an,,  are  hH  call«i  ii|M,n  to  form  fixe.1  supp<,rts  for  maples  which' 
pa..Mn,'  fr,m,  them  to  the  thorax,  elevate  ami  rotate  the  ril«  forwar.1  ami 
o.it»ar.l.  that  the  thoraeic-  *a^  may  attain  its  Kn-ate,t  rapadtv  a-s 
mm.  I     •  the  incmisc.  in  the  n.-Kative  prevsurr-  within  the  thVrax'iiiav 
,aus,.  i„„„  f.,r.il.le  inha  ation.     'iV  more  in.,,o,.a„t  of  thes«.  ,„„s<|,; 
arv  tl,..  >t.rn.mia.stoi.i.s.  fhe  ,*etoralts  minor  aiui  lower  part  of  the  im^- 
lorali,  major,  and   the  l„wer  se^tments  of  th.-  .^-rralns   niairniis      In 
-K,.mal  ii.spimtion  uUo  the  central  <       on  of  the  diaphra^n,.  does  not 
» (•■  I    (H^m„„:  „-,th  form!  irispiratio.,,  with  more  vi^r^nMis  rontra.ti..,, 
of  h.  .laphr  .^,,1,0  mas<le.  it  i,  pull„l  downward,  thu.s  ra.,i,.»r  verv 
mafnally   ,}„    ,„.^^„ve   intn,thon.<-ir   pr,.^sure.     ^  ,      „,her  a.-,t.M,rV 
.mwl...    ma-     .    „ot«l.     k^.  n    ,n    onlii.ary    respiration,  the    larvn'x 
mov.,.|„vvnwar.l  .unng inspiration  thn.u>;h  theco, Ta.tion  of  ih.-  s.ern<^ 

U  ..IT  a,.l,.l   l,v   Uie   thyror  ^...d   musoles.     In    (      .^   in^piratL.    fhe 

.,  ,r  '  '"  ""l"  r'*""/  P"'  "'  •'"*■"«•""«  »'y  "h-  descent  !.f  the  lungs 
.  'Kl  no  ,.a.  In  or.,-,  ins,  ut.on.  also.  an.l  where  ther.-  is  ruisal  ..(,. 
Mn,H,.,n  and  ,n  th,-  qui.  -  Wathing  of  childr.,.,  .ds..  wi.i.  th.  smaller 
'"Eniiatlon'v" ''''"'"'  "«n-.H,mes  into  play.  wi,l.  Jn^  the  nostril-. 
Kxpiration.  N.^na!  ,.xpir,  ,n  i.  wholly,  or  ainu^t  wh.,ll>  a 
■   I"  As  Marling  .     .res.ses  it.  the  in>pirator^  .i.larKem.nt 

u.--  I  ..t  only  acts  ajp.      i  j;rav.ry  in  rai-  i.«  the  ■  ,l,>,  hut  also 
'ip  }«,.., hal  enerp-  in  wn.sef,uen«>  of  a  stref.  In.      „f  ,i,e  ril. 

■I     ^tore  t      !h„rax  to  Its  resting  state  and  original  size.     Wher.- 
re  ,s       ..motion  an.l  forcer!  expir  uio„.  ther,-  mu..  ular  aid 
■<.s,.„u,^  „   the  fh.>racic  cavity,  mof.-  parti.ularlv  hv  ,ontr;. 
•■  at-   ,mii,aUvall.  wherehy  the  aUloininal  .-..ntent,' for.-,-  th.- 

'  "«ar,l.      I  he  lower  rilxs  ar,-   furth.  ■   pull,.|  downwani   hv 
"-  ("•sfKiis  inferwr  and  the  .sacr,)liiml.ali.s. 


of  111, 

-ior,'- 
i-art 
n-ia 
f'lav. 

!-Ott-C. 


'crr.'ii- 


briiii; 


•Mv 


THE  PLIUBAL  CAVniES 

ass,^-iate.|  with   the  muscular  apparatus  of  the  th.. 
t  tlH.  diMensio',    ,f  the  lungs  we  ha  v.   toonsider  th. 
I"^l  cavities  ur.  omd  eith-r  lung.     Were  the  lung^ 


I  i 


2-k>      THE  RESPIRATORY  FUNCTION  AND  ITS  DISTURBANCES 

attuc-luti  to  thf  jjaru'tt's  (as  liapiiens  in  cast's  of  universal  plmiral  adhe- 
sions), expansion  and  i-ontrac-tion  eould  m-cur,  but  the  extent  would  van 
greatly  in  «lifferent  regions.  With  diaphragmatic  contraction  then- 
would  l>e  great  expaasion  of  the  lower  lobes,  whereas  the  apices  would  lie 
scanrly  influenced,  and,  as  a  conseijuenee,  there  would  be  little  inter- 
change of  air  occurring  in  them.  The  pleural  cavity,  with  the  free  move- 
ment of  the  visceral  over  the  parietal  pleura,  insures  that  with  insplratinn 
the  lungs  undergo  unifonn  expansion;  if  the  excursion  of  the  lower  parts 
of  the  lower  lobes  is  the  greatest,  this  at  the  san.e  time  causes  the  expan- 
sion of  the  whole  organ  and  of  its  individual  air  sacs. 

According  to  Donders,  the  elastic  pull  of  the  lungs  in  expiration  -ami 
this  is  equivalent  to  the  negative  pressure  in  the  pleural  cavififs— is 
7.5  mm.  Hg.  in  the  expiratory  phase;  it  is  increa.sed  to  about  !l  mm. 
in  onlinar}'  inspiration,  and  to  30  mm.  in  the  deepest  inspiration. 

Pneumothorax. — This  negative  may  be  converted  into  u  \Hmm 
prt'ssure  in  either  or  both  cavities  by  the  entrance  of  air  or  gas  into  them, 
whether  by  traumatic  or  other  communication  with  the  exterior,  or  with 
ga.s-containing  abdominal  viscera;  by  rupture  of  the  visceral  pleura, 
and  communication  betwwn  the  air  sacs  and  the  pleural  cavity;  or 
thirdly,  by  the  generation  of  ga.ses  in  the  cavity  through  the  activitv  of 
giis-pro<lucing  Imcteria.  Contrary  to  the  general  teaching,  we  would 
point  out  that  a  small  opening  into  the  healthy  pleural  cavity  is  not 
necessjirily  followed  by  pneumothorax.  We  hdve  made  such  an  opening 
in  the  dog  (without  artificial  respiration)  ami  seen  the  visceral  pleura 
move  acrass  it  with  each  breath  without  the  lung  undergoinu'  collapse, 
the  viscwis  adhesion  of  the  two  layers  of  the  pleura  surrniunlinj;  the 
opening  being  sufficient  to  neutralize  the  pasitive  pressure  u[k)ii  the 
exjM)se<l  surface.  This,  it  must  be  added,  is  exceptional;  ordinarily, 
air  rushes  into  the  cavity,  and  the  pressure  it  exerts  u|)on  the  luiij;  <-aiises 
c»)llapse  of  the  .same.  Nay,  more,  where  the  orifice,  either  in  tlic  thoraeir 
wall  or  in  the  lung,  is  of  a  valvular  nature,  the  air  drawn  into  tlic  pleural 
(■a^ity  during  inspiration,  and  unable  to  escape  during  expiration,  may 
acciinudate  and  come  to  exert  a  pressure  upon  the  lung  in  excess  of  the 
atnv  ispheric  pn-ssun-,  causing  an  extreme  filling  of  the  si<le  of  the  chest, 
even  to  the  extent  of  displacing  the  heart  an(l  compri'ssiii^'  l,ir}.'cly  the 
other  lung,  thus  rendering  adei^uate  respiration  and  continued  existence 
ini|)ossible. 

Two  forms  of  pneumothorax  may  l)e  distinguished,  the  o|>eM  and  the 
closwl.  In  the  former  there  is  free  communication  with  the  external 
air,  either  through  the  thoracic  wall,  or  an  abdominal  viscu>,  or  mo<i 
often  through  the  lung;  here  «)f  necessity  the  pressure  within  the  caviti 
is  |)ositivc,  and  the  lung  undergiK's  complete  collapse,  unlc~^  there  lie 
pleural  adhesions  which  ki-ep  |>ortions  of  the  organ  distended.  In 
closcil  pneumothorax  the  communication  has  l)ecomeoccluiiid,or,asin 
gu^cous  pneumothorax,  may  never  have  existed.  In  such  casr  ,  airurdinj; 
to  the  amount  of  containe<l  air  or  gas,  we  may  have  menly  iliniiiiution 
of  the  negative  pressure  or  low  positive  pressure;  and  here  respiration 
is  not  wholly  arrestwl  in  the  affected  lung.    There  is  i  nii>,iderablf 


J 


PLEURAL  EFFUSIONS 


247 


(liverK.ii(f  of  opinion  regarding  the  effect  of  these  two  forms  upon 
respiration.  In  general  it  would  seem  that  in  both  there  is  a  tendency 
lodetp<r  respiration,  with  increased  rapidity  in  the  open  form  and  some 
slowing  ill  the  closed.' 

nearal  Iflosions.— The  mechanics  and  the  effects  upon  respira- 
tion of  the  accumulation  of  fluid  in  a  pleural  cavity  form  an  interesting 
study.    Ipon  first  consideration  we  would  imagine  that  the  effect  of 
aoeuraiilation  of  fluid  in  a  closed  cavity  is  to  diminish  the  space  that 
can  be  (k< iipied  by  the  lung;  that  the  lung  in  consequence  cannot  fully 
expand,  and  that  thus  the  effects  are  similar  to  those  of  a  positive  pressure 
exerttnl  upn  the  lung,  which,  as  a  matter  of  fact,  in  extreme  cases  be- 
comes completely  collapsed,  lying  against  the  vertebral  column.     Gar- 
land,  however,  urges  (1)  that  a  pleuritic  exudation  does  not  compress 
the  lung  as  universally  taught,  but,  on  the  contrary,  by  virtue  of  its  weight 
exerts  a  negative  pressure;  (2)  that  the  lung  does  not  swim  upon  the 
effusion,  l)ut  by  virtue  of  its  retractility  it  supports  the  entire  body 
of  the  effusion,  together  with  the  diaphragm,  •  "♦!>  the  weight  of  the  fluid 
excee.ls  the  liftmg  force  of  the  lung;  (3)  that  the  diaphragm  does  not 
bag  down  until  the  weight  of  the  fluid  exceeds  the  lifting  force  of  the 
lung,  and  (4)  that  the  heart  is  not  pushed  out  of  place  by  an  effusion 
whether  of  air  or  fluid,  but  that  those  parts  are  drawn  over  by  the  negative 
pressure  in  the  other  pleural  cavity.     Enormous  effusions  increase  this 
ilisplacement.    While  there  is  much  that  we  must  accept  in  these  con- 
clusions of  (Jarland,  it  is  difficult  to  accept  them  in  their  entirety.    Let 
us  iM-gm  by  considering  the  normal  lung  at  the  end  of  expiration.     That 
organ  is  still  in  a  state  of  distension— of  distension  so  considerable  that 
Its  elasticity  or  the  force  necessary  to  keep  it  distended,  is,  as  already 
tated.  »H|iiivalent  to  a  negative  pressure  of  about  7  mm.  Hg     With 
nrilinarv  inspiration  that  force  is  only  increased  by  about  2  mm   Hg 
.^upp<.si;  that  now  the  pleural  cavity  became  filled  in  the  expiratonr 
phase  either  with  fluid  or  with  a  solid  growth.    The  lung  would  thereby 
iKxoine  collapsed  and  airless,  and  with  ordinary  inspiration,  instead  of 
expanding  to  the  extent  of  bringing  about  a  negative  pressure  of  9  mm 
t^rte  totiil  amount  that  it  could  exert  would  be  onlv  2  mm    (i  e    9- 
'  inni).    In  other  words,  the  elasticity  of  the  lun^  which  causes'  the 
negative  pres.siire  to  come  into  play  b  exerted  to  a  very  slight  extent 
When  tin;  organ  is  collapsed;  just  as  a  rublier  band  exerts  very  little  pull 
»tien  It  is  Haccid  compared  to  the  pull  exerted  when  it  is  taut.    This 
prognssiv,.  n.luction  of  the  pull  exerted  by  the  lung, due  to  the  elasticity 
'rf  he  s.„„..  would  seem  to  have  been  lai^^ly  neglected  by  Garland. 
rZ  "    ,  ""'.'■  '''^  •ntra'ho'-acic  negative  pressure  that  keeps  the  dia- 
phragm l»,w,^|  upward  in  spite  of  extensive  fluid  in  the  pleural  cavitv 
A  nmrc  ,M,,x.rtant  factor  is  the  upward  pressure  of  the  abdominal' 
iMtra  uml.r  the  influence  of  the  muscles  of  the  abdominal  wall.     It  is 
f-n  ft.n  1,  i„at  we  find  the  diaphragm  bulging  actually  downward,  and 

"'■"PiiMlV;  |L««i  u  :',S^™^^^^^         pneumothorax,  *o  Emo^on.  John«  Hopkin« 


248     THK  RESPIRATORY  FUXCTIOX  AXl)  ITS  DISTVRBA\('ES 

then  in  conditions  of  nmrluHl  ulxloniinal  flaecidity.  Wlien  tills  (xtiirs 
it  is  to  be  nottnl  thut  euch  contraction  of  the  diaphra^,  instead  of  pro. 
(iucing  a  negative,  must  materially  increase  the  positive  prossure  in  the 
pleural  cavity. 

Thus,  our  opinion  is  that  (iarland's  conclusioas  are  only  valid  for 
conditions  where  there  is  but  relatively  small  accumulation  of  Huid  in 
either  6avity;  any  considerable  (juantity  so  hinders  the  expansion  of 
the  lung  that  its  elasticity  cannot  be  effective,  while  the  very  wiijjht  of 
the  uuid,  if  it  does  not  materially  lower  the  diaphragm,  and  so  li'.s.sen  its 
excursion  and  with  that  the  distension  of  the  lung,  must  at  least  interfere 
with  the  excursion  of  the  thorax  by  increasing  the  load  which  the  c-ostal 
muscles  of  inspiration  have  to  carry.  Whether  the  diaphrapn  or  the 
costal  muscles  l»ear  the  brunt  of  the  increased  load  will  clepend  iiiateriallv 
upon  the  position  of  the  patient.  Here  we  would  add  that  the  accumula- 
tion of  fluid  below  the  lung  in  the  lower  part  of  the  thorax  can  onlv 
e.xert  a  negative  pressure  upon  the  lung  when  its  weight  has  l)econie 
sufficient  to  neutralize  the  upward  pressure  of  the  abdominal  organs  upon 
the  <liaphragnt.  As  a  matter  of  fact,  the  singular  freetlom  with  whirh. 
in  general,  Huid  escajies  fnnn  the  chest  in  thoracocentesis,  and  this 
during  lx)th  the  inspiratorj-  and  the  expiratorj'  ac',  and  the  al)st'nceof 
suction  of  air  into  the  chest,  demonstrate  that  this  fluid  is  under  a  |M)sitive, 
and  not  under  a  negative  pri'ssure.  It  is  only  when  the  amount  of  fluid 
is,  or  has  liecome,  small  that  there  is  danger  to  Ix'  anticipated  of  suction. 
or,  niori'  acciimtelv,  of  forcible  entrance  of  air  into  the  cavitv. 


THE  MERVOnS  MECHANISM  OF  RESPIRATION. 

The  acts  of  inspiration  and  i  xpiration  Ix-ing  determined  by  muscular 
activity, and  the  skeletal  muscles  not  acting  automatinilK^biitcontnictin)! 
under  nervous  .stimidi,  it  is  clear  that  we  have  in  the  ••st  place  to  look 
to  the  nervous  .system  for  the  initiation  of  active  breathing,  and  that 
disturlwnces  affecting  the  centres  controlling  the  work  acconiplisluil 
by  the  individual  muscles  which  bring  alxiut  the  acts  of  in.spiration  ami 
expiration  must  materially  affect  those  acts. 

There  must,  in  the  first  place,  Ix'  as  many  centres  as  there  arc  individual 
mu-scles.  We  know,  in  the  first  place,  that  the  interctxstal  tnnsclcs  have 
their  iimervation  through  the  .series  of  dorsal  motor  nxits,  and  cDUclude 
that  the  neurons  that  cau.se  these  mu.scles  to  contract  origiMMtc  in  the 
anterior  horns  of  the  dorsal  cord.  The  diaphragm  is  innervaicd  liy  the 
phn-nic  nerves,  and  these  have  their  origin  from  the  fourth  and  fifth 
cervicals;  the  ahe  nasi  are  nnierv..!«Hl  l)y  the  .seventh  cranial;  I  lie  nuwies 
«»f  th"  V(X'al  cords  by  the  recurn-nt  i„ryngeal  branches  of  ilic  viipis. 
It  follows  from  this  that  the  jx-rforinance  of  normal  acts  of  ir>i)irati(»n 
(lepends  upon  the  cooniiiiatitl  .stiuiulatioti  of  u  seri.-.s  of  cctilit  -itimted 
in  the  medulla  and  cervical  and  ilorsal  cori"  as  also  that  doiniciion  of 
particidar  centres,  or  of  the  nerves  passing  from  them  to  |iarticnlar 
inascles,  must  modify  the  re.spiratory  act  in  particular  dircc  ilons;  tlipl 


THE  NERVOUS  MECHAXISM  OF  RESPIRATION  249 

section  of  one  phrenic,  for  example,  must  arrest  diaphragmatic  ■  i-spira- 
tion  upon  one  side.     But  if  these  centres  are  coordinatec],  there  mast 
be  some  supreme  or  coordinatinf;  centre.    The  striking  fact  Ls  that 
after  ull  these  years  we  still  an-  unable  to  state  exactly  what  particular 
group  of  cells  forms  this  centre.     We  know  that  if  the  brain  be  separated 
from  the  cord  by  section  through  the  upper  part  of  the  medulla  oblongata, 
respiration  is  unaltered;  that,  therefore,  the  centre  -s  not  in  the  brain. 
The  ohst-rvations  of  Floureas  and  several  others  indicate  that  it  is  bilateral 
and  situated  in  the  medulla;  but  the  experiments  of  Gad  and  Marinesco 
show  that  the  localization  given  by  Flourens,  Gierke,  and  Mislawsky 
is  either  incorrect  or  too  limited;  while  the  very  extent  of  the  area  which 
they,  in  their  turn,  lay  down,  namely,  the  cells  of  the  formatio  reticularis 
upon  either  side  of  the  median  line,  would  seem  too  vague  and  widesprea^l 
to  constitute  what  Ls  generally  considered  a  spinal  or  cranial  centre. 
Granted  that  there  be  such  a  coordinative  respiratory  centre — which 
some  still  deny— how  does  it  work?    Does  it  send  down  automatic  and 
rhythmic  impulses,  or,  on  the  contrary,  Ls  it  only  stimulated  by  afferent 
impulses,  or,  thinlly,  is  its  activity  rhythmic,  but  capable  of'  material 
modification  by  afferent  impulses  reaching  it  from  other  regions  of  the 
organism,  as  again  by  nutritional  influences  due  to  alteration  in  the 
gaseous  contents  of  the  bIoo<l  circulating  through  it?    These  questions 
also  cannot  be  said   to  have  gaine<l  an  alxsolutely  uncertain   answer. 
This  much  is  clear:  (1)  That  stimulation  of  several'regions  of  the  brain, 
as  again  of  many  peripheral  nerves,  mwlifies,  at  least  temporarilv,  the 
respirator}-  act,  and  that  thus  the  respiratory  rh\-thm  is  influenced  by 
afferent  impulses;  (2)  that  the  pulmonary  branches  of  the  vagus  ner\es 
stand  out  preeminently  in  exerting  an  influence  upon  the  respiratorv 
rhythm;  they  are  the  foremost  afferent  nen-es  of  respiration;  and  (3) 
that  the  activity  of  the  centre  is  materially  affected  by  the  blood  passing 
througli  the  metiulla,  being  stimulated  by  increased  presence  of  CO  , 
and  depressed,  not  so  much  by  over-oxygenation,  as  ased  to  be  taught! 
as  hy  reduced  CO,  tension.     The  brilliant  studies  carrieil  out  by  Head' 
m  Hiritig's  lalwratory  established  firmly  the  second  of  these  conclusions, 
studies  in  which  he  was  able  to  obser>e  the  uncomplicate<l  movements 
of  th<'  main  muscle  of  respiration— the  dieohragm— bv  recording  the 
contnictions  of  a  small  isolated  band  of  the  same,  which,  in  the  rabbit, 
passes  t(.  tile  ensifonu  cartilage,  and  is  capable  of  isolation  along  with 
Its  nerve  and  blood  supply  without  disturbing  the  thorax  or  its  contents. 
Ihe ext.iit  of  the  contractions  of  this  masclc  and  variation  in  the  rate  of 
Its  com  I  action  can  be  recorded  without  being  disturlied  bv  passive  move- 
ments of  tlie  thorax.     By  this  means  the  observations  of  Hering  aiul 
Bniicr  were  confirmed,  that  the  normal  stimulus  to  both  the  inspira- 
tory an.  I  tiic  expiratory-  act  is  due  to  influence  of  the  intrapulmonarv 
rondith.iis  upon  the  nerve  endings  of  the  vagus.     Collapse  of  the  lung, 
for  (xnuple,  induces  a  prolonged  contraction  of  the  diaphragm— as  it 
wens  Mil  nitcnse  ijispiratorj-  effort  on  the  part  of  thLs  muscle;  inflation  of 

'Jour,  of  Physiol.,  10:  IKSi):  27U. 


^r 


nirps. 
lera- 


2")()     THK  RKSPIRATORY  FUNCTION  AND  ITS  D/STURBAXCtlS 

the  lung,  on  the  contrar)-,  relaxation  of  the  diaphniffm  .such  us  accom- 
panies the  jm-ssive  expiratory  act  in  the  ral)l)it.     The  imme<liatc  cIltHt  of 
seetion  of  Uith  vagi  is  to  pnHhu-e  inspiratory  tone,  or  partial  eontraction 
of  the  (iiaphrogni,  and  to  lengthen  individual  inspiratory  <i)nfractions 
of  the  same;  the  individual  contractions  are  slower  and  mon-  violent. 
What  is  the  meaning  of  these  phenomena  Ls  still  a  matter  of  dcljate- 
whether,  for  example,  with  relaxation  of  the  hmg,  stimuli  pjiss  up  the 
vagi  which  .set  in  action  the  inspiratory  muscles,  or,  on  the  contrarv, 
inhibit  the  cxpiratorj-  mechanism;  or  whether,  again,  the  only  iip    Is^' 
which  pass  up  the  nerve  are  expiratory  in  nature;  or,  lastly,  wlictluT,  as 
Meltzer'  has  urgetl,  the  vagus  contains  Iwth  positive,  inspiratory  and 
inhihitive,  expiratory  fibers.     Further,  it  is  to  be  kept  in  niiiul  that 
vagiis  stimulation  is  not  necessarj-  for  respiration;  after  division  of  Iwth 
vagi    respiration  gradually  assumes  a   n-gular  although  slower  rate, 
with  long  and  powerful  inspiratioas  with  intervening  complete  cxpira- 
ti()ns.     These  may,  it  Ls  true,  Im>  brought  about  by  impulses  reachiti); 
the  c-oiinlinating  centres  through  other  afferent  nerves.     Tht-y,  at  the 
.same  time,  raise  the  question  whether  the  centre  may  not  po.s.se.s.s  an  auto- 
matic rhythm  of  its  own,  normally  always  in  action,  but  iiKMlificd  by 
impulses  pnK-ee<liiig  from  the  lungs  and  other  cerebral  an<l  spinul  ecu 
The  existence  of  this  automatic  rhythm  Is  inferred  from  several  (•<)n.si( 
tions.     Thus,  more  particularly,  .several  observers  have  shown  that  if 
the  miHlulla  Ik-  .separated  from  the  brain  above,  and  the  lower  (rrvical 
con!  1k>  cut  across,  along  with  all  .sensory  nerves  reaching  the  conl  l)e- 
tween  these  two  .sections,  a  rhythmical  contraction  of  the  iliaphragm 
Is  still  in  evidence,  slow  but  definite.     It  may,  however,  lie  objected  that 
the  trauma  of  the  cut  ends  of  the  sensory  ner\es  still  acts  as  a  scn.son 
stimulus.     The  problem  thus  is  one  that  it  is  practically  inipossiWe  ti) 
.solve  by  ilirect  means.     We  can  only  repeat  that  the  biilk  of  cvi.leiice 
is  in  favor  of  this  automatic  rhythmic  action  of  the  coiirdinatiii;.'  centre. 
And  further,  we  must  inicJgine  that  the  condition  of  the  IiI.h^I  raises 
or  depre.s.ses  the  activity  of  the  main  respiratorj-  centre,  thereby  incrcitsiiij; 
or  decreiusing  l)oth  the  rate  of  the  rhythm  and'  the  force  of  tlie  iti.lividual 
nvspiration.     Hoth    Miescher   and    Head    have   shown    that    l>v  over- 
ventilation  of  the  lungs,  and,  therefore,  of  the  blood,  a  coinlition  nf 
apnwn  or  arrest  of  the  respiratory  acts  can  Ik-  pnxluced  even  wlicii  lK)th 
vagi  are  cut;  when,  thert-fore,  the  arrest  is  not  ilue  to  afferent  impulses 
from  the  liuigs.  but  presumably  is  due  to  the  influence  of  the  Mood 
u|Mni  tlu'  n-spiratory  centre.     Similarly,  ajtphyria  may  Ix*  bn)u;:ht  alK)iit 
by  cutting  off  the  blcMxl  supply  to  the  medulla,  or  by  "bletHiing  an  animal 
so  as  to  produce  universal  anemia,  and  such  asphyxia,  as  will  be  |)resently 
nottnl,  is  characterized  in  its  earlier  stages  by  the  contrarv  vtap'  lif 
excessive  fon-e  of  the  respiratory  movements.     The  researehes  nl  I laldanc 
and  Priestley  show  that  it  is  not  want  of  oxygen  but  inert-ascfl  ^niiunnt  of 
carlK)?!  dioxide  that  is  the  influence  excititig  the  re.spir«tiirv  ..Mtre  to 
incn'a.s«Hl  a<'tivitv. 


'  .\rcli.  f.  Physiol.,  Leip/.iR,  1892:  340. 


DYSPS'(EA 


251 


With  this  general  and  brief  review  of  what  is  a  nii«t  complicated  sul>- 
ject,  wo  may  now  pass  on  to  coasider  the  more  characteristic  disturbances 
of  the  nspiratory  process. 

Sneezing.— ^neezing  ia  characteristically  a  reflex  act;  the  usual  caase 
Ls  fn>in  nasal  irritation,  by  stimulation  of  a  branch  or  branches  of  the 
fifth  inne;  it  may  be  initiated,  however,  by  exposure  to  intense  light, 
and  thus  by  stimulation  of  the  optic  nerve.  The  act  consists  of  a  spas- 
nwxlic,  deep  inspiration,  followed  by  a  strong  expiratory  effort.  \Vhile 
this  last  is  pnxveding,  the  mouth  passage  is  at  first  closed  by  approxima- 
tion r)f  the  dorsum  of  the  tongue  to  the  soft  palate.  The  first  portion  of 
the  expired  air  passes,  therefore,  with  considerable  force  through  the 
nostrils,  tending  to  dislodge  irritant  particles  if  they  be  present.  Almost 
immwiiately  the  tongue  is  slightly  depressed,  so  that  the  remainder  of 
the  air  is  force<l  through  a  relatively  narrow  passage  between  the  tongue 
and  the  upper  jaw,  producing  a  characteristic  sound. 

Coughing.— Coughing-  may  be  either  a  voluntan-  or  a  reflex  act, 
the  reflex  originating  either  from  irritation  in  the  larynx  (most  common). 
in  the  lungs,  or  of  the  pleural  surfaces.  Here  a  deep  inspiration  is  fol- 
lowed by  closure  of  the  glottis,  which  continues  during  the  first  part  of 
the  stn)ng  expiratory  act,  so  that  with  sudden  opening  of  the  glottis, 
the  air  under  coasiderable  pressure  in  the  main  air  passages  is  liberated, 
and  escapes  with  much  force,  carrying  with  it  mucus  or  other  matter 
in  the  bronchi,  trachea,  or  larynx. 

Dyspnoea.— The  term  dyspncea  is  used  in  two  seases,  to  indicate 
lioth  the  sensation  of  air-hunger  and,  more  commonly,  and  we  think 
more  correctly,  the  condition  of  labored  respiration  brought  about  by 
ol)stru(tion  to  the  entrance  of  an  adequate  amount  of  air  into  the  lungs, 
and  tiroiidly  by  all  conditioas  of  accumulation  of  increased  amounts  c 
(( K  ill  the  blood,  with  or  without  deficiency  of  oxygen.  The  condition 
may  or  inav  not  be  accompanied  by  cyanosis,  according  to  the  activity 
of  (fascdus  interchange  possible  in  the  lungs.  Here  we  have  to  recognize 
the  existence  of  a  protective  mechanism;  whenever  there  is  a  teiulencv 
to  deficient  ventilation  in  the  lungs,  then  coastantly  the  general  nietalx)- 
hsni  iHconies  lessened  by  all  p(xs.sible  means;  th.  "individual  indulges  in 
the  least  |)o.ssible  muscular  and  other  exercise,  whereby  both  the  call  for 
oxy^'eii  IS  brought  to  a  minimum,  as  is  also  the  discharge  of  carbonic 
acid.  Coincidcntly.  even  it  he  absence  of  seasation  of  air-hunger, 
ther.  iiiiiy  Ih'  increase  in  the  te  of  the  respiratorj-  act,  the  more  rapid 
if  shalli.w  inspirations  leading;  to  increased  respirator\'  interchange, 
and  favoring  thus  a  better  condition  of  the  blood.  \Mien  the  venous 
(oiidiiK.ii  of  the  blood  l)ecomes  more  aggravated,  such  rapid  respiration  is 
replac .  d  by  di-eix-r  inspirations  and  slow,  labored  breathing,  correspond- 
uij.'  to  I  lie  first  stage  of  asphyxia.  But  at  the  same  time  it  is  evident  that 
proion-.d  relative  venasity  of  the  blood  dulls  the  respiratorv  centre:  in 
otii<i  v»,,rds,  the  subject  of  respiratorv  obstruction  mav  endure  with 
little  iv.[,irator\-  distress  a  state  of  venasity  of  the  blooil,  which,  sud- 
<lenly  I  .,«luced  in  a  healthy  person,  would  l)e'accompanied  by  the  gravest 
"•^|)ii  ii-iy  distress.    This  is  equivalent  to  recognizing— as  from  other 


i   < 


i'l 


III 


2ri2     THE  RKSPIRATOHY  FUSCTIOS  .J.\7>  ITS  DISTURtt.Wds 
••oiwulemtum.s  w«>  iniist  n-foftnizf   -that  tlu-  wiisilivnufw  of  tin-  iv> 


tory  cf  ntre  is  fajMihlc  of  c-oasidenihlc  vuriation;  aiul,  us  a  matter  <.f  fa,t 
there  exists  the  ()|)piisite  coiuiitiuii  (»f  liyiHT!*eiLsitivene.s.s  of  tln'  (rntn. 
Thus,  we  otrasionally  eiic-ounter  a  jiroimuiiee*!  «ly.s|iini>ic  eoixljtion  in 
connection  with  hysteria  and  niehineholia,  in  states,  that  is.  in  «hi,l, 
there  Ls  no  evidence  of  any  inodiKcation  in  the  fpiseoai  tension  in  ih,. 
blood. 

Keeping  these  matters  in  nn'nd,  we  may  snm  np  the  conililions  iitul.r 
which  dyspnuea  may  manifest  its<'lf.     They  an>: 

1.  Conditions  of  .severe  hindrance  t«»  entrance  of  normal  amount  of  air- 
(n)  In  the  air  passages,  leading  to  diminished  ingn-.ss  and  •,;re.ss  (,f 
air  (foreign  Inxlies,  inflammatork-  and  other  narrowings  of  the  limns 
trachea,  or  hn»nchi,  compression  fn>in  without),  (fc)  In  the  \\nm 
themselves— collapse,  diminution  of  the  ventilating  surface  hv  exudates 
into  the  alveoli,  tulHTculons  and  either  gniwths  in  the  lung  sultstanct 
destruction  of  the  lung  suixstance  (gangrene,  cavitation,  etc.).  fibroid 
induration,  atrophy,  emphysema. 

2.  Conditions  aff»fting  the  nuiseulur  mechanism  of  n'spinition' 
(a)  Diseased  ccmditions,  inflammatitm,  et<-.,  of  the  diaphragm  or  other 
respiratorj-  mu.scles,  mow  particularly  the  former,  {h)  Patliolo^Hfal 
condition  of  the  main  and  swonclary  n-spinitory  centn-s  and  of  the 
nerves  forming  the  respiratory  ar<-,  jwiralysis  or  irritation  of  the  ceiitrtx. 
trauma  or  destruction  of  the  affen-nt  (vagus)  ner>es,  as  again  of  ihJ 
efferent  nenes  (more  |)articularly  the  phrcnics). 

3.  Conditions  obstructing  the  circulation  of  bltKxl:  («)  Tiiroufrli  the 
lungs  (obstructive  heart  disease,  emphysema,  chronic  interstitial  piieii- 
monia,  etc.);  (b)  through  the  medulla. 

4.  Conditions  modifying  the  constitution  of  the  inspired  air  rarefac- 
tion of  the  air  »us  at  high  altitudes,  mluction  of  the  amount  of  containeil 
oxvgen,  increased  CO,  content,  presence  of  carlxin  monoxide,  wlii(h, 
uniting  with  the  hemoglobin,  p«'rmits  less  o.xygen  to  Ik«  taken  up.  and 
nnluces  thus  the  gaseous  intcrchangi>  in  the  meilulla  and  tissues  tr<ner;illv. 

Asphjrxia.— Dyspmea  <-onnotes  the  existence  of  at  least  the  niiiiiiniini 
gaseous  interchangi-  necessary  to  maintain  life,  the  obstructioi'  to  that 
inteichangi'  lieing  overcome  either  by  iiicreasjHl  rate  or  increavd  ampli- 
tude of  the  respiratory  acts,  and  the  calling  into  plav  of  the  acressorv 
muscles  of  the  n>spiration.  Asphyxia  or  sutfcK-ation,  on  the  oiin  r  liaiid, 
conn«)tes  a  condition  in  which  that  minimum  camn)t  Ix-  atiaiiie.1,  and 
ill  which,  as  a  coiise(|uencc.  the  progri'ssive  accumulation  nf  rarUm 
•lioxide  in  the  bliMxl  circulating  through  the  medulla  cvciitnalK  arrests 
the  action  of  the  respirator}-  centre,  and  brings  alx)ut  deatli  uu\v^>  the 
obstruction  to  the  gast-ous  interchange  lx>  rapidly  removeil.  I 
that  the  progressive  exhaustion  of  the  respiratory  centre  in  . 
through  overstimulation  may  n.sher  in  a  quiet  death  with  pi. 
cvano.sis,  !>nt  little  or  no  struggle.  But  mun-  often  in  dyspna .,  . 
venosity  of  the  bhxxl  liecomes  exc«'ssive,  and  always  when  the  ! 
to  «-spiration  is  of  sndilen  ih-velopment.  we  obtain  that  intense  i . 
struggle  which  forms  the  typical  pictun-  of  a.sphy.xia.     h,  tl  -  acute 


!rvs 

t  is  true 
1)  -piMra 
..Tessive 

.  inil  thf 

iiilramr 
.'■iratorv 


CHE  YSE-STOKEH  RESPIRA  TKtS 


25;j 


(■(imlitioii  thre*-  .stag«^  may  !»«•  ntxifniizefi :  a  first,  of  increased  amplitude, 
a^*  wtll  as  rate  of  the  respirator}-  movements;  a  .s€-«>nd,  with  inrrea-se  of 
the  tx|)iraton.-  movements  out  of  all  prr>portion  to  the  iaspirator>-,  the 
pxpiratiiiii  lieeoming  prrWonged,  the  iaspiratioas  short  and  c-onvulsive. 
To  priNliicp  these  violent  expirations  the  whole  museuiature  of  the  IxmIv 
app«-ar>  to  lie  called  into  play.  In  the  final  stajte  these  \-iolent  expiratioiis 
reasf  almost  suddenly,  and  now  slow,  deep  inspirations  manifest  them- 
selves. 'I'he  mouth  is  widely  open,  the  head  Ls  stretched  back,  so  a.s  to 
gain  the  fullest  freedom  for  entrance  of  air  into  the  trachea,  the  htxiv 
^tretdu^l,  the  arms  rai^.  There  Is  now  complete  insensibility;  the 
(liiatpil  pupils  do  not  react,  the  inspiratorj-  movements  become  farther 
ami  farther  apart,  become  weaker  and  weaker,  until,  in  the  course  of 
a  few  tninutes  ( the  time  \-arjinft)  the  la.st  jjasp  Ls  taken. 

Thts«"  stape.s  are  accompaniinl  by  changes  in  the  circulation, of  which 
the  most  marked  Ls  rLse  in  the  blood  pressure.  It  is  evident  that  the 
venous  l(l(Ktd  stimulates  the  vagtis  anil  vasomotor  centres  in  the  medulla, 
so  that  then-  Ls  Ijoth  slowing  of  the  heart  beat  and  contraction  of  the  arteri- 
oles. With  the  advent  of  the  thini  stage,  the  heart  poisoned  with  venous 
blooil  U'>:iiis  to  fail;  its  Ijeats  liecome  weaker  and  ineffective,  and  death 
occurs  with  all  the  chambers  of  both  sides  hugely  distendefi,  and  «-ith  the 
hloiMJ  pres^sure  rapidly  sinking.  It  may  he  noted  in  pa.ssitig  that  during 
the  s.'iond  stage,  if  the  blood  pressure  lie  taken,  large  .sec<»ndari  waves 
-how  theinselves  of  progressive  increa.se  and  decrea.se  of  the  general 
hliKwl  pressure,  embracing  many  puLse  waves.  These,  the  "Traube- 
HeriiiL'  iiir\es,"  indicate  the  e.xLstence  of  a  rh\-thmic  action  of  the 
vasoinciior  centres  in  the  medulla.  They  are  of  no  .small  interest,  a.s 
Ix-iti:;  atialogrjiLs  to  the  phenomenon  to  be  immediatelv  discussed. 

Cheyne-Stokes  Respiration.— The  first  clear  description  of  this 
t\pe  of  rtspiration  was  given  by  Cheyne,  of  Dublin,  in  1818;  the  first 
full  stu.ly  by  Stokes  of  the  same  city  in  1S.S4.  Both  these  phvsicians 
ohsentii  it  in  connection  with  cases  "of  fatty  degeii,  -ation  of  the  heart. 
To  fjuoic  Stokes:  "It  consists  in  the  occurrence  »)t  a  series  of  inspira- 
tion, increasing  to  a  ma.ximum,  and  then  declining  in  force  and  length 
until  a  >tate  of  apparent  apncea  is  establishetl.  In  this  condition  the 
patient  may  remain  for  such  a  length  of  time  as  to  make  his  attendants 
t"'li<\.  that  he  is  dead,  when  a  low  inspiration,  followed  by  one  more 
ile<  i(l.',l,  marks  the  commencement  of  a  new  ascending  and  then  descend- 
in;;  M  ri.s  of  inspirations.  This  symptom,  as  occurring  in  its  highest 
.here--,  I  have  only  seen  during  a  few  weeks  previous  to  the  tieath  of 
a  patient."  Herein  fuller  .study  has  shown  that  although  fn<|U*iitlv 
s«ii  in  association  with  fatty  degeneration  of  the  heart,  and  alihougii 
most  livjiieiitly  manifested  in  the  last  few  days  of  life,  periodic  breathing 
"f  til.  ..ime  onler  may  present  it.self  in  several  morbid  states,  and  not 
nece-siinly  as  a  penultimate  event.  As  Traulie  pointed  out.  there  are 
nvo  ni;,i!i  groups  of  conditions  in  which  these  rt-spirations  make  their 
ap[x  ;i„!.,v-circulator>-  disturlwnces  with  no  obvious  brain  di.sease,  and 
intra.  ;,;,i;,l  ,|isea.ses  without  heart  disease.  Of  the  first  group,  the  mast 
coniii,(  ;  (lisonlers  are  those  associated  with  chronic  interstitial  nephritis 


ll   ;■ 


;   [i 


I  ■;  i 


254     THE  RESPIRATORY  FVSCTinS  AND  ITS  DISTURHA\Ch:.s 

ami  arteria!irlrm!ti.s— caniiac  ilej{»'rMTati»ii,  aortic  ami  mitral  su-inm 
and  im-unipetenee,  etc.;  of  the  swoml.  ccrehral  hcmorrhaj^c  uiid  (iiimir* 
tiilierculoiM  meningitis.  hydnKt«phalus.  ami  other  c«»mlitions  l.u.lini;  hi 
incr(>a.so«l  intracranial  pressure,  with  (presumahlv)  c-ompnssjoii  atMJ 
loweretl  bloo<J  supply  to  the  nMtJulIa.  Yet  a  thlnl  group  should  be 
added,  that  of  the  intoxications,  including  (rare)  cas<'s  of  infiTtion 
(typhoi«l,  diphtheria,  smallpox,  pneumonia),  and  the  narcotic (niiin)hinf 
ether,  and  chloroform  in  association  with  morphine,  chloral).  .\  mikj 
form  of  the  same  t\-pe  of  ascemling  ami  desi-ending  periwlic  hnmhinij 
with  brief  apixric  pause,  may  not  infrt-fiuently  Ik-  heanl  <luriiij;  the 
afternoon  siesta  of  the  mi<ltlle-age«l  who  have  many  years  of  life  still 
l»efore  them.  Ac<x)nling  t«»  E<le,  the  bwathing  of  certain  imlividiul, 
during  sleep  is  constantly  perio<lic,  and  (iilison'  sujg^ts  that  this  is  a 
familial  peculiarity.  We  encounter  grades  of  the  periodic  bniithiiu; 
from  thase  in  which  ascent  follows  descent  with  no  absolute  piiase,  to 
others  in  which  the  apnopa  may  persist  for  half  a  minute  and  moif. 
There  may  or  may  not  Ik-  asstniatwl  changes  in  the  geiuml  blood 
pressure,  uncoasciousness  during  the  apno-ic  pause,  contraction  ami 
dilatation  of  the  pupil. 

In  attempting  to  elucidate  this  pecidiar  phenomenon,  iionUm  Douglas 
and  Haldane,'  as  also  Haldanc  and  Poulton,'  found  they  couhl  prodiuv 
it  experimentally  by  breathing  det  ply  and  rapidly  for  alxiut  two  minutes. 
Whenever  any  desire  to  breathe  nturmnl,  the'pnx-css  was  allowtil  to 
take  its  own  course,  with  the  residt  that  the  Chevne-Stokes  tvw-  of 
r-spiration  was  induc»<l.  The  first-nientiom d  obsmers,  in  stmlvinj; 
farther  the  intra-alvcolar  air  in  ri'ganl  to  oxvgen  ami  cariM)nic  dioxide 
pressure,  conchnle:  (1)  that  the  jjcriodic  breathing  is  excitwi  bv  the 
pcrKxIic  (K-currcnce  and  di.siippcarance  of  the  (indirect)  stiiniil'ating 
effwt  of  want  of  oxygen  on  the  n-spiratory  centre;  (2)  the  want  of 
o.wgcii  may  lie  due  to  an  abnormal  defit-iency  in  the  intra-alvcolar 
oxyg«'n  pressure  or  to  the  effcc-t  on  the  circulation  of  changes  in  the 
iireathing,  or  to  both  causes  cond>ined. 

There  have  bn-n  abundant  tluorie.s,  and  at  times  angrv  .liliatp  .is 
to  the  meaning  of  this  type  of  n-spiratioii;  more  particular! v  the  studies 
and  views  of  Traidx-.  Filehiic.  Wellcnltergh,  Luciani, "  Hos.  iiliach. 
Mosso,  .Murri,  and  'nb.«on  .stand  out  prominently.  But  notwitlisiandintr 
all  this  work,  it  cannot  lie  said  that  any  consi-nsus  of  opinion  ha-  iieen 
reachwl.  Without  attempting  to  lay  dcwn  any  full  hvpothesis.  «.■  conld 
point  out : 

1.  That  the  phenomena  and  the  rccoixls  taken  of  those  pli.  iioniena 
have  es.senti8lly  th?  chara*  ters  <»f  what  physicists  term  iriit  ifcrenee 
curves,  /.  r.,  of  a  series  of  wav<s  of  one  rhythm  modifie<l  bv  li..  Miper- 
po  ■  ion  of  waves  of  another  rhythm,  which  at  one  peritld  n.u'ment, 
at        ther  neutralize,  each  other. 

'  (Ir  yne-Stokes  Ht'spiratiDii,  pjiinlmrgh,  Oliver  and  Itovcl,  1H92:  122.  I  U\*  work 
gives  a  full  bibliography  of  Iho  subject  up  U>  date,  with  discuNsion  i>i  •!  <  miny 
theories. 

Mciirn.  of  I'hysiol.,  38:  ISKW:  401.  '  .Medico-Chir.  Trans.,  40:  I'M',    1... 


THE  AIR  SACS 


2M 


2.  That  there  is  a  curiou.s  likeness  between  these  Cheyne^Stokes 
runes  ami  those  of  certain  forms  (the  so-called  "extra-systolic";  of 
periixiic  cardiac  irregularity;  and  that,  if  in  the  latter  ca!se  we  con- 
dude  that  in  addition  to  evidence  of  the  manifestation  of  an  automatic 
rhythm,  there  are  manifested  opposite  phases  of  muscular  contraction 
and  dilatation,  so  in  connection  with  the  respiratory-  act  we  have  similar 
indications. 

3.  Tt)  the  existence  of  an  automatic  rhythm  reference  has  alreadv 
been  niaile  (p.  2.tO).  Whether  this  is  truly  automatic,  or  whether  it  rep- 
resents tiie  rhythmic  resultant  of  stimuli  other  than  thase  proceeding 
from  the  lungs  must,  for  the  present,  be  left  an  open  question.  What 
is  of  import  is  that  in  the  absence  of  normal  vagus  stimuli  the  centre  has 
l)«en  (iemoiistrated  to  initiate  rhythmic  contractions. 

4.  'i'he  respiratorj-  cyde  is  what  may  be  termed  a  double-phase  act: 
iaspimtioii  demands  that  expiratoni-  stimuli  1*  inhibited,  and  vice  verm. 
The  inspiratoiy  contraction  with  the  succeeding  expiratory-  contraction 
may  \>e  compared  with  the  cardiac  mu-scular  contriction  with  the  suc- 
ceeding' refractorj-  period,  which,  as  we  have  pointed  out,  may  be 
recardwl  as  indicating  active  dilatation  of  the  cardiac  fil)ers. ' 

,').  As  ill  connection  with  cardiac  irregularity,  so  here,  we  may  presume 
that  want  of  coordination  between  these  factors  and  the  establishment 
of  interft-ritig  rhythms  is  at  the  Iwttom  of  the  production  of  these  periodic 
alterations  in  rate  and  volume  of  the  respiratory  cunes. 

6.  Then-  are  other  forms  of  irregular  breathing,  not  possessing, 
on  the  one  hand,  the  marke<l  periodic  character  of  the  Cheyne-vStokes 
iv-pe.  and  on  the  other  hand,  not  manifesting  the  progressive  ascent  and 
(lescfiit  in  the  amplitude  of  the  contractions.  Thus,  some  would  separate 
what  is  termed  " Biot's  respiration."  This  b  seen  in  meningitis  ami  some 
other  eases  of  brain  di.sea.se,  and  is  characterized  by  irregidarly  periodic 
[K-riods  „r  apiKca.  lasting  for  many  seconds  up  to  half  a  minute.  These 
may  Ih-  encountered  in  uremia,  diabetes,  and  suiidrj-  fier\-ous  states, 
as  ajiaiii  under  the  acfioti  of  certain  drugs.  Here  presumably  stimuli 
of  another  type  act  upon  the  main  respiratorv  centre.  Still  less  "is  known 
repmlinj;  the  mode  of  development  of  thes^  than  of  the  Clievne-ytokes 
ty[K', 


THl  Ant  SA08. 

\\e  hail  in  the  next  chapter  describe  in  detail  the  various  disorders 
vvhieh  iM.iv  affect  the  air  .sacs.  Here  we  have  to  c-oiisider  the  broad 
effects  Ml  ihcse  disorders  upon  the  work  of  the  lung  and  upon  the  svstein 
m  pjM  r.l  SiH-aking  generally,  these  disorelers  range  themselves  into 
two  ( I.,-., ,:  those  m  which  more  particularly  the  entrance  into  and  egres,s 
from  1,!,  :,ir  sacs  of  the  proper  amount  of  air  Is  prevented,  and  those  in 
«liieii  .  MMiifres  occurring  in  the  walls  of  the  air  sacs  prevent  the  air 
«li'(ii  I  ..>  entered  them  from  being  properlv  utilized  for  punxxses  of 

{;?"'■ '"••"•haiige.     There  are  not  a  few  ca.<ies  in  which  di.s«-a^s  of  the 

nrst  K  ■    i-  lead  to  the  development  of  disorders  of  the  second;  we  might 


25«     TIIK  HKSPIKATOKY   l-'UMTIOS  AM)  ITS  DISTVKHAXCHH 

ehiw  ruii.<(titute  a  tliini  gnmp  of  the  comhiiMtl  (ii.N)iiilt>r!«.  It  will,  |h,». 
I  viT.  U-  .simpItT  to  (iiii.HHl«>r  tin-  c'ii'<«'»  u<t'<inliii^  as  oii  •  or  oiIht  of  ihr 
two  iiiaiii  onU'rs  is  priiiiurv.  l^-i>vitif{  out  of  <i)ii.>iiil«i.i*bii  those  (usw 
ill  wlik'h  olistnirtioii  (x-i-nn  !ii  (he  iiir  po-tsaf^,  tln>  ontramr  of  a  iIim* 
amount  irf  air  into  the  sjm-s  may  U-  prrvcntril  oithor  liy  want  of  distj-iwion 
of  the  sacs,  as  in  sMtetMlf  ami  eollapt*,  or  hy  the  eollwtinn  within 

them  of  fluid  or  .solid  matter.     Hy  atele<-ta.Hi.M  Is  uiiderstooii  th< iHliiiim 

<if  primary  iin|)erfe«-t  ex|>iiii.sion  of  tlM>  air  .<mm'.s  {nrtir^;,  inti.inplrte; 
ixTdat;,  e.X|>tin.sion>,  by  collaikse,  the  elasiirc  «>f  air  .saes  wliicli  ligvp 
previoiuly  iM-eii  expamled,  although  -we are  ineliiHil  to  tliiiik  iiuom.,i|v 
— the  term  alele«-ta.sLs  in  coming  to  lie  uae«l  for  Imth  eondilioas.  '|V 
foniier  c-oiMlition  thas  dates  fnmi  tlie  moment  of  birth,  the  latftr  max !». 
brouf;ht  aUmt  either  by  e«itnplete  hninehial  oKstnietion  with  sul)se<|iM'nt 
aliMorption  of  the  air  already  eoiitairuHl  in  the  air  .sacs,  or  more  coiiimonlv 
by  «)mpn's.sion  from  without,  as  by  the  pres.sure  of  air  (piieuniothomxi. 
Huiil  matter,  the  eoniraetion  of  inflammatory  or^'Miiizetl  priMlmts  t-ithrr 
on  the  surfac-e  or  within  the  tissues  of  the  luiijts.  the  pre.s.sim>  of  i;nimili». 
matoas  and  other  new-growtlts.  If  of  limited  extent,  neither  romjition 
pnxluces  any  recognizable  dlsturiNiiue;  the  surrounding  uiiol.MriKiol 
air  .sacs  undergc  a  comjieasatory  enlargement;  nay,  more,  the  wholv  nf 
one  lung  may  undergo  collapse,  and  if  tiie  other  U-  healthy  il  i-  al)li- 1» 
sufl[ice  for  the  iM>e»ls  of  the  organism.  ( )nly.  as  already  notetl,  if  the  our 
lung  l)e  put  out  of  action  suddenly,  there  is  a  period  of  tiiiiiiiliiious 
breatiiing  aiiil  dyspmra  iK'fore  adaptation  to  the  changed  cin iiinsiaruw 
iK-j-jimes  complete,  while,  furthi-r.  the  n>spinitory  system  is  workinj; 
pcriloasly  near  to  the  limit  of  its  reserve  fori-e.  so  that  broiiciiiii!  and 
other  disturliances,  of  little  import  when  lK>th  lungs  are  fiiiHtional,  now 
assume  a  .serious  as|Mft. 

The  air  .sacs  may  In-i-oine  fille<l,  and  the  air  they  should  contain  lie 
rcplaci-d.  (1)  by  .serous  fluid,  as  in  cases  of  acute  or  chronic  coii>.f>ti(in; 
(2)  by  bl(Kxl.  as  in  rupture  of  an  aneuri.sm  of  one  of  the  bnim  lii>  of  the 
pulmoiiiiry  artery  in  a  tulM-rculous  cavitation,  or  of  an  aortic  jimiirisiD 
into  the  trachea,  from  an  infant,  etc.;  (.3)  by  water  or  other  Hiiid  frtmi 
without,  as  in  cases  of  dmwning;  (4)  by  i'nflammatorv  .Muliiics  and 
migrate<l  cells,  as  in  pneumonia.  The  effects  upon  respiration  arc  of  th* 
.same  order  as  in  the  former  group  of  cases;  whether  there  Ix-  no  noticeablf 
results,  or  rapid  respiration,  dyspnoea,  and  eventual  a<iii|)t:iii.in.  or 
the  development  of  asphyxia  and  <leath.  depends  primarily  ii|M.n  the 
extent  of  lung  ti.ssue  involvetl,  .secondarily,  upon  the  causative  ap-ni. 
'Phe  diffusion  of  the  products  of  coagulation  and  death  of  the  rr}  iliroc  vte< 
in  cases  of  hemorrhage,  and  of  toxins  and  cytolytic  pnMliict>  in  cases  of 
pneumonia,  .sets  up  a  febrile  .state,  and  doing'this,  inlrr  ali!.  diredly 
affects  the  respiratory  centre,  inducing  an  increa.se«l  rate  of  '  reathiiic 
out  of  rt>latioaship  to  the  extent  of  lung  substance  involved.  1  iinher. 
it  inu-st  l)e  rememliered  that  an  unite  Ii)h(tr  pneumonia  i.ialir- .  ■■  j'l"'-^ 
pneumonia,  and  that  the  painful  irritation  of  the  pleural  stirfn.r  inhibit 
the  excursion  of  the  thorax;  here,  again,  is  a  cause  of  tin  i  ipid  and 
shallow  respirations  present  in  this  condition.     But  even  in   .  uie 


KMPHYSEMA 


257 


|in«'i:nii>iiiu  the  exudate  nwy  rnmpletely  ilLtteiMi  all  the  air  i^ae^i  of  a 
»h<»lf  liiiijf,  or  the  lower  loJies  of  lM>th  lunjp,  bihI  bring  alM-iil  •  -implete 
liitpliniiiuiit  of  the  air  in  the  .same,  without  a  fatal  .••suit,  or,  more 
wtnniKlv,  at  autonsy  we  may  encounter  tuses  nhowini;  a  (iLslrihution 
(rf  the  |iii«-umfMiic  (li^turlwnre,  whi«-h  hni  eviilently  liee-n  of  sum*'  days' 
fiiiRiiiiiii,  uimI  in  whieh  the  lethal  •■vent  is  seen  to  Ix*  due  to  rei-ent  ami 
furtlii  r  ( xlcnsion  of  the  priK-cM  lieyomi  the^'  limits.  Certain  distitu-tions 
of  Mitiic  practicHi  ini[)ortRnee  mast  lie  drawn  U-twifn  the  fluid  aKcnt.s 
aiNi  llii»c  whieh,  like  blood  ami  inflammatory'  exudates,  are  liable  to 
(iiHpilation  ami  .solidification.  In  the  first  plac-e  the  site  of  accumulation 
of  Hiiiti  «le|»«-ml.s  upon  the  position  of  the  imlividiial;  these  naturallv 
iKiiiiimlaie  in  the  mori-  depeiHient  [wrts  «if  the  lunjfs,  ami,  indetfl,  bv  turn- 
iiii!  ihr  individual  upjin  one  or  other  side,  they  may  drain  from  one  .side 

<"  ll 'Ii<r,  often  with  jrrave  distur>Nince  ofthe  respiratory  act  in  the 

\m»T>^.  ( )r,  as  in  Sylvester  ami  Schafer's  meth«Kls  of  resas<"itation  from 
ilrcwtiinc  the  fluids  can  \w  draim-d  out  through  the  trachea.  In  the 
^«t1Hlll  jilact-,  when  the  air  sacs  U-come  distcndtsl  with  solid  c-ontents, 
thrn-  is  the  greater  interferenc-e  with  the  «irculntion.  In  collapse  and 
ueksiaM.  the  absem-e  of  the  air  pressure  within  the  alveoli,  a.s  again 
the  lack  .if  distf  usion  of  the  .same,  uml  of  cons(>(|uent  flattening  ami 
cloiicaliim  (if  th<  capillaries  within  their  walls,  imluces  u  dilatation  of  the 
IiIimhIv. ^MJs  of  .lie  afTccttsl  area,  and  (s>nM'(|uenl  fr«f  flow  of  bloo«l 
ihroiicli  the  same,  ^^'hen  senilis  fluid  iH-n-olalcs  into  the  air  sacs,  then 
alM(  wf  find  a  congestion,  either  active  or  passive.  When  pa.ssive,  it 
i>  not  tlif  lung  c<inditioii,  but  cibstruction  to  the  onflow  of  lilood  from 
iintnil  or  other  olislructive  di.sea.s«»  in  tin-  h-ft  heart  that  is  the  cause  of 
liic  trtvat  .lilatation  tif  the  capillaries,  ami  this  dilatution  continues, 
liowtv.r  a<l\aiK«l  the  senilis  accimniliitions  within  the  alveoli.  In' 
jMHiiiiioiiia  aii<l  hemorrhagic  infan-ts,  with  coagulation  and  progressive 
passaj;.-  of  mon-  material  into  the  air  sacs,  these  \wtm\v  ovcniistended, 
iiiid  tl,.  r,>ult  now  is  that  eventually,  fniin  great  congestion,  we  pa.ss  to 
a  >tat.  of  iiarniwiiig  ami  compn'ssion  of  the  interalv«Hilar  capillarity. 
iiiiil  wli.  M  ihr  conditions  affect  any  large  |Mirtion  of  the  lungs,  the  result 
I-  will-in  irk.sl  iiicnnise  in  the  work  of  the  right  heart,  with  .lilatation  of 
till'  sainr.  and  some  ineomplcncc.  It  is  ntnarkabic  how  n-lativciv 
nirc  ai.  |,„al  necnisis  ami  gangrene  of  the  alFcitwl  lung  as  the  result  (If 
IMS  ni.liir.d  anemia;   neverthel«-ss  these  ctimlitions  o<-c-asionallv  show 

tlli'nivKr-. 

Changes  in  the  WaUs  of  the  Air  Sacs  Eindering  Dae  Aeration. 

'  1  Ih  ..■ .  haiigcs  may  be  of  two  onlers.  either  atniphic,  or  of  the  natiin- 
"I  iiiiTMma!  .lefKi.sifs  in  the  alveolar  walls.  The  first  of  these  leads  to 
"r  a(roi„|Mm.'s  the  mit  uncommon  comlition  «if  either  localizcnl  or  geiier- 
Hlizcl  u  M(  nlar  emphysema.  A.s  will  be  more  fullv  descrilH-d  in  the 
'"•'^1  '  ll  ,,,„.r.  we  find  in  these  .states  a  gmit  dilatation  of  the  air  si.cs 
wit.  piMiionncsl  thinning  of  the  inforalveolar  septa,  l«uiing  l<,  aln.phv 
•"  "»•  -  !'nc,  with  fusion  of  «-ontiguous  air  sacs  into  large  «hanil)ers, 
*  pr«H ,  -   PI.  vitalily  amimjwnied,  not  onlv  bv  reduction  of  the  n-spiraforv 

iinac       ,1  also  by  a  harmful  alteration  in  the  nlationship  betwwn  the 


2.W     THU  /tUSPIHATOHY  FUSrTl(>.\  AM>  /r.S  DISTURBAM  fs 

HMM  of  oir  wiiliin  thi^  nlvt-oli,  ami  IIm'  Niirfact'  of  the  samr,  hii>'  •<>    ,,. 

tlrarHi'  of  the  gasooiu  intprrhHii)(c  with  the  hl<KMl  in  rhe  nlvcolur  u  ,|. 

■aphyMiM. — To  iiiHlrrNtHiid  the  ill  i  hti.'*  <if  thr  t>mpli  v.it-iiiuiiii.    ,^ 

tlilion,  it  is  [Nt'««!4ur)'  to  nniiixc  the  iiM-rhaiii<-^  of  itt  pnMhHiiiin.    i^t  ih 

Fia.  63 


Km|ili.v>rina  i>f  liiii«       Ix-iti  ■■!>]    No.  T.  wilhoui  iirutar.     TIip  ^Ini-liinl  nlvmlur  ».tll>  u  ^ 
ruiiiiira  of  ■••vrrBl  ><l  thfin  *r*  wfll  »hi>wii.     (Kr<<ni  lh»  i"ll»  liim  <>f  l>r   A.  (i    NictuilU 


I'm.  m 


A  H 

Diacram  (n  tlvmonntrair  tlir  elfwl  i>(  i-ui.h.vwiimtKUn  ililalfitiim  <if  tlM-sir-i.  ii-"  >  ■■  1J- 
thplial  liniiiK  of  thi*  uir  J»a<'  <ri)  anil  u|Min  ihi*  r-ipilliiry  IH-I^"rk  of  the  al\i->.l,ir  ^A\'  '>  ^. 
normal  air  tiar;   H,  <'\|>an(le<l  air  nar. 


t«ke  first  the  <-<>iKlitio!i  of  liun',;.:!  <-n)physi>in:i,  in  wliiih  <\f  chiiiKf 
affwts  one  smi !'  iiroiichial  tn-:-  aiui  '  ^  ussoeiat*-" I  air  sacs,  l!i<  i'  -I  of  tii,' 
lun^  l)eing  in  a  n(mnal  state,  it  is  ohvioiis  here  that  the  pts  muP'  hi- 
dition  has  involvtHi  the  bronelius.     W'v  can  l)eHt  explain  the  di  vc!.  i  irn: 


UMPffrsEMA 


avj 


t«  pr» Miming  «  inifri>wiru{  „(  the  lumen  of  the  >.mn<hiis.  wlw-flMT  iy>< 
srnitui  -T iiMhK-ci  bv  intliiamiitton-  thi(  kcninv.or  hv  the  pn*?wnri>  nf  thick 
xmlati  nithiii  ti      In  suctj  a  iW  th»-  for  ihle  iiatnrt-  of  the  iaspiratorj- 
Id  .Int.  ~  iir  into  the  stsswiated  air  .■wcs;  t\\r  pas.>.iv.-  nature  of  the  exnim- 
urn  m  iiu(y  prevent  uti  equal  amount  <>f  air  liMtmiiriK  expirtfl.    Tlw 
n-tiiil  will  l»  that  with  successive  acts  .>f  in-spiration,  the  air  ^acs  will 
[mtirm-  i..  re  hihJ   rmm'  «li.Htemle«l,  as  «lemoKstniu-.l   bv   Bnnli.-  ami 
Divui's  ,vj»-riiiieni>,  already  note.1  (p.  2   '>     'IVre  is." it  i^  true,  mi 
adivf  f..nr  .^)po;»iiij;  ov«r,|isten.sion.  nanaiy.  the  fairlv  abuiHlant  ela^i. 
iMif  in  III.  ;ilveoUr  WHik.     T\m  force  us  most  effirtive  when  the  air 
sir.  an-  ill  a  stale  of  .li>U-asi<Mi.  it  is  of  little  eff«-<t  when  the  alveoli  are 
(ilv  iii.Hlc-ai.ly  filhsi     Time an.l  ujrain at  autopsy  we  notice  that  a  ver>- 
A\fh<  i:nu\f,,{  broiuhitLs  suffices  fo  prevent  the  jiosi  n.    »,  m  ct>llapNe  of 
ihe  I  if.k'^.    Th.is.  under  the  coralifion  postulattd,  '«  •!    »he  expiratorv 
Ht   iml  ilif  ciijstiiity  of  the  alveolar  walls  «!.•  uiiaMt-  to  reduce  the 
«i>  -a.s  r..  ih.'  coliafwed  expiratory  state     Fij{.  »«).     If  the  sute  of 
01  union  U   kept  up,  it  maf.rially  atfects  the  ai)iiiidant  capillarv  net- 
«..rk  nf  (1...  alveolar  wall.     When  that  wall  is  n.llapse*!,  the  pressure 
frtMi,    Aiilinit   ii|M>ii    the  capillarus   is   re.!iM-e<l.   Uh-v  an'   >  ircular   in 
Mr(i.      mil  tluri-  is  a  minimal  ..l.stnMtion  to  the  oiifl.nv  of  bLxnl.     When 
I  li.    ..Hilary,  th.-  air  .sac  is  di     •IKh^l,  not  .,nlv  ilo  tin-  capillaries  Im-ome 
■'M.l   ,|.  1,111  in  a.lilition.they  an-  suhj.-cted  fo  i  .-rea-se.!  pre.ssurv  from 
&r  -n  aia,    d  air.     The  result  is  that  the  iiHlivi.lu«I  capillaries  iM-wme 
tir  tiMsl  iui.l  flhp'i.al  III  scetioii;  not  ..iilv  can  thev  contain  less  blood 
l.nt  that  Mimll.r  amount  of  bl.xKi  is  e.\p(')se.|  to  a'lanjer  .siii'ice   and 
.;mse<|ujnil    I..  i,Krea.s.  d  friction.     Thus,  if  the  distension  Ik'  .-ontinueil 
III.'  r.Milt  I,  ( ..ntimi.'.l  ii.aii„itrition  of  the  alveolar  wall.  re«luc.-.|  ifaseoas 
inur.  laiii:..,  atrophy  of  the  wall.  .liininL*he,l  clastic  cissiie,  and  diminishe,! 
Hast,,  ry;  y..,  further  dilatation,  with  fasion  of  the  air  sa-s.  until  now 
.'.n  If  tl„-  .,!,sini.tion  U-  remove,!  ».„|  the  in>{«-s,s  and  eKre.s,s  of  air  u' 
r.M.md,  .,1..  mn,p|.v  of  th..  fissu..  .u'.!  lac  want  of  pr»,H.rtion  U-twirn 

"r  \ '"•  "f  '•"•  »'^  '"  ""■  >f  '  i--'  system  h.mI  the  cross-^.ti.m 

"f  th..   .-in.r;:....!    I.ron,  liioi,  Vi     ■  ..•    einphvscmatoii.s    condition 

iH-nii.iM.Mt,  M.  that  in  an  ..th.  r,.  .,t  i.ea.ii.y  Iuiik  we  mav  en«.unter  thiri- 
»allnl  traM.I,.,tnt  sacs  with  ,Hvi.sional  i:.ii.  septa  cnKsin^  them  which 
may  a.MiM  t,,  ii„.  sue  of  a  pip  ..n's  efia  or  larpr.  -.nd  proj«-t  prominentiv 

.«ne«I.M  ,litf,  r,nt  means  in  the  comlltion  of  ct,mpellsat..r^•  emphvsema 

t-r...  with  ...llapsc  „f  the  air  sacs  coimecte,!  with  trrtain  brtinchi.  the 

"^".•..f  ,[,..  ,„sp,rai.,ry  nepuive  pressure  Iea«ls  t..  an  ovenlistension  of 

air   ;ms  ,,.„n,.c,„l  ^.th  other  Im.n.-hi.  and  especiallv  of  such  air  .sacs 

".I'ni!,..    I'T"    <,  "'*''*'' "^  "if  '"••♦^-a.s  are  m.t  support,.!  bv  mutual 
."'•i'"    "•"     Mich  cxtr,-me  .l.stension  is  apt  to  overstrain  the  elastic 
'"  alv.s.lar  walls  and  brinj;  alnuit  atrophv. 

N.in..  con.litions  mti.st  Im>  operative  in  causinj;  K.-neralize<l 
111  prhaps  the  majority  of  ca.ses  micmscopic  examination 
Mst.iiM.  „f  a  chn.nic  bronchitis  and  p«'ribronchitis    /   ,■ 
ilic  main  causati\"  f,:"tor  has  been  a  diminution  of  the 


llssiu 
.N'tiw  (:,, 

'■iii|)liyvcrii 
ffifak  ill. 


iR^. 


260     THE  RESPIRATORY  FUNCTION  AND  ITS  DISTURBAM  ES 

lumen  of  entranre  and  exit  of  air  to  and  from  the  air  saes.    liut  in  other 
rases,  as  in  ehildo'n  after  prolonged  whoopinR-eoujfh,  in  glasshlowcrs, 

flayers  upon  wind-instruments,  the  olwtruction  has  l)een  situated 
ifjher  up  in  the  respiratory  passages.  But  in  many  of  these  cases  also  it 
is  to  Ik-  noted  that  the  condition  develops  with  advancing  life;  /.  r, 
jast  as  in  the  vessels,  so  in  the  lungs,  there  is  a  progressive  diiiiinution 
in  t}>e  elasticity,  and  an  atrophy  of  the  elastic  connective  tlssiifs,  so  that 
the  lung-tissue  does  not  sufficiently  aid  the  thoracic  wall  in  l)rinpng 
alKiut  expiratory  contraction  of  the  lungs. 

The  effects  of  such  generalized  emphysema  are  thus:  g«tni^lizf,j 
expansion  of  the  lungs,  coincident  enlargement  of  the  thonix.  which 
assumes  a  characteristic  barrel  shape  (the  "air  hunger"  dcnmiuis  con. 
stantly  the  entrance  of  more  air  into  the  already  overfillwl  air  shcs,  him! 
therewith  increa.setl  inspiratory  expansion  of  the  thorax),  |>rok)npil 
expiration,  diminished  gaseous  interchange,  obstruction  to  tin-  [Kissap' of 
bliKxl  through  the  lungs,  hj-pertrophy  and  dilatation  of  thi-  rijilit  heart. 
and  eventually  dyspnoea  and  cardiac  failure.     . 

How,  it  may  be  asked,  does  this  conception  agree  witli  tlic  various 
views  that  have  been  enunciated  regarding  the  etiology  of  vesicular 
emphysema?  I^ennec  was  of  opinion  that  mucus  in  tin'  liiincii  of  the 
brt)nchi  exercised  a  l«ll-valve  action  admitting  the  entry,  hut  prcventinc 
the  <lischiirge  of  air  from  the  air  sacs.  This,  it  will  Ik-  n-cofriiizcd,  is  a 
possible  cause  of  one  series  of  cases.  Gainlner,  in  ]S.')7,  lirM  that  col- 
lapse, either  complete  or  partial,  of  one  portion  of  the  liiii};  was  a 
njH-essarv-  antectnlent  of  emphysema  in  another  part;  that  llir  condition 
was  compensjitory.  This,  again,  can  Ih'  applie«l  to  only  one  scries  of 
cases,  and  cannot  ex|)lain  diffuse  emjihysema.  Of  more  iinfjortaiur 
are  tiic  views  of  Mendelssohn,  f(>llow«Hl  by  Jenner,  tliitt  dltstriicliil 
expiration  is  the  essential  cause.  They  showe<l  clearly  that  the  empliv- 
scuiatous  condition  followwl  violent  expiraton*-  effort,  ami  |«)inte<l  out 
that  the  in<-rea.sed  pn'ssure  in  the  alveoli  must  tend  to  affec  t  most  thfl>e 
|)ortions  of  the  lung  which  have  least  sup|M)rt  from  their  siirninndini.'s. 
and  that  so,  as  a  matter  of  fact,  emphysema  shows  its«'lf  most  extensivdv 
along  the  e<iges.  This  view,  however,  leaves  out  of  accdiint  the  naiiiie 
of  the  lung  substance  as  a  factor  in  the  devclopnieiit  of  the  (Diiditioii. 
,1.  .lackson,  Jr.,  of  Boston,  was  the  first  to  dirtn-t  attention  to  ;in  iiihcritrd 
liai>i!ity  to  emj/nysenia,  and  to  the  fact  that  it  is  mon-  eoinnion  in  \ht 
young  than  is  usually  siipiHwinl.  This  secmwl  to  |)oiiit  to  sonic  <lts 
velopincntal  defect  in  the  luiiT  tissue  a.  a  factor.  Cohrilu  irii  ( cdichidol 
that  the  explanation  was  to  Ik-  sought  in  a  congenital  inipeilV<  i  formation 
of  the  elastic  tissue,  l)asiiig  the  view  ujxvi  exfH'riineiils  uliiili  demon- 
str.ite<l  the  singular  loss  of  elasticity  of  ihe  lung  in  ailvan< nl  .  inpliysiinii, 
Kppinger,  admitting  this  loss  of  elasticity,  held  tlmt  in  ili''  majority 
of  cases  it  was  u  siH-oiidarily  induced,  anil  not  a  priiiiny  eoiMlition. 
Lastly,  Isaaksolm  reganlc<l  the  disease  as  essentially  dn.  to  vascular 
disturbanec.  .Vs  we  have  jniintt-d  out,  tin-  vascular  disturlMii  e  naturdll) 
follows  |MTsistent  distensio?)  of  the  alveoli.  It  will  Ik-  m.  i  iliiit  our  con- 
c-eplion  of  liie  natiin-  of  the  priHcss  takes  into  account  !"';!'  tlie  factors 


MODIFICATIONS  IN  THE  CONSTITUTION  OF  INSPIRED  AIR    2«)1 

which  may  be  regarded  as  clearly  esitaiJlshed,  namely,  (I)  increased 
(iiffiriilf  of  expiration,  leading  to  raised  intra-alveular  pressure,  and 
(2)  (liiiiiiiislied  elasticity  of  the  alveolar  wall.  It  must  lie  freely  admittecl 
that  tlitso  interact,  and  that  one  or  the  other  may  be  the  more  prominent 
in  the  early  stage.  Thus  a  congenital  deficiency  in  elasticity  will  render 
a  n-lativi-ly  slight  obstruction  to  expiration  the  more  effective,  while, 
fontrariwise,  in  the  lung  passessing  well-marked  elasticity,  prolonged 
(listfiision  of  the  alveoli  eventually  brings  about  atrophy  of  the  elastic 
tissuf.  Further,  it  has  to  Iw  noted  that  the  elastic  tissues  of  the  bofly 
are  lialilc  to  lose  their  elasticity  with  advancing  age,  and  that  so,  condi- 
tiiins  wliioli  have  little  effect  in  early  life  favor  the  development  of  em- 
physema at  a  later  period ;  this  loss  of  elasticity  is  a  characteristic  feature 
(if  arteridsclerosis;  we  are  thas  prepared  to  find  that  emphysema  and 
arterioselerosis  are  very  commonly  associated  conditions. 

Bronchiectasis.— Here,  in  passing,  may  be  noted  the  contraste<l  condi- 
tion of  l)n)nchiectasis,  in  which,  through  atrophy  of  their  walls  or,  again, 
throiiuli  tension  cxerti-d  upon  them  from  without  by  the  contniction 
(if  interstitial  fibnius  tissue,  the  bronchi  and  bronchioles  undergo  dilu- 
tatioii.  Whether,  as  in  the  latter  category  of  cases,  the  alveoli  have 
iiiuler);(ine  a  coincident  compression  by  the  interstitial  tissue  or  not,  the 
(iilat  ii  iiroiichi  take  the  space  that  should  be  occupied  by  functionating 
air  .aes.  Here  also  the  result  is  a  diminished  aeration  of  the  blootl. 
'Hk  (litrereiit  fonns  will  \k  found  <lescril)ed  on  p.  2.S1. 

Interstitial  Deposits.— \cw  tissue,  whether  fibrous,  as  in  chronic 
interstitial  piicuinoiiiu;  granulomatous,  as  in  tuliereulosis,  syphilis, 
mtimimvitisis;  or  neoplastic,  leads  to  compression  and  diminution,  if  not 
alisohite  (Kilusion  of  the  air  sacs,  and  in  addition  affords  a  mechanical 
resistance  to  their  expansion  during  inspiration.  According,  therefore, 
III  the  extent  of  tiie  development  of  these  interstitial  dep<xsits  within  the 
inn;;  siilistaiicc,  so  do  we  obtain  greater  or  less  reduction  in  the  functional 
eapiicity  (if  tile  lungs.  Nor  has  the  amount  only  of  the  new  tissue  to  lie 
taiien  nito  coiisidenition,  anil  the  lessened  amount  oi  air  which  in  consc- 
i|iieii(r  (ill!  Ik-  inspired.  Such  interstitial  deposits  gravely  olxstruct  also 
the  iMihiKiiiary  circulation;  interstitial  fibrous  tissue,  as  it  contracts, 
()lilit«-at(s  hir^'ciy  the  capillaries  of  the  alveolar  walls;  the  granulomas 
an.!  iiiMiors,  as  they  grow,  obliterate  the  surroimding  air  sacs,  and  if 
sitiiaie,!  within  the  lung  sulwtance  rather  than  at  the  surface,  obstruct  the 
''1'«hI  Mi|.,,|y  of  the  tissue  lying  between  them  and  that  surface. 

Modifications  in  the  Constitution  of  the  Inspired  Air.- This  is 
asiil.j.rt  (hat  is  treated  so  fully  in  the  larger  text-books  of  physiology 
"'at  Ik ;n  it  ,s  only  necessa."^  to  recall  the  main  facLs  that  have  IxH-ii 
iisirriaiiH,!  Oxygran  is  the  essential  constituent  of  the  inhale*!  air. 
In  the  nnriiiHl  animal  this  may  lie  materially  increased  in  amount  without 
"i-Hlih.minn  ,,f  the  respiratory  exchange;  nav,  if  the  animal  breathe 
jHire  „x,,M  „  instead  of  air,  there  is  little  immediate  effect,  metalwli.-in 
•"■'ii;:  n  ,,ila(„i  l,y  the  needs  of  the  tissu.-.,.  and  not  iiv  the  amount 
(It  (i\v-, .,  i.rescnt.Hl.  When,  however,  the  WckkI  comes  to  contain  one- 
inini  i,„„,.  ..xvffcn  than  normal,  metjdwiism  is  arrcste.1  and  the  animal 


m 


262     THE  RESPIRATORY  FUXCTION  AND  ITS  DISTURBAS'CES 

dies.  Such  increase  may  Ite  brought  about  by  inhalation  of  the  pis  niHlrr 
pressure,  and,  as  shown  by  Paul  Bert,  if  this  pressure  be  incroii.sed  to 
six  atmospheres,  the  animal  dies  in  violent  convulsions.  The  same 
effects  may  be  induced  Uy  breathing  air  under  pressure,  altliou^'h  hcrr 
the  pressure  has  to  be  rai.sed  to  a  much  greater  extent  in  onier  to  attain 
a  partial  pressure  of  the  contained  >)xygen  of  the  same  value.  .\.s  shown 
recently  by  I<eonard  Hill,  where  the  individual  through  masfiilur  exercisf 
— as  in  runners  and  those  engaged  in  football  matches — is  in  nwl  of 
oxygen,  the  effects  of  inhaling  pure  oxygen  are  immediate,  reiievinj;  the 
hyperpnoea  (i.  e.,  rapid,  lalmred  breathing)  and  fatigue.  The  sarnt-  is  tnie 
when  the  respiratory  surface  is  diminished,  as  in  pneumonia.  Tlif  oppo- 
site condition  of  diminLshetl  atmospheric  pressure  produces  its  icsiijts  hv 
iliminution  of  the  partial  pressure  of  the  oxygen,  and  so  of  the  lunoiint 
of  this  gas  which  can  diffuse  or  otherwise  gain  entrance  iiitu  tlie  hlooi. 
When  the  atmaspheric  pressure  is  reduced  to  half  an  atmosphere,  inarkwl 
discomfort  is  felt,  with  dyspnoea  and  rapid  breathing;  with  reduction  to 
250  mm.,  the  symptoms  l)ecome  violent,  with  profound  tliniiniition  of 
the  oxygen  in  the  arterial  blcNNl,  convulsions,  in.sensibility.  and  death. 
Similar  r«>sults  are  produce*!  by  maintaining  the  normal  atniosphfrir 
pressure,  while  retlucing  the  amount  of  containe<l  oxygen.  /.  <.,  riHliicin); 
the  (mrtial  pressure  of  the  oxygen.  An  air,  for  example,  that  eontairK 
only  o  per  trnt.  of  oxygen  produces  insensibility  in  man  within  a  minute. 

The  nitroftn  of  the  air  is  wholly  inert,  and  variations  in  it.s  aininint  are 
without  effect  so  long  as  the  |)artial  pn-.ssure  of  the  oxygen  is  uiaiiiiainrd. 
Though  here,  again,  as  in  eaiMon  diiMMe,  with  increa.se  in  alnii>spli('ri( 
pressure,  an  increa-sed  amoutit  is  taken  up  by  the  blocxl,  and  if  the  pns^- 
ure  1h'  suddenly  removed,  the  lilK>ration  of  the  gas  in  the  eapillarics  in 
ga.sfH>iis  form  lea<ls  to  profotmd  and  often  fatal  results.  Hydrogu 
is  .similarly  inert;  animals  can  breathe  without  apparent  ill  etftrt> 
a  mixture  of  i>(|ual  |)arLs  of  oxygen  and  hydrogen.  Argon  is  aKo  statfl 
to  Ik'  inactive. 

Gubon  Diozido. — E.xcess  of  this  gas  in  the  air  produce^  etftris 
more  rapiilly  than  d<M's  deficiency  in  oxygen,  or  otherwise,  to  this  pis 
more  jwrticularly  are  due  the  deleterious  effects  of  air  vitiatnl  l>y  Uiiij 
brcathetl  over  again  in  a  confinwl  space  without  ventilation.  Thr 
figun's  given  by  diffennit  olwerwrs  for  the  maximum  amount  of  iliispi^ 
which  can  l)c  in.spire<l  without  ili.sc«mifort  vary  .somewhat  wiilcly.  Thi 
mo.st  accurate  app<>ar  to  Im>  tlio.se  of  Haldane  and  I./orrain  .'^njiiii.  Tht} 
found  that  the  pn-stMu-e  of  IS.(»  |ht  cent.  in<luce<l  in  them  li\|Kr|)n(ra 
and  di-stress,  with  flushing,  cyanosis,  and  mental  ctmfusion.  .iiul  this 
within  a  minute  or  two,  and  that  when  the  carlK>n  dioxide  in  \iiiaiitiiiir 
rose  to  from  .1  to  4  jier  cent.,  .symptoms  of  hyperpnieit  iiinl  ili-trcsMil 
Im'athing  gradually  dcvelop'tl.  On  the  other  hand,  liy|)t  i|piiiia  fmni 
deftrt  of  oxygen  only  showed  itself  when  the  oxygi-n  was  nilnml  lo  I- 
|>er  i-ent.  in  one  individual,  to  (>  per  cent,  in  another.  I  hi  volatiif 
substances  exhalol  or  given  off  from  the  .skin,  whixse  preseii'  •  i-*  so  pni- 
nouiMfcl  in  the  air  of  cn»wded  and  ill-ventilate«l  nMiins,  .ii-'  loiilitfiilly 
toxic,    but    im<ioubtcdlv    thev    caiLse   di.s(H)mfort    in    hrea'  iiii;.    l^f 


aikit; 


CARBON  MOSOXIDE  POISONING 


263 


rarlMin  dioxide  is  irmpirahle;  it  causes  an  immediate  spasm  of  the 
glottis.  TLe  '•yanosis  and  toxic  etfeets  of  the  gas  are  due  to  iu  accumula- 
tion in  flic  1)I(mh1  ;  where  the  amount  in  the  iaspired  air  is  excessive,  thert-, 
iasteud  of  lieinjf  discharged  from  the  blood,  it  is  alisorlied  from  the 
pulmonurv  air.  Speck  found  abundant  altsorption  when  the  air  con- 
tiiined  1 1  ..il  per  cent.  CO,. 

Other  pLses,  like  ammonia  and  nitric  ozida,  are  irrespirable  even  in 
small  amounts,  in  consequence  of  the  spasm  of  the  (glottis  induced  bv 
them,  ^'et  others,  like  nitroni  oxide,  carbon  monozido,  and  hydrogen 
lulpbide,  can  lie  breathed  and  undergo  absorption,  pnxiucing  specific 
I'tftt'tv  Of  these,  the  most  important  is  carbon  monoxide,  and  this 
iK-caiiM-  the  hemoglobin  of  the  corpuscles  has  an  intense  avidity  for 
the  siunc.  ctimbining  with  it  to  the  exclusion  of  oxygen.  As  shiiwn  by 
Haldanc,  symptoms  manifest  themselves  when  the  corpu.scles  l)ecome 
aliout  one-thini  saturated,  and  liecome  urgi>nt  when  they  are  half  satu- 
rated. These  symptoms  arc  itientical  with  the  effects  "of  retlucing  the 
amount  of  o.xygen  in  the  respired  air.  With  the  presence  of  0.05  per 
cent,  of  this  gas  in  the  air,  .symptoms  show  them-selves ;  when  the  per- 
centage rises  to  0.2  they  become  severe.  It  is  this  carbon  monoxide 
poisoning  that  is  the  cause  of  the  fretiuent  deaths  from  inhalation  of 
coal  ga.s,  from  the  fumes  of  charcoal  and  coke  fires,  kilns,  and  noxious 
gases  in  coal  mines,  more  especially  after  explasions. 


CHAPTER    XII. 

THK  IfRSI'IHATOHY  P.\SSA<iKS. 

THINOSS. 

OONQKNITAL  AH0MALIE8. 

The  most  oommon  anomaly  is  nn  asymmetrical  position,  jiciicnillv 
(lue  to  deviation  of  the  lM)ny  septum,  a  condition  which  is  present  iii 
more  than  .K)  jht  cent,  of  individuals.  Malformations  of  lii>;li  ^rradc, 
however,  an-  almost  invariably  associated  with  other  defects  of  tlie  face! 
For  example,  in  the  condition  known  as  cydopi  the  nose  may  Ik-  iilwrit 
or  rudimentary.  One  or  more  of  the  turbinated  bones  may  Ik-  altsetit. 
the  anterior  or  {xxsterior  nares  may  Ix'  (xx-luded,  or  there  mav  lie  (jefcd 
in  th«'  ahe  or  the  H<M)r  of  the  nasal  cavity.  The  last-mentioned  (oiidition 
may  Ik-  found  ass(x-iat(Hi  with  harelip  or  cleft-palate. 

OIBOULATOKT  DUTUBBANOBS. 

Owinj;  to  its  excessive  vascularity,  the  nasal  mucosa,  parliciil.iriv  the 
erectile  portion  of  it  in  the  neighborho<xl  of  the  lowest  tmhinal.  i> 
s|M-(ially  liable  to  sudden  ami  extn-me  disorders  of  circulation. 

Hyperemia.-  PuaiTe  Oongestloii.— Passive  congestion  is  found  in 
heart  and  lung  diseases,  and  in  consequence  of  the  presence  of  tumors 
in  the  nasal  cavity. 

Active  Hyparamu.  -.\ctive  hyperemia  is  common  at  the  enunnpncc- 
nient  of  iiiHiuninatory  prix-esses  and  in  some  infective  fever-,  sueli  as 
measles,  ty|>hoi(l.  and  inHuen74i.  It  very  readily  lead-  to  riipture  aiid 
heinorrliaj;e  (episUxis). 

Hemorrhages.  -Hemorrhages  are  also  common  in  heniopliilia.  leuke- 
mia, death  from  sufftxation,  and  as  a  msult  of  trauma.  Of  more  tlian 
ordinary  interest  are  the  cases  of  vicuious  hemoirhsge  takinj:  iln'  place 
of  ordinary  menstruation.  In  fact,  there  .seems  to  Ix;  some  suri|iatlietic 
n-latioiiship  Ix'tween  the  nasal  mucosa  and  the  sexual  organs,  for  duriii); 
sexual  ex(il«inent  the  membrane  Ixtomes  turgcscent. 

(Edema.    (F/lema  is  a  fre«|uent  result  of  inflammation. 

nrrLAMMATIONS. 

Acute  Catarrh  or  Gorysa  (Acute  Ehinitis).— .\cufe  rliinii-  mmr* 
as  a  primary  airectioii  which  is  ustndly  attributcil  to  the  .  iln  ts  of 
ex|x»sur«'  to  ((dfl  and  wet.  and  to  Imcterial  influences.     It  i    prolable 


..».a  '--1":^. 


Hiiixins 


205 


that  iii<livi»lual  peculiarities  are  also  o|>erative.  Chemical  irritants, 
such  as  aininonia,  formalin,  nitric  and  osniic  acids,  can  induce  severe 
rhinilis.  Some  people  are  very  sasceptihle  to  the  influence  of  certain 
volatilf  siilwtantvs,  like  ipecacuanha,  the  scent  of  certain  flowers  or 
iiniin  lis,  jHillcn,  etc.  To  this  group  l)elongs  hftjr  fever,  which  seems  to 
IxMJiu-  to  personal  iiliosyncrasy  of  this  kind.  Coryza  us  met  with  also 
as  tt  complication  of  many  infections,  as  measles,  typhus  fever,  and 
infliiciizti. 

The  condition  is  often  important,  as  the  inflammation  may  spread  to 
the  acccssorj-  cavities  ami  siniLS«>s,  to  the  throat,  to  the  Eustachian  tubes, 
ami  middle  ear.  In  acute  <tiryztt  the  muctxsa  is  swollen,  hypcremic, 
of  a  (lfc|K'ned  color,  with  often  considend)le  thickening,  and  feels  drv 
siiui  irritahlc.  After  this  first  stage  there  is  an  abundant  secretion  of  a 
clear,  watery,  very  slightly  viscid,  irritating  fluid,  which  contains  leuko- 
cytes and  ciliated  epithelium.  Erosion  of  the  edges  of  the  nose  and 
ii|)|)cr  li|)  is  fre<piently  the  n>sult  of  its  irritating  qualities. 

Purulent  Bhinitia. — This  form  may  develop  into  a  purulent  rhinitis. 
It  is  cliaracterizt'd  by  gn-ater  inflammatory'  reddening  and  swelling  of 
ihf  miicosn,  with  an  al>undant  purulent  exudate,  often  mixed  with 
hiixxi,  and  having  a  foul  (Mior.  It  may  lead  to  collections  of  pus  in  the 
various  accessory  cavities  (p.  (/..  empyema  of  the  antrum  of  Highmore). 
The  suppurative  pnx^.ss  may  extend  into  the  deeper  parts,  leading  to 
the  formation  of  Iwal  abscesses  and  erosion  of  i)onc  or  cartilage.  Sup- 
purative riiinitis  may  occur  jis  a  primary  infection,  or  may  lie  a  compli- 
cation of  infectious  diseases,  such  as  .scarlatina,  variola,  and  diphtheria. 

Croupous  and  Phlegmonoos  Inflammation. — Croupous  and  phlegmonous 
inflammation  are  also  descril)e<l. 

Chronic  Rhinitis. — Chronic  rhinitis  iK-ciirs  frequently  in  thase  of  a 
phthJMcal  or  syphilitic  habit,  but  sometimes  in  healthy  individuals. 

In  tli(  |)ro(iuctive  forms  there  is  a  gener)ili/.(Hl  cellular  infiltration  of 
the  nuKDsa,  particularly  that  covering  the  lowest  luri>inals,  which  leads 
to  a  more  or  less  extensive  thickening  of  the  membrane  (rhinith  hyper- 
trnphirin.  This  gradually  gives  way  to  «  contracting  fibrous  tissue, 
relatively  |Mwr  in  cellular  elements,  in  which  the  glands  are  atrophic, 
that  iiitimatcly  leads  to  atrophy  of  the  bony  parts  (rhinitis  atrophica). 
In  tli(  M  later  stages  the  mucosa  is  coverc<i  with  a  thick  vellowish  or 
yilloHi.||-;rr,rn  purulent  .secretion,  together  with  thick  scabs.  These 
liavi  ,1  MTV  cliaracteristic  and  offensive  (xlor  {ozirna). 

Tuberculosis.  -  Tul)erculasis  takes  the  form  of  tul>ercul()us  granula- 
lions  or  actual  ulceration.  It  is,  on  the  whole,  not  frequent,  except 
ttlien  iliii,.  is  rnost  advancetl  tul>crculous  di.sease  of  the  respiratorv 
passip  V  the  pahite,  or  the  pharynx.  Lupus  of  the  face,  however, 
frti|iir!,il ,  extends  into  the  nose  and  cau.ses  widespread  destruction. 

Syphilis.  .Syphilis  takes  the  form  of  a  purulent  catarrh,  which  is 
|<ry  ,oi„:ii,,„  i„  ,|„.  eruptive  stagi>  of  the  disea.se,  and  in  the  congenital 
lusoi  .;„.  MewlH»rn.  As  with  other  muc-ous  surfaces,  the  na.sal  muccxsa 
can  I,,  I  ,,  .it,.  „f  eondyhnnata.  More  fre«pient  is  the  gumnmtous  form 
of  th,    li  ,;„,..  whieh  may  In'gin  cither  in  the  inuc<xsa  or  in  the  bonv 


W0 


THE  SOSK 


I 


iiiul  cartilti^inous  .striH-tim>.s.  'I'his  leads  often  to  |>erfnfBtioii  of  the  -««». 
turn  Hiitl  tlif  ImnI  (Nilate,  with  tlie  pnxliH-tioii  of  the  dmnu-teristir  sidiH,^ 
.sha|»e«l  ilcfoniiity  |i  is  uss<MiHte<l  with  a  thick  purulent  sicntidti, 
whiili  liries  into  hani  sj-alxs  and  has  a  ven'  offensive  (nlor  kimwo 
xifphilitira). 

OliBCleri.  — (ilwnders  causes  a  purulent  or  a  purulent-hciiiorrlmpc 
diM-hHrge  fnmi  fliv  nose,  and  pnxluces  in  the  mucosa  either  a  (jitfusf 
inflanitnation  or  multiple  small  aUsj-esses.  The  pr«Mt'.ss  nmv  lead  tii 
(iestru<-rion  of  tlie  lione. 

Lefurwjr.  I^pmsy  is  found  in  the  form  of  ncKlular  jrniimlomas, 
which  may  form  uU-crs  covered  with  thick  crusts. 

RhuuwclerOHM.  llhinos<'len)ma  is  a  [M-culiar  disease  first  stiiiltril 
fully  hy  V.  Frisrh,  I'altauf.v.  Kis»-lslier>t,  and  ().  Chiari,  which  is  (liiinic- 
teri7,«-«l  hy  the  fcrrmatiim  of  nixtular  masses  of  almost  ivory  roD^istciuv. 
chiefly  uptin  tiic  iiasjil  iinicosa,  hut  also  upon  the  skin  and  the  iipixr  lii). 
I^ter,  the  masses  c-oalestv  and  lol>ulate<l  tumors  are  priHlucctl. 

Mic-rosi-opically,  in  the  suhmui-osa  and  sulN-utaneous  tissues  a  nHind 
and  spindle-<vlle<l  infiltnition  is  set>n.  The  infiltration  is  |)erlia[)> 
more  marked  in  the  deeptT  layers  where  the  c«'lls  are  larger  and  often 
hyaline  or  show  mucoid  de^>neration.  The  walls  of  the  vessels  arc 
ihicken«-d,  and  ail  jwrts  show  a  chr»)nic  priNiuetive  inHaiiunalioii. 
Numen>us  "mastzellen"  are  found  in  the  infiltrate<l  an'as.  Tlie  condi- 
tion is  due  to  a  sfMfific  miero(>rpinism  which  is  found  ahiniilaiiilv  in  the 
swollen  cells. 

Paraaites.  A  frreat  variety  of  th«'se  have  l»een  des<'rilH*(i.  Hesides 
till'  .ichizomifrrlts.  may  l)e  mentioned  the  Oidium  nlhifiiiiK,  the  .NVii/n- 
pniini,  and  the  larvie  of  various  diptera  (producing  a  condition  of 
myiuis). 

Foreign  Bodies.  —These  are  very  friHpiently  insertwl  into  the  iiosp  In 
childn'n.  Many  siihstances  iiavj-  U-en  found,  such  as  niurlilcs,  peas, 
iH-ans.  pajH-r,  and  wimmI.  H.  .S,  Flirkett'  has  riH-ently  ref-onitd  a  curious 
<ast'  in  which  a  thimlile  was  eml>edde«l  in  the  nose  for  cif;hlccii  years. 
It  was  found  In  \h'  incrustcd  with  salts,  the  surfaer  In-inj;  (|iiit('  >iTi(K)tli. 


RETR00RB8SIVE  METAMORPHOSES. 

Calcification.-  Calcification  of  the  muco.sa  is  ri'c-ordcd.  It  takc^ 
the  form  of  scattcretl  spicules  of  lime  enilHHlde<l  in  the  niciiilitaiir,  ornf 
actual  plates. 

Bhinoliths.—  Uhinoliths,  or  concretions,  may  Ih-  forniid  iji  |)lii).'s 
of  inspi.s.sate<l  nuicus,  hut  more  usually  the  .salts  are  dcfxivii-d  alMHit 
foreign  ImmUcs.  Sometimes,  instea<l  of  a  calcare«)us  couliii};.  a  ( aseoiis- 
l(M>kinj;  mass  composed  of  <lead  e|)ithelium,  lenkcHytes,  ar„l  detriiiis 
may  In-  d«'|>osit»'d  upm  the  offending  sulwtantT. 

\  i>tr/orafliifj  iilrtr  of  the  septum  (apart   fn)m  the  >\ii'iilitic  anil 


i  :• 


Montnal  .Mislical  .Journal,  2.S:  IS'H):  44!!. 


llU.  J-.. 


PROORKSSI VE  .\fETA  AtORPHOSKS 


2B7 


tuherciiliuLs  variety)  is  decidedly  rare.  Aeconliiijj  to  Zuckerkandl,  it 
dors  not  net-essariiy  fuiluw  inflamtnati(>n,  hut  may  >k-  a  purely  retro- 
jjrwsivt'  plienomenon.  It  may  perforate  «ir,  healing,  leave  a  (lease  scar. 
ITie  c-oiiditioii  has  l)een  attrihuted  to  coagulation-necnxsis,  capillary 
thnxnlxxsLs,  the  action  of  Itacteria,  aiMl  to  a  truphoneurusLs. 


PEOORIUIVI  MITAMOBPHOSU. 

The  mticoiLS  membrane  of  the  nose  and  of  the  accessory  cavities  often 
shows  hjuwpliirtlB  growth  or  actual  tamor  fonnation,  which  may  be  due 
to  a  preexisting  inflammation  or  may  arise  without  discoverable  caase. 
The  lesion  is  diffuse  or  may  result  in  the  formation  <»f  Ux-al  excrescences 
or  putjipn.  A  common  form  is  the  soft  or  myzomatoui  polyp,  which  is 
of  a  jtniyish  semitransUicent  appearance.  Nasal  polyps  are  fre<juentlv 
multiple  and  may  attain  a  considerable  size.     They  are  composed  of 

Km.  M 


IVl* 


MvM.iiitttims  iMilyp  irom  the  none.      Winckel  iibj.  No.  (I.  williuut  iicular.      (Kn.m  the 
rollectiun  of  Dr  A.  (■.  Nir)i')ll<t. i 

tissue  i.l(  iitical  with  that  of  the  mucoids  nicntbrane,  except  that  it  is  more 
Hliihi!  Within  this  growth  gbnds  may  Ufome  entangled,  which  soine- 
liiiit-  la  (  onif  <lilate<l,  owing  to  the  retention  of  secretion,  so  that  cystic 
liiimiiN  ,ih  tilt-  result.  In  other  cas«'s  the  glandular  elements  proliferate, 
pviii;;  li-i  to  adenoma.  From  the  dee|)er  Kbrous  structures,  particularly 
froiii  !!i,  t,(,iiy  parts,  flbromu  often  develop.  These  often  InHome 
(^1ll■rnM,.l|^,  thus  simulating  the  my.\omatous  polyp.  They  have  a 
mor.        !,iw  color,  however.     Owing  to  excessive  development  of  the 


i  i 


r ; 


;,  r 


'2i-K< 


THE  I.ARYSX  ,1V/)  THACIIKA 


biHOfivciiseLs,  UlugiteUtie  or  MTtrnou  flbroaM  are  pnxlmtil.  \a.,al 
polj-ps may urMlriyii hyaliiir or c-alcareoii.s (iefrencration.  Strictly siM;ikiiiu. 
must  «»f  these  polyps  are  not  true  tumors  hut  should  \tc  ria.ss<>«l  wiih  iIh' 
hypcqilastic  fonnntioiLs  n-sulliiiK  fn>m  u  pnH'xisting  influminHtioii. 

Oardnonu.-  Primary  carcinoina  takes  the  form  of  medtillarv  vunm 
or  of  epitheliomatous  growths  of  the  onler  of  Kroni|)eeher's  "iNisaJ. 
ci'lle*!"  cancer  (vol.  i,  p.  735). 

Sarcoma.— Sarcoma,  as  a  primary  disease,  is  ran'  in  the  n.^,.,  |,„t 
usually  extends  from  sarcoma  of  the  antrum  or  the  neinlihorin;;  parts. 
It  iN-easionally  forms  polypoid  excres<rnct's. 

More  rarely,  ehondroou  and  ottMma  are  met  with. 

THIPHABnrZ. 

This  will  l>e  considered  along  with  the  Digestive  Tract  in  (']y,^l^. 
terXVII. 

TBI  LARYNX  AND  TRAOHEA. 

The  predominant  etioh>gical  factor  in  the  pnMluction  of  distaMs  of 
the  larynx  is  the  character  of  the  respinnl  air.  The  physical  and  cliiiiiicul 
IM-culiaritics  of  the  air;  atfectioas  of  neighlxmng  orguiLs,  |)iir(i(ulariv 
the  pharynx,  the  thyroid  glaml.and  the  lungs;  constitutional  ttiiilciicics, 
all  play  their  part.  "Catching  cold"  is  an  important  pr(ilis|)(.,int 
cause.  It  has  Invn  shown  expi>rimentally  by  UixssInicIi  thai  .•iiitniic 
and  hy|H'rcinic  conditions  of  the  larynx  can  Ik-  inducetl  l»y  rlic  aciidii 
of  heat  and  cold  upon  the  skin  of  the  iHxly  at  .some  dLstaticc  Irom  ilir 
larynx  its«'lf. 

MALFORMATIONS. 

C'omph-tc  abisnceof  tlu'  air  passages,  in  <-onnnon  with  ahscm  i  of  liinpi, 

o<-curs  only  in  coniuH-tion  with  other  grave  defects,  as  in  tlic  < liiinn 

of  .\canliacus  anii>rphus  and  A.  acephalus.  Particular  cariiLips  or 
portions  of  thcin  may  In-  deficient  or  absent.  HypopUiia  on  iir<  in 
api.isia  of  the  (cuticles  or  eariy  castration.  Partial  or  c-ompKi.  fissuring 
of  ill.-  epiglottis  has  Ik-cu  observed.  There  may  be  sacculai..!  (Ii\tr- 
ticiihi  of  the  sinus  of  Morgagni,  as  again  of  the  .sacculi  larynf;i>.  nralliii; 
lilt-  j)oii<lics  normally  found  in  monkeys.  The  most  imporumi  aimiii- 
alics  of  the  trachea  an-  •tresia  or  abnormal  narrowing  of  the  iiii« .  fijtn- 
loni  communication  with  the  (esophagus,  or  iiufM'rfwt  cIomik  nf  iIh 
branchial  defls. 

OIROULATORT  OnTURBANCKS. 

Owin;;  to  the  loose  tissue  of  the  submucosa,  circulatory  (linUanri-; 
can  (|iii(kly  arise  and  as  <|uickly  <lisap|)ear.  Thus  it  is,  li  t  hen. 
for  iiist.uice,  niarki-d  (cdi-ina  of  the  ghtttis  has  Imi-u  pn-sent  il  iii;;  lifi', 
at  |Misinii>rteni  cxaniination  all  traces  of  it  may  have  pas,sed  oil 


lu  iii. 


ACUTK  CATARRHAL  LARYS  ilTlH 


269 


AsemiA  ud  HyptrwnU.— Anemia  ami  li\'p<>n-niia  may  Ije  I(k-uI  or 
a  part  <if  u  gt-nrrai  coiHiition,  ami  iior-ur  umier  tiie  same  eomliiioas  as 
fisi-wlicn-.  Anemia  of  the  larvnx  i.s  well  knuwn  to  he  an  early  mani- 
fe:*tali()ii  in  .some  cases  of  tuberculo8i'<  ami  eiildrusis. 

I'nil()ii|;eil  pa-snive  livperemia  may  lead  to  a  permanent  dilatation  of 
iIk-  veins  (phlehecttuia  laryngra).  Hemorrha^^  may  ocfur  fn>m 
traiiiiiutiHm,  acute  inflammation,  ulceration,  the  hemorrhagic  diathesis, 
morlins  inuculosus,  scorbutiw,  and  phosphorus  poisoning.  Thev  mav 
amount  to  the  formation  of  a  hematoma  which  may  lead  to  death  fruiii 
sutfiK-iition. 

(Zdenu. — The  ino.st  ini|M>rtant  condition  Is  that  of  odaiu,  which 
Itwis  to  partial  or  complete  olxstniction  of  the  rima  glottidLs.  The  swell- 
ing utr(rts  those  parts  in  whicli  I(m)s<>  submucous  tissue  abounds,  the 
iirvf|ii>;lottic  folds,  the  epiglottis,  the  falsi'  curds,  the  arytenoid  cartilages, 
ami  iiiort'  rarely  on  the  v«H-nl  conls.  The  <-on<lition  is  due  to  a  variety 
of  (-.iiisfs,  among  which  may  U*  mcntiontsl  cardiac  and  renal  dn>psy, 
prcssiiri'  from  cer\'ical  and  meiliastinal  tiim(»rs,  aneurisms.  These  forms 
ari'  iiidstly  chronic.     The  acute  type  is,  as  a  rule,  inflammatory  in  origin. 


nrrLAMMATiom. 


Acute  Laryngitis. —  .Vcivmling  to  the  character  and  intensity  of 
tlic  (aiisativc  agent,  acute  laryngitis  may  U-  classified  as  catarrhal, 
hrjutlr.  jihrlnoiui  {memhrammn  larijiiijitlii),  liiphlfirritir,  phlegmonow, 
arid  iilirriilirr,  in  a<ldition  to  ct-rtain  inon-  sjH-i-ific  forms  found  in  tiibcr- 
(•/(/(«(.«,  .ii/phllix,  iiiriiJa,  rhintmrleroma,  ijUimlirK,  and  leprosy. 

Acute  Caturbal  LarjmgitU. — Acute  catarrhal  laryngitis  is  a  very  common 
atfiriidii,  but  comes  much  more  fnHiuently  umler  the  obscr\atioii  of 
tlif  larvngologist  than  of  the  pathologist. 

Tlic  nuidition  is  usually  bnxight  ttlH)ut  by  me<liunical,  chemical. 
IT  thcrinic  irritation,  and  wcurs  in  one  of  tho.s«'  situations  that  is  affccti  <l 
nadily  bv  climatic  ami  atmcispheric  con.liti;)iis.  It  occurs  also  in  the 
niiirv  111"  the  infective  fevers,  niea.sles,  .scarlatina,  variola,  typhoid,  while 
ill  <<rtaiii  others,  such  as  influenza  and  whooping-tHiugii,  it  is  often 
till-  ii:  .1  prominent  featun-.  The  distribution  and  intensity  of  the 
priMt^^  :,ri-  afft-cttnl  mainly  by  the  natur(>  and  virulence  of  the  infwtiiig 
a>.'r!it.  Tlic  epiglottis  «>r  the  vocal  conls  may  Ik-  .hiefly  afl'ectt-d,  or  else 
til"  inn  rimsliate  |M>rtion.  At  fir^t  there  is  mor*-  or  less  n-dness  and 
swi  llin-  ,,f  the  parts.  Sooner  or  latei,  a  catarrhal  secretion  makes  its 
a|i|Mir;iii(i>,  which  is  at  first  viscid  anil  glits,sy,  but  .s(Htn  Ikh-oiiks  more 
•  11111(1,  ;;iavisli,  (,r  grayi-^h-yellow  fnun  admixture  with  leiikiKvtes. 
"liiiii  rarely  forms  ha-fl  i-rusts.  From  loss  of  the  lining  epi- 
■inall  supi'rficial  en)sio;,^  m-  pnxluct-d.  Frrnn  the  irritation 
!  by  coughing,  .smali  <|imntities  of  bhxNl  an-  often  effn~'Hl. 
I  irrli  from  influenza  usually  Ix-gins  in  the  nose  and  s[i>-e;,  Is 
'!  into  the  Immchi  and  the  lungs.  The  secretion  i>  ...vid, 
nil  lit,  and  glairy-,  and  of  a  pale  greenish  color.  Within  itic 
'.'  '.and  lying  fn-e,  the  minute  bacillus  of  I'feiffer  cuii  l)e  domon- 


Tllr    .,. 
t!..'ii,M 

|)n«|ii. 
Thr  , 
dowi. ., 

inili'ii;' 

Ifiik.. -. 


270 


Tin:  LAHYSX  AND  TRACHKA 


'ii 


i 


r     t 


J 


•i 


ittratitl.    Thr  prtK-e**  in  wh<Mi|)ii)|{-4'MUf(h  iMtially  beKiat  beluw  ili<-  vimil 
(■MnlM,  and  thenc«  spmul.i  into  tht-  bn>iK-hi. 

Amrt*  Oituikkl  Tnehcitii.— Arute  ralarrhal  trecheitiii  tloejt  not  differ 
niatrriallv  in  its  otiolu^v  ami  prugn>s.s  from  <>atarr)uil  laryn^iii.'*.  Aciiir 
c-atarrh,  if  ncKltH'twl,  or  if  the  caaw  lie  not  n>moved,  nwy  ultinmtplv 
asMunip  B  chntnio  (vunse,  partinilarly  in  thtiae  who  .tuffor  fn>iii  mmw 
(•oiwtitutional  taint.  Catarrh  niay  aLto  U-  chronic  from  the  (irsi  ji, 
*hiwc  who  use  the  voiit-  much  or  are  aiiilicteii  to  the  immodcnili>  um,-  i»f 
u[<i>hol  or  tolmcco. 

Lwynffitif  Harpttin.— I.aryn);itiH  heq)etivH  U  chanicterijMil  l,v  the 
fc>rinnti..ii  of  vesicles  on  tlie  vi\fy  of  the  epifrlottis  an<l  on  the  vikhI  i^cnl,. 
Small  erosioiw  may  lie  causeii  l)y  the  rupture  of  the  ve.sicli'>.  Tin- 
ciiiulition  is  rare. 

MtmlmuuNU  LaiTiiffltU.-  This  form  U  characterize«l  by  the  priHJucfjori 
of  a  fibrinous  membrane  of  a  ^ray  or  grayish-white  color,  ^omcwiuii 
elevateil  aimve  the  ({eneral  level  of  the  mucosa  ami  varying  in  cvtrnt. 
The  comlition  Ls  usually  not  confined  to  the  larynx,  but  extciids  ii|iwanl 
to  the  epiglottis,  throat,  toasils,  an<l  buccal  cavity,  and  downwani  lo 
the  trtu'hea  an<l  bronchi.  The  infection  is  usually  a  destfiiijiii);  one. 
but  not  invariably  so,  for  the  larynx  may  be  affe<-te«l  while  the  pliiirvn){«-ai 
structiiri's  remain  free.  When  the  membrane  is  removed,  wliich  can 
often  U-  accomplished  without  difficulty,  the  surfatv  Ls  foun<l  lo  In-  ml- 
(letM-il  and  more  or  less  swollen.  The  thii'ker  the  meinbnuic  is,  tho 
firmer  and  num-  elastic  it  appears  to  lie.  In  the  neighl>orli<MHl  of  the 
piitili  the  mucosa  shows  the  usual  changes  of  a  .simple  or  niiu opiinilenl 
••tttjirrh. 

.Micn)s«i)pi(idly,  the  membrane  is  .seen  to  coiLslst  of  fin«"  threads 
of  fibrin,  or  sometimes  broader  Imnds.  which  form  a  thick  iiiisliworii 
ami  in  many  "iistancTs  have  undergone  hyaline  change,  so  that  it  |)rcs«'iits 
a  su|M'rfi<ial  resembiaiK-e  to  cartilaginous  tissue.  In  the  meshes  of  this 
membniiie  an-  ninncrous  cells,  chiefly  leuk(K-ytes  an<i  d<s<|iiiiirwte(l 
epitlieliiini.  Tlies*-  cells  often  show  signs  of  necrosis.  It  is  not  alwavs 
|M)ssiblc  to  ditfen'ntiate  inucroscopically  the  true  diphtherial  from  other 
fonns  of  ineini)rHnoiis  infliinnniition.  A  <listinction  is  drawn,  pailmlopc- 
aliy,  U-twet'n  a  filirinous  or  crou()<)iLs,  .sometimes  calle«l  pseiidoinein- 
branoiis,  cMidatc,  which  nien-ly  lies  upon  the  top  of  an  epitheliiil  Mirfa(r 
and  wliicii  can  n-adiiy  Jm-  remove<l,  fnmi  another  form,  of  wliiih  true 
diphtheria  is  the  ty|H',  when'  the  mucosa  and  subinuc<xs4i  are  the  sitcnf 
11  fibrinous  iiiHamination,  and  Ixith  the  exudate  and  the  d(H|>ir  tissues 
have  iindcrgotu-  a  fonn  «if  coagidation-necrtxsis,  welding  tliiin  into  a 
imif«sl  mass.  It  should,  liowever,  Ik-  mentioned  that  the  atllicsion  or 
()therwis<-  of  the  mcmltranc  de(>eiids  largi-ly  on  the  nature  of  iln  iiiider- 
lyiiig  cpitlii'liiun.  Where  coluniiiiii  epithelium  exists,  the  iinrnl>raiif  N 
readily  reniove<l,  but  where  the  epithelium  is  absent  or  wh(iv  the  (rib 
are  of  the  si|iiaiiioiis  variety,  the  exudate  Ix-comcs  firmly  attin  In  .1.  The 
term  "cniii|)"  has  unfortunately  given  ris«'  to  miu-h  mi.suiiilerstaiicliii);in 
flii  coiMHHtion.  If  we  employ  it  in  n-gard  to  ihos*-  forms  of  I  irvtij;iiis 
charatfcrized   by  a  stridorous   respiration,  we  have   to   rceo-  vy  with 


TVBEKUUWS  LARYSCITia 


271 


Mnliow  H  caUrrtMl,  ■  fibrinous,  and  a  diphthfritk-  fiirtn.  It  i<«  iiHtcr, 
himi'vtr.  tci  ilucontinue  the  iu«>  of  the  woni  "rmup"  a»  mlsleiuiinf;,  hihI 
npi-ak  of  H  Hbrinoiu  laryngitu. 

Willi  ppjpinl  to  the  etiol(if(A'  of  larynf^tw,  a  variety  of  farton  may 
he  at  work.  Any  oaa-ie  which  ilRttroy.1  the  lining  epithelium  of  the  lannx 
awl  irritntet  the  luiilerlyinK  stHM'tiirex  is  .suffkirnt.  Chiklirn  have  a 
l^-atir  liiihility  to  the  affeetion  than  have  adulti.  Chemieal  and  thermic 
initatilH  play  a  c(>rtain  part,  but  by  far  the  mont  important  factors  aw 
the  infiMtiiMW  dMea-seM,  siK'h  as  variohi,  measles,  typhoid,  pyemia,  atul 
piKMiinitiiiii.  The  most  fn><|uent  causes  an-  diphtheria  itiid Warlatiiia. 
In  Uitii  ilie  last-named  diseases,  the  eonditiim  is  usually  .se<-«indarv  to 
an  utrntiiin  «>f  the  pharynx,  but  in  some  few  cases  the  larvnx  alone  is 
aiCtu'k<><l.  It  must  be  admitted  that  whatever  tlie  orif(inai  cause  of  a 
larvii)tiii'«  may  In-,  Imcteria  s«ioner  or  later  play  ati  important  role.  The 
pTOis  cliicHy  comrrned  are  the  diphtheria  liacillus  and  the  various  pus- 
pnnliiiiii^'  orpuilsms,  notablv  the  strepttKiH-cus.  It  should  not  iH>  for- 
pAWw  that  the  pyo^>nic  i-inri  an'  ipiite  c(mi|M-letit  to  priMiucr  an  adherent 
iiH'niliriiiit'  cldHcly  rest'mblinf;  that  of  diphtheria. 

Tlif  fcriiis  due  to  th«'  Klelis-I<oefiler  JMicilliis  and  pyoftenic  cocci  are 
HUM  li  iimrc  intens4'  tliiin  an*  the  others.  Any  cas«'  of  membranous  larvn- 
triiis  that  lasts  longtT  limn  twenty-four  hours  should  roUM*  the  suspicion 
(if  (li|)htln'riu.  The  <  \uinination  of  swalxs  from  the  thnwt,  or  of  the 
ixpc<toraiion,  for  the  sp«'<-ific  jjerm  is,  however,  the  only  surv  wav  of 
timkin;;  a  diHrereiitiul  dia^iiDsis. 

Pbltgmonotu  LaryngiUi.-I'hlettnionoiLs  laryti)(itis  is  characterized 
hy  thf  foriimtion  of  a  purulent  or  iibrinopurulent  inKltratioii  in  the 
iniKtisi  and  siilmuicosa,  and  frequently  is  a  late  complication  of  inflam- 
matorv  (iilcina  of  the  larjux.  'ITic  |>aiis  afTecte«l  are  the  loose  «-onnwtive 
ii»ius,  the  1  pijilottis,  the  arjepiglottic  folds,  and  the  fals*'  conls.  more 
rarely  the  under  surface  of  the  true  j-ords.  IxH-td  abstvss  formation 
with  ulceration  is  not  uncommon.  It  is  a  fmiuent  complication  of 
iliphiheria.  .•^^si^»elas  of  the  faw,  and  the  other  infwtious  disea.s«'s. 
It  may  spreaii  to  the  cartila),'»'s,  caiLsinjr  a  perichondritis,  that  may  lead 
lo  s.H|iie>iration  of  the  |)art  and  the  formation  of  a  fistula. 

Chronic  CaUnh— ("hnmic  catarrh  of  the  larynx  leads  to  liv|Mnnna 
I'f  the  parts,  with  hypertrophy  of  the  muc«xsa  and  subnuK-osa."  toj^fther 
with  tihrcMis-tissue  prt)liferaticm.      Ixx-aliy.«Hl  thickeninjpt.  either  Hat  or 
ill.    found  not  infre(|uently  upon  the  vocal  conls.  of  a  fjrav  or 

>  '■"'"•■•    They  are  often  found  in  sp<>akers  and  sinj^-rs."   In 

the  ulands  are  enlar^l,  so  that  a  ^ranidar  condition  is  pn)- 


wiirty 

whiti.h-j:i,n  color.    They  are  often  found  in  sp««akers  and  sininTs.     In 

iither  (M-      •>       ■      • 

lillcni. 

Tuberculous  Laryngitis.-This  is  a  vcrv  fn-«|uent  compli.ation  of 
puhnnuMiN  iiilKTcuh.sis.     Ilan-ly.  the  larynx  is  afrcf-t.-tl  in  >c«'nenil  miliury 
.  and  nion-  ran-ly  still  primary  tulien-ulosis  of  th«-  larvnx 
cc.irdcd  (Orth).     The   infectio'n   is   usually   brought  alJout 
s|iMta.     The  lesicMis  gi-nendly  take  two  forms,  ulcenition 
iiifiltnition. 


tlllKTeii 
has  Ui 
ihriMi.'li 
ami  ijil! 
Till,. 


I'lis  ulcers  var)'  a  goo.1  deal  in  appearance.     Tin;,  may  be 


1* 


MKROCOPV   RBOIUTION  TBT  CHART 

(ANSI  ond  ISO  TEST  CHART  No.  2| 


Li  1^8 

1^ 

|Z2 

i25   111.4 


1.8 


1.6 


/APPLIED  IM^GE    Inc 

'65 J    East   Mom   Street 

Rochester.    New   Yorh         14609       USA 
(7'6)   482  -  0300  -  Phon« 
(7!6)   288  -  5989  -  To* 


■S     I 


272 


THE  LARYNX  AND  TRACHEA 


shallow  and  lenticular,  deep  and  crateriform,  few  or  numemiis.  The 
lenticular  form  is  seen  most  tj-pically  on  the  epiglottis  with  a  pule,  Hat 
liase  and  rounded  margin.  In  other  cases,  on  the  contrary,  hvpcreinia 
is  marked.  The  process  begins  with  small  foci  of  cellular  infiltralion 
in  the  subepithelial  tissue,  which  gives  rise  to  minute  no«lules  projcctin;; 
above  the  surface.  These  caseate  and  produce  shallow  ulcers.  !  n  other 
cases  the  infiltration  is  more  extensive  and  .severe,  forming  a  .sulxpitlKlial 
granulation  tissue  in  which  typical  tulx-rcles  arc  found  emlMxldcil.  Tliis 
gives  rise  to  warty  projections  of  the  epithelial  surface,  .so  that  a  liv[H'r- 
trophic  appearance  is  produced.  Through  caseation  ulcers  are  produced 
in  this  form  also. 

llu.  Go 


Chnihii'   lulH-nul 


f   the   larynx   ami   trachea.      The  thickening  i>f  the  i|.il'I  tii-  i~  »tII 


!»lH»wn,  and  nunierou-s  wuperficial  erosions  are  also  apparent, 
of  .McCiill  University.) 


(Kniiii  the  l'alli.iiu>rir:il  Museum 


IIIH'Ilt  (•' 


On  tlie  primary  infection  can  supervene  a  secondary  dcv 
tul)ereles  in  the  neighlmrhood  of  the  original  lesion,  whit  li  takes  ih 
form  of  .small  inflammatory  fini  in  the  mucosa,  submucosM.  ;in(l  jHri- 
chonilrium,  or  in  the  mucous  glanils,  or  even  Ix-twcen  the  must  1.  I)iin(llt'>. 
Microscopically,  the  ap|M-arances  are  those  of  a  vascular  ^i^iiniiatwn 
tissue,  with  epithelioitl  ant'  giant  cells  anil  central  ca.seatit>n.  I'lie  ulcers 
are  fouiul  on  the  epig'  ttis,  the  anterior  or  posterior  \wrU<m 
thyroitl  cartilage,  the  arytenoid  cartilagi's,  the  false  ami  ivne  eonis, 
biit  the  greatest  variety  exists  iii  the  distribution  of  the  lesioi 


)f  the 

onis, 

II  atiiii- 


*«p 


SIMPLE  ATROPHY 


273 


tioii  to  the  specific  lesion,  there  is  usually  a  marked  simple  catarrh. 
SiiiH'rvcning  upon  the  condition,  oedema  of  the  glottis,  phlegmon,  an<l 
,se(|ii(stration  of  cartilage  may  occur.  In  the  most  severe  cases  of  tuln-r- 
(•ul()iis  laryngitis  scattered  ulcers  are  to  be  found  for  some  distance  down 
the  tnicliea. 

Syphilitic  Laryngitis.— Syphilis  may  produce  a  simple  congestion 
or  catarrh  of  the  parts,  hut  there  is  often  a  definite  infiUnrtioii.  Ulcera- 
tion may  take  place,  the  base  and  edges  of  the  erosions  being  greativ 
thickened.  Owing  to  the  prolonged  irritation,  the  mucosa  is  often 
liyprplastic  and  thrown  into  polj-poid  or  warty  elevations,  which  later  on 
may  ulcerate  and  finally  may  liecotne  more  or  less  normal  from  absorp- 
tion of  the  exudate.  The  ulcers  are  found  usually  upon  the  epiglottis, 
the  vocal  cords,  and  the  back  part  of  the  larynx. 

A  second  variety  is  characterize*!  by  the  formation  of  gummas,  which 
are  to  1k'  found  usually  in  the  submucosa  of  the  epiglottis  and  on  the 
vmal  cords.  From  their  size  they  may  obstruct  the  lumen  of  the  air 
pii.ssiii;es.  Perichondritis  and  necrosis  of  the  cartilages  and  epiglottis 
lire  not  uncommon.  Small  gunnnas  may  be  absorl)ed,  but  when  there 
is  destruction  of  tissue,  scars  are  the  n>sult.  These  are  hard,  whitish, 
and  conrracted,  leading  to  great  deformity  of  the  organ  with  stenosis  of 
the  iiMiien.  The  mucosa  between  the  contracted  bands  often  shows 
warty  or  |M>lyp<)id  hyperplastic  growth. 

Typhoid  Fever.— This  may  give  rise  to  catarrh,  which  leads  to 
(lts(|naniation  of  the  epithelium,  hemorrhagic  infiltration,  and  super- 
ticial  erosion.  The  lesions  are  usually  to  l)e  found  on  the  edges  of  the 
epifriottis.  There  is  very  little  exudate,  and  the  inflammation  is  apt  to  be 
<les(|iiaiimtive  in  character.  Often  there  is  market!  oetlema  of  the  parts, 
and  ])criclioii(lritis  and  erosion  of  tlie  cartilages  are  not  uncommon.' 
in  otlier  cases  there  is  a  fibrinous  or  .so-called  "croupous"  exudate.  In 
this  case  tlie  mucosa  of  the  epiglottis,  the  anterior  surface  of  the  larynx, 
and  the  vocal  cords  are  covered  with  a  distinct  membrane  composed  of 
(lesquaniatw!  and  necrotic  epithelium,  leukocytes,  fibrin,  and  bacteria. 

.\  specific  tj-phoid  lesion,  however,  exists,  in  which  there  is  swelling 
»f  the  lymphoid  follicles  at  the  base  of  the  epiglottis,  the  false  cords,  the 
inner  side  of  the  arytenoid  cartilages,  and  the  anterior  commissure. 
•lust  as  111  the  intestine,  the  swelling  of  the  lymphoid  tissue  tends  to  the 
jtriHJiK Hon  of  definite  elevations  upon  the  mucous  membrane.  'Ihese 
necrotic  and  may  develop  into  ulcers  with  swollen  infiltrated 
In  severe  cases  the  infiltration  can  extend  bevond  the  limits 
viiiplioid  tissue  to  the  neighlmring  parts.  I'lVcrs  analogous 
tothos,.  toiiiid  m  the  intestine  are  thus  produced. 

llceniiion  of  the  larynx  may  also  occur  in  glanders,  leprosv,  variola, 
and  rliiiiiiscicroma. 


..■:.,':?;„!. 


in'oinu 
marpii 
<if  the 


RETROGRESSIVE  METAMORPHOSES. 

Simple  Atrophy.-Simple   atrophy,   leading   to  a   thinning  of   the 
lucasM,  -^niinution  of  secretion,  atropliy  of  muscle  and  cartilage,  fatty 


274 


THE  LAKVSX  WP  THACHKA 


degeneration,  and  calrififation  of  tlie  various  t-artiluges,  is  fouml  in  oli| 
age,  premature  senesceiife,  and  in  certain  eaeliexias. 

OssifiCAtion. — Ossification  of  tlic  cartilages  lias  In'en  recorded  as  a 
result  of  chronic  inflammatory  pnK-esses. 

Rarelv,  a  depasit  of  iirir  arid  mllx  has  l)een  ol)ser\ed  in  the  cartiiagt's 
and  ligaments  in  goutv  cases. 


PROORESSIVE  METAMORPHOCES. 

Simple  Hypertrophy. —Simple  hypertrophy  of  the  mucosa  Kails  to 
the  pro<luetioii  of  small  Kx-al  verrucose  overgrowths,  often  takiii};  the  form 
of  polypi.  These  are  found  hy  preference  in  those  sittiatioiis  tiiat  air 
rich  in  glandidar  elements.  Polypoid  mass(<s  are  also  met  with  in  the 
neighborhoo<l  of  tumors  and  scars. 


Vlii.  lili 


, 


If 


furcim.lna  .il  llie  Uryiix.      (Knmi  the  PallKiIonicnl  Mii«-um  iit  Mcdill  Vnivii-ilv  i 

Tumors. — The  most  co-nmoii  form  of  tumor  is  the  papilloma  <>r 
papiUary  fibroma.  This  forms  a  warty  or  papiliimiatous  fiidwili,  often 
reseml»ling  the  acuminate  condyloma.  It  is  usually  sitnatcl  on  the 
vcK-al  cords,  and  consists  of  a  fibrous  ground  sul>stiinc«>  cnvciid  with 
stratified  pavement  epithelimn.  Houiul  cells  arc  often  mcii  anil  the 
growth  may  contain  innneroiis  wide  vessels.  The  dilliii'  itiity  is 
called  hy  'some  pachydermia  laryngis.  These  growili^  tniiiicntiy 
n-turn  after  removal,  hut  only  rarely  develop  into  carcinoni;i. 

NfKhilar  fibromas  are  found  alsd  on  the  vo<al  cords,  i)iii'"  nlaily  in 
singers. 


\A 


THE  BRONCHI 


275 


Knchondronu,  lipomk,  myzonu,  kngiomt,  lymphanfionu,  adenoou, 
and  lymphtdenoiiu  have  been  found.  Oyiti  are  fairly  rare,  and  are 
fuiirid  ill  the  epiglottis'  and  on  the  sinuses  of  Morgngni. 

Of  iiiiilignant  growths,  the  most  frequent  is  the  ckreinoiu.  This 
is  usually  of  the  squamous  variety,  but  a  soft  glandular  carcinoma  and 
even  scirrhiis  have  l)een  recorded. 

Ciircinoina  of  the  larynx  usually  starts  from  the  true  or  false  vocal 
cords,  the  ventricles,  or  even  lower  down  (intrinsic  larynrfeal  carcinoma). 
Rarclv,  it  extends  from  the  epiglottis,  pharynx,  or  adjacent  parts 
{exfriimic  carcinoma).  It  is  apt  to  spread  locally,  but  Jistant  metastases 
may  I  •-  formed,  particularly  in  the  liver. 

8ucom>,  cither  rouhd  or  spindle-celled,  is  rarer. 

S<'<((iKlary  growth  is  rare. 


ALTEKATI0H8  DT  SIZE  AND  8HAPX. 

Tht'sc  afTfct  mainly  the  trachea,  but  the  lumen  of  the  larynx  may  be 
ol)stru(ti'(l  either  partially  or  completely  by  oedema,  inflammatory 
infiltnitioti,  tumors,  or  exostoses.  Atresift,  or  narrowing  of  the  lumen, 
may  Ix-  due  to  structural  defects  or  to  a  contraction  of  scar  tissue,  but 
usually  is  due  to  pressure  e.xerted  upon  the  tube  from  without.  Such 
may  \w  brought  about  by  tumors  of  the  thyroid  glands,  peritracheal 
ahscrsscs,  enlarged  glands,  and  aneurisms.  Pressure,  if  long  continued, 
may  lead  to  atrophy  of  the  cartilages  and  give  rise  to  the  clinical  symp- 
toms of  asthma,  as  in  a  case  under  our  own  observation  at  the  Royal 
Victoria  Hospital,  whore  the  obstruction  was  brought  about  by  an  en- 
larged middle  lol)e  of  the  tiiyroirt  and  led  to  acute  bronchitis  and  death 
from  atelectasis  of  the  lungs  and  sectindary  pneumonia.'  Perforation  of 
the  tnichea  may  be  due  to  ulcerating  tumors,  peritracheal  suppuration, 
ami  aneurisms. 

Matation.— Dilatation,  either  complete  or  partial,  in  the  latter  case 
Icaiiiiii:  to  the  formation  of  saccular  diverticula,  is  occasionallv  found. 


The 
tree  are  si 
mndKieil 
the  iaix'ei 
path()loi,ri( 
while  tlic 
lunfi  sii 
other. 


THE  BRONCHI. 

thological  changes  that  are  apt  to  l)e  met  with  in  the  bronchial 
Miiewliat  diverse,  the  details  of  the  processes  l)eing  considerably 
l>y  the  anatomical  peculiarities  of  the  parts  affected.  Thus, 
bronchi  which  have  cartilaginous  walls  bear  a  closer  relation, 
ally  speaking,  to  the  larj-nx  and  trachea  than  to  the  lungs, 
terminal  bronchioles  are  in  such  intimate  connection  with  the 
lance  that  lesions  of  the  one  structue  profoundly  affect  the 


'  See  H.  D.  Hamilton,  Montreal  Med.  .lour.,  2S:  1899:  602. 
■  .Xdunii,  ("anaila  Ijincct,  35  :  1902  :  373, 


mkRi. 


27(3 


Tim  BROScin 


OOMOKNITAL  AH0MALU8. 

SapereameTary  bronchi  have  lieen  met  with.    Congenital  itresia  and 
bronehiecUiii  are  more  frequent. 


OIROULATOBT  DUTURBANOU. 

Passive  Congestion.— Passive  congestion  is  frefjuently  met  with,  ami 
is  found  typically  in  connection  with  valvular  discn  <s  of  the  lu-art. 
The  mucous  membrane  is  swollen  and  deep  red  in  color.  When  latarrhal 
inflammation  supervenes,  as  it  so  frequently  does,  there  is  a  siif;lit  stickv 
mucoid  exudate.  The  congestion  affects  not  only  the  mucosa,  lnii  the 
deeper  structures  as  well.  In  other  cases  small  ecchymoses  arc  priHliuwl 
or  even  extravasation  of  blooti  inti  the  lumen  of  the  bronchi.  ( 'ongi'stioii 
is  a  constant  accompaniment  of  bronchitis. 

Hemorrhage.— Hemorrhage  into  a  bronchus  (loes  not  oftin  iKtiir, 
unless  from  erosion  a  communication  is  made  with  some  hraiicli  of  the 
pulmonary  artery,  or  when  an  aneurism  ruptures  into  the  tuln-.  Pihrhk 
are  seen  also  in  the  hemorrhagic  diatheses  and  in  many  of  tin-  infwtive 
fevers. 

Vkarious  menstruation  from  the  bronchi  is  also  recordwl. 


IHTLIMMATIONS. 

Bronchitis.— Bronchitis  is  one  of  the  most  frequent  patlit.lopcal 
changes  that  we  meet  with.  The  inflammation  may  he  re.stri(  ted  t.)  the 
bronchial  structure,  but  it  is  frequently  associateil  with  i)tiior  and  more 
serious  distuilmnces.  The  condition  is  usually  bilateral,  but  not  in- 
variably co-extensive  with  the  whole  bronchial  tree.  Certain  portions 
seem  to  be  more  often  affected  than  others.  Bronchitis  aff.rtiiis  the 
larger  bronchi  is  always  associated  with  tracheitis  and  often  witli  laryn- 
gitis. A  similar  condition  of  the  minuter  bronchioles  is  ai)t  to  If 
associated  with  peribronchitis  and  bronchopneumonia. 

Bronchitis  arises  from  many  causes  and  assumes  various  forms,  ll 
mav  result  from  the  inhalatioii  of  irritating  substances  derived  from  tiu' 
air'or  the  nasopharyngeal  cavity,  and  is  a  frequent  acconipainnient  cf 
tiie  infective  fevers.'particularly  typhoid,  measles,  diphtheria,  tiiUnii- 
losis,  influenza,  and  variola.  Bronchitis  is  a  constant  aceoinpainim'nt 
of  emphysema  of  the  lungs,  bronchiectasis,  pneumonia,  and  alisirss 
of  the  lung.  In  bronchiectasis  it  is  very  apt  to  assume  the  putrnl  v^Y- 
Passive  congestion  of  the  lungs,  especially  when  due  to  a  valvular  heart 
lesion,  favors  the  development  of  bronchial  inflammation. 

The  macroscopic  appearances  of  the  lungs  in  this  condition  \arv  some- 
what according  to  the  type  of  the  affection  present,  but  lis  t!?'-  -^""P'^ 
catarrhal  form  tiie  mucous  membrane  is  reddened,  swollen,  and  covered 


PURULKST  BROSCHITIS 


277 


with  mow  or  less  sticky  extulate.  In  the  simpler  forms,  this  is  of  a  clear 
(trayi-h  appearance  and  largely  murx)icl  in  nature,  hut  when  the  exudate 
a  more  rcllular,  and  tends  to  approach  the  mucrjpurulent  or  purulent 
ivDf,  ili<-  secretion  is  thicker  and  more  oparjue.  \Mien  a  section  is  made 
t!.,oiii;H  the  lung,  small  drops  of  muoo-pus  may  often  be  squeezed  out 
of  the  (i[)enings  of  the  bronchioles.  Usually  the  lung  substance  b  more 
or  !<■>>  rc<ldencd. 

Acute  Bronchitif . — Acute  bronchitis  may  be  divided  into  the  follow- 
ing foniH :  Simple  catarrhal,  purulent,  memhranoiu,  putrid  or  gangrenous, 
anil  npffifir. 

Fio.  «7 


:,A/v, 


-,  '■^i**'^. 


v*/A 


^.....i^^-. 


sji-  'J.:-         r- 


Acute  purulftit  bromSitU  with  e«rly  broochopDeumonis.      Leiii  obj.  No.  7.  without  ocular. 
(From  the  privmts  collection  of  Dr.  A.  G.  Nichollj.) 

In  catarrhal  bronchitis  the  character  of  the  secretion  may  varv  con- 
>iilcrably.  As  a  rule,  desquamation  of  the  epithelium  is  not  such  a 
prominent  feature  as  the  conversion  of  the  epithelial  into  piuciniparous 
M-lls,  resulting  in  h\-persecretion.  Sometimes  the  secretion  is  onlv 
^•anty,  transparent,  and  adherent,  the  so-called  "dry  catarrh."  In 
other  (|Hfs  it  is  more  abundant,  mucoid,  or  even  purulent.  In  still 
other.-,  it  i<  verj-  abundant,  thin,  and  waterj-  (serous  catarrh).  The  last 
form  H  :i|,t  to  occur  in  passive  congestion  of  the  lungs.  A  few  instances 
have  U-cii  met  with  where  several  liters  of  fluid  have  been  expectorated 
daily.  '^ 

Puralent  Bronchitis  (Bronchoblennoirhas).— This  is  a  more  serious  affec- 
tion iuA  is  apt  to  be  found  in  the  smaller  bronchi  associated  with 
C' --tain  , !  r.,ni(  pulmonary  affections,  such  as  bronchiectr.sis.  tuberculosis. 
afwt".  iiiii  the  like.  When  the  secretion  b  retained  and  becomes 
Uef.imp.  .  ,1  from  the  action  of  putrefactive  microorganisms,  it  becomes 


278 


THE  BRONCHI 


■       :     ^ 


altrred  in  color  and  very  fetid.  In  surh  casi  •  wall  of  the  hri.mliiis 
may  l«e  destroyeil.  This  Is  pntiid  or  gtngre&ou*  bronehitli.  It  is  often 
the  result  of  alweess  of  the  lung,  but  may  Ik-  primary. 

Microscopically,  .sectioas  through  an  aff«'te«l  hronchas  .show  udema, 
congestion,  and  cellular  infiltration  in  the  mucasa,  .ind  in  seven'  citses 
in  the  submucosa.  ITiere  is  a  wrtain  amount  of  desquamation  of  the 
lining  epithelium,  with  an  abundance  of  mucin-containing  goldtt  (tils. 
On  the  free  surface  is  a  certain  amount  of  exwiate  made  up  of  imuin, 
fibrin,  and  leukocytes. 

Under  the  term  "  broneUolitia  ezudatlTa,"  Curschmann'  has  de- 
scribed a  form  of  bronchial  catarrh  that  Ls  by  .some  regarded  as  the 
main  lesion  of  bronchial  asthma.  In  this  form  the  exudate  is  siantv. 
clear  and  gla.ssy,  and  very  vi.scid.  It  Is  cougheil  up  in  small  jM-aris  that 
are  characteristic.  ^Vhen  these  are  spread  out  on  a  gla.ss  plate  on  a  hluck 
background  a  very  peculiar  apparance  can  In?  olxserve*!.  Tliis  in- 
sists in  the  arrangement  of  the  sputum  in  a  spiral  form  alwut  a  <tiitrai 
fine  thread.  These  are  the  so-called  "  Curschmann's  spirals,"  aiitl  nuiv 
often  be  made  out  with  the  help  of  a  hand-lens.  They  are  not  absolutely 
pathognomonic  of  asthma,  as  they  have  l)een  describeil  a.s  present  occa- 
sionally  in  lol>ar  and  U)bular  pneumonia.  In  the  secretion.  (KtaluHJra! 
crystal's,  the  so-called  "  Charcot-Leyden  crystals,"  have  Ikh'h  met  with 
in  asthma,  but  are  found  in  fibrinous  bronchitis  alst).  X  striking 
feature  of  asthmatic  sputum  is  the  presence  of  considerable  nuinkTs  of 
eosinophile  cells.    They  are  found  in  other  conditions  a.s  well. 

Membranous  BronehitU. — Membranoits  bronchitis  is  nearly  always 
associated  with  a  similar  affection  of  the  trachea.  It  is  most  often  (hie 
to  the  diphtheria  bacillas.  but  is  occasionally  due  to  the  inhahitioii  ()f 
septic  microorganisms  from  the  mouth.  The  mucosa  is  covered  with 
a  membrane  of  varjing  thickness,  usually  mast  extensive  in  the  larger 
bronchi.    The  bronchioles  may  be  blocked  with  leukcKvtes  and  fibrin 

intermingled. 

Ohronic  Bronchitis.— Chronic  bronchitis  is  practically  always  pnrulent, 
and  while,  in  most  particulars,  it  closely  resembles  the  acute  form,  it 
differs  from  it  in  the  presence  of  a  more  deeply  penetrating  inHannnation 
and  in  the  production  of  fibrous  tissue.  It  is  common  in  emphysema 
and  bronchiectasis.  The  mucoas  membrane  is  swollen,  reddened. 
infiltrated,  and  covered  with  purulent  secretion.  Leuko(yti(  infihra- 
tion  can  be  made  out  in  all  the  layers  of  the  bronchi,  the  walls  of  which 
are  «lso,  according  to  Orth,  hypertrophic.  Not  infrequently  tlie  i.mcosa 
is  thrown  into  little  polypoid  excrescences,  partly  due  to  (oiitraction 
and  partlv  to  fibrous  proliferation.  The  walls  of  the  brondu  Uwonie 
thickened' and  there  is  often  a  fibrous  peribronchitis,  which  in  time  may 
lead  to  induration  of  the  lung  (iiuiurative  pneumonia). 

Under  the  specific  forms  are  included  tuberculosis  and  sy|)liilis. 

Tnberenloiu  Bronchitis.— Tuberculous  bronchitis  is  a  V(r\  froiuent 
occurrence  in  the  course  of  pulmonary  tuberculosis,  and  may  1"  found 

«  Deut.  Archiv  f  klin.  Med.,  32: 1882: 1. 


mmm^ 


^mmmmmmmf^ 


IIYI'KHTHOrilY 


279 


jis  n  ^<'<i>iiiliin'uffi-('tioii  in  the  a.s]iiratiiiii  fonn  of  tli<-  tllseaM'.  In  other 
luH'^  ilic  liroticliiLs  is  involved  liy  the  extension  of  a  caseous  fix-as  from 
witliiiir.  Ill  the  first  form  little  tiilM-n-les  develop  in  the  muerMa  anil 
>iil)iiiiM'<»ii  anil  ity  ile^e  leration  leail  to  the  formation  of  smaij  ulcers. 
Thi'^i'  limy  eoalcM-e  ami  in  some  cases  the  whole  lironchial  wall  liecomes 

I'riiiiiiry  tiil)en'iilosis  of  the  trachea  anil  bronchi  has  l»een  ol>ser\'ed.' 

lypLUi.  Syphilis  of  the  bronchi  resi-mhles  the  same  affection  of  the 
iarviix  itnil  tnich"a.  Frimi  filmms  contraction,  );reat  ilLstiirtion  of  the 
hntiir  hi  may  oii-ur.     It  is,  however,  a  ran-  conilition. 

Foreign  Bodies  and  Parasites.  —  Fon-i^n  iMNlies,  such  as  corks, 
prtirlcs  of  lK»ne,  slate-jH-ncils,  etc  ,  an-  iK-casionally  inhaled  into  the 
l(n>ii<lii.  They  an-  most  friinienfly  found  in  the  rijjht  side,  the  right 
l>n)iHhiis  IkIiij;  wider  and  more  vertically  situateil  tlian  the  left.  The 
svniptoiiis  priMluceil  de|M-nd  larj;ely  on  the  nature  of  the  suUstanre 
inhaliil.  If  this  lie  septic,  putEid  hn)nchitis  and  aKsce.ss  of  the  lung 
an'  the  results.  In  other  cases  a  mild  ItronchilLs  or  pneumonia  is  the 
ivsiilt.  When  the  obstruction  of  the  branch  of  the  bnmchial  tree  is 
completf.  ii)lla()se  of  the  lung  iKt-urs. 

Broncholitlu.  Ikoncholiths  formeil  of  inspLssateii  secretion  in  which 
lime  salts  have  Im-cu  dejM)siteil  an-  iK-c-asionally  met  with,  especially 
in  casf^  of  broni'hiectasis. 

Apart  from  the  various  schizomywtes,  parasites  are  not  commonly 
fcHitiii  ill  the  himuin  lung.  In  the  low  -r  animals  a  very  common  parasite 
H  liif  Strdiir/i/luK,  of  which  several  varieties  have  Ijeen  noted. 

Mycosis  AspergiUina. — .\  mycosis  aspergillina,  due  to  the  growth  of  the 
Anj)* n/l II U.I  fiimlgatug,  haa  l)eeii  descrilieil  in  connection  with  bronchiec- 
la.Ms.    llarclv  erhinorocri  and  nematode  worms  have  been  met  with. 


RETBOaKESSIVE  1IETAM0RPH08E8. 


These  an'  not  of  mi. 
tioii  of  tlic  muscle  of  t 
fatty  defeneration  of 
(■av>  cf  I'eiieralizeil  i 


'  importance.  Atrophy  and  degenera- 
occur  in  chn>nic  bronchitis,  as  well  as 
•UiMis  rings.  More  noteworthy  are  the 
(leger:  lation  of  the  bronchi,  analogous 


to  the  <  haiisres  in  the  catina^e.i  elsevvli  ,e,  that  are  met  with  in  old  people. 


PSOORESSIVE  METAMOBPH08E8. 

Hypertrophy. — Hypertrophy  of  the  muscular  tissue  is  frefjuently 
foiim!  in  (hroiiic  bronchitis.  \  general  hyp-rplasia  of  the  bronchial 
wall  ha-  lieeii  describeil  by  Heller  in  cases  of  bronchitis,  and  ihis  seems 
ti)  form  II  -tartiiig  |)i)int  for  many  varieties  of  tumors,  such  as  the  chon- 
linmiii.  i-teoina,  myxoma,  papilloma,   lijioma,   adenoma,  and   mixeil 


Sec  Hedinpr,  Verb.  il.  (Iciitsch.  path.  Ges..  liJtH. 


280 


THE  BRONCHI 


);n>wth.s,  for  it  htt-s  lung  \)evn  known  that  these  are  rclutivtlv  hmtv 
trvi\uent  in  connection  with  broncl'icctiutis  than  in  affections  of  the  iuii); 
proper. 

Tomort. — 'Hk  Iw-nign  growths  are  exccitlingly  rare.  Mali^^nunt 
growths,  originating  as  primary  tumors  in  the  larger  bronchi,  an>  iiiicoin- 
nion.  Those  begiiming  in  the  finer  branches  cannot  be  distinguished 
fn>m  those  beginning  in  the  lung  itself.  Oudnomu  either  ori^'inate 
fmm  the  lining  columnar  epithelium  or  from  the  peribronchial  niiicuuit 
gluiuls.  Si/iuimou*  epithelioma  of  a  bronchus  has  been  reportwl.'  'ITiin 
is  probably  due  to  metaplasia  of  the  lining  columnar  epithelium  of  the 
nuicasa.  Streoma  and  iTmphoiareoBU  are  rare.  Metastatic  growths, 
however,  are  common  enough. 


ALTlKATIOm  or  TBI  OONDITIOir  OF  TBI  LQMIH. 

Perforation. — Perforation  of  the  bronchial  wall  may  arise  irum  a 
variety  of  causes.  Tuberculous  or  purulent  inflammation,  parasites, 
or  foreign  Ixxlies  may  erode  tlmnigh  the  bronchial  wall  into  the  lun): 
substance.  Ca.seous  lymph-glands,  cancer  of  the  oesophagus,  alist'osses, 
and  more  rarely  aneurisms,  may  I    rst  in  from  without. 

Bronchial  Ocdnaion. — Bronchial  occlusion  may  )>e  brought  about 
by  foreign  Iwdies,  such  as  corks,  slate-pencils,  or  bits  of  [mhw,  that 
have  been  accidentally  inhaled.  Exudates  and  excretions  sometimes 
also  collect  in  the  tubes,  and,  while  they  are  often  got  rid  of  by  coughiri); 
they  may,  owing  to  inspissations  or  caseation,  form  a  permanent  <)l)struc- 
tion.  Such  exudations  may  become  calcified  and  form  broncholiths. 
In  rare  instances,  as  in  a  case  recorded  by  one  of  us,'  the  occlusion  is 
brought  aliout  by  infrabronchial  tumors.  Pressure  from  without  Is  a 
not  infrequent  cause,  and  is  iLsually  due  to  inflammatory  processes  in 
the  neighlwrhood  of  the  bronchus,  tumors  of  the  lung  or  crsophagus, 
and  aortic  aneurisms.  By  far  the  most  potent  cause  is  inflammation 
of  the  bronchial  wall,  which  is  often  associated  with  inflainmatorv 
clmngi's  in  the  lung  substance  in  the  immediate  neighborhood.  In 
such  cases  secretion  and  exudation  are  iLsually  present.  Wluii  IuIht- 
culosis  is  the  underlying  condition,  the  bronchial  wall  is  often  caseous 
and  the  lumen  plugged  with  a  more  or  less  dry,  cheesy  mass.  In  some 
forms  of  inflammation,  notably  the  .syphilitic,  the  process  us  it  heals 
leaves  a  contracting  scar-tissue,  that  gnidually  squeezes  in  tin-  hidiichial 
wall  and  thus  produces  distortion,  or  even  complete  occlusion.  Fn  those 
cases  where  the  obstruction  of  the  bronchus  is  complete,  tiic  corre- 
sponding lobule  of  the  lung  becomes  in  time  quite  colJapstnl,  owiiij;  to 
the  absorption  of  the  contained  air.  VVIien  the  obstruction  is  only  par- 
tial, the  alv«H>li  become  dilated  and  a  form  of  emphysema  is  tht  rcsuh. 
Much  depends,  too,  upon  the  nature  of  the  oKstructing  siilistance. 


II 

liii 

'  1'.  Krnst,  Ziegler's  HcitrnRe,  20: 18<)fi:155. 

'  Adami,  Montreal  Medical  Journal,  24:1895-96:510. 


BRONCHIECTASIS 


281 


'i'lilK'n  iiluMM  ia,  of  foiirse,  a  pro^rfMive  affivtion,  ami  may  lead  to  a 
|<ii-al  (li'stnic'tioii  uf  a  limiK-h  <n  ami  of  the  lun{{  itscir  Even  when  the 
otfiiiiliiij:  sulwtttmr  is  of  a  lienif;n  nature,  seenndary  infection  Ls  apt  to 
iMfiir,  so  that  septic  pneutnoniu,  abscess,  ami  even  gangrene  are  m>t 
infr('(|in'iit  results.  In  many  instances  the  trouble  is  only  temporary', 
for  if  till-  olwtructing  sulistance  be  coughed  up,  restoration  to  the  normal 
(■oniliiii>n  is  more  or  less  complete. 

BronchiectMil. — Bronchiectasis  is  the  comlition  in  which  the  bronchi 
andilattsi  niul  often  distortinl.  The  factors  concert  d  in  its  pnxiuctioii 
an'  iiuToascd  intrapuhnonar}'  pressure,  disease  of  lae  bronchial  walls, 
prrssurc  of  accumulated  secretion  within  the  bronchi,  and  certain  chn>nic 
utfi'f'tions  involving  the  parenchyma  of  the  lung.  Usually  more  than 
one  cause  is  at  work  in  any  given  case.  According  to  the  appearam-e  of 
tlHMlilutations,  the  following  varieties  have  lieen  recognizeti:  the  saccular. 
the  rjiliiulrival,  the  fusiform,  iind  the  varicose.  The  condition  may  lie 
loi'alizc<l  to  one  region  of  the  lung  or  may  Im*  disseminated.  In  the  sac- 
rulur  fiirni,  (lie  dilated  portion  is  somewhat  globular  in  shape  and  often 
mon-  or  liss  eccentrically  situated;  in  the  cylindrical,  the  whole  tulie 
Is  cvt'iilv  dilute*!.  The  fusiforta  and  the  varicose  are  sufficiently  de- 
MriUil  ill  tlu'ir  designations.  The  condition  of  the  bronchial  wall 
varies  a  pnxl  deal  acconling  to  the  etiological  factor  at  work,  being  at 
one  time  dilated  and  thinne<l  (atrophic  form),  at  another  dilated  and 
ihickeiicd  (hypertrophic  form).  When  the  bronchial  wall  is  weakened, 
as,  for  instance,  from  long-continutnl  inflammation,  iiicrea.sed  pressure 
of  air  within  tiie  tuln'  will  naturally  produce  simple  dilatation  and  atrophy. 
Ill  the  atro[>hic  form  the  dilatation  is  usually  cylindrical,  but  if  the  pressure 
has  Iktii  unevenly  exertetl,  the  sacculated  form  will  be  produce<l. 
Williiti  tlic  lumen  the  wall  is  seen  to  be  encircled  by  a  numlier  of  sharp 
ri(l);es  wliicli  represent  the  muscular  and  elastic  constituents  of  the  wall, 
while  the  iiior»'  widely  dilated  portion  is  the  connective  tissue. 

Tlu-  liyiHTfrophic  form  is  most  frequently  found  in  those  cases  where 
&  'iin^'  is  tilvroid  and  certain  po-'  s  are,  as  a  consequence,  imperme- 
al).,  air  The  dilatation  is  not  luch  due  to  weakness  of  the  walls 
as  to  iiTi  pillar  i)resstn\'.  .\s  can  Ix  readily  understood,  when  a  portion 
of  tlip  liiii;;  is  cut  off  in  any  way  from  its  air  supply  the  bronchi  of  the 
iiiiatfcdi-.l  }K)rtion  are  subjected  to  increase<l  pressure  and  therefore 
tlilatc.  1 II  clironic  indurative  pneumonia  bronchiectasis  is  not  uncommon 
where  ilicrc  are  pleural  adhesions,  owing  to  traction  of  the  fibrous  bands 
ii[)on  the  lironchi.     Great  dilatation  and  deformity  may  thus  result. 

We  iiiiiy,  further,  recognize,  with  Orth,  a  prioary  and  a  secondan,- 
Imiiichifciiisis. 

In  tlic  |)riinury  f»»rm,  chronic  catarrh  and  productive  inflammation  ai:> 
the  niii>t  potent  causes.  Owing  to  the  cellular  infiltration  and  the  exu- 
liativi'  .111(1  productive  processes,  the  bronchial  vail  l)ecomes  less  resist- 
ant, so  that  it  gives  way  before  any  increased  u.mand  upon  it,  such  as 
IS  mail.  1  <v  prolonged  coughing,  and  difficult  respiration.  The  s^H-ondary 
variety  i  .Inc  to  some  caase  apart  from  the  condition  i  the  bronchial 
»all.      I  he   forms    described    are    the    compensatory,    the   atelectatic, 


2H2 


TIIK  BRONCHI 


the  rirrhntic,  himI  thf  pitrrtic.  'ITie  cumprnitftiory  form  w  m>«-ii  v\|i,n' 
a  portion  of  the  lung  U  eompremed,  collapiml,  or  imiumteii,  so  dial  iIh- 
bronchioles,  in  pskl,  are  oliHtructed;  thooe  in  the  more  heultliv  |M)rtii)n 
may  then  lM>conie  liilattil.  Thli  affonLn  the  inoBt  typiciil  exuiii|>lf  of 
atrophic  brunchiertusls.  The  atelcctHtii-  form  ix  m> .  Mrith  in  chscs  wIhtc 
a  lobe  of  the  lung  is  collapsed  but  not  compressed,  as  in  piciind  ctriisionH 
and  in  congenital  atelectasis.  'Vhe  bronchi  of  the  affected  |Nirti(iii  inav 
dilate  and  their  walU  become  hypertrophic.  Cirrhotic  diliitiilion  is 
found  in  fibroid  lungs.  Here  the  condition  is  due  not  only  to  iiunHM.I 
intrabronchial  pressure,  but  also  to  traction  upon  the  broncliial  »ull 
by  the  newly-fomie<l  fibrous  tissue.  In  the  paretic  form,  nont'  of  ilic 
ordinary  causes  are  at  work,  but  the  most  important  factor  is  tlu'  pn-Nsiirr 
of  secretion  which  has  .stagnated  in  some  portion  of  the  broncliiul  tn-e. 

'ITie  appearance  of  the  lung  in  bronchiectasis  will,  of  courM-,  vniv 
according  to  the  causes  at  work.  The  condition  is  usually  n-f'o^'inzrd 
from  the  fact  that  the  bmiu-hi  are  dilit"!  and  com4C(|Ufntly  iNtiipv 
more  than  they  should  of  the  pulmonary  area.  The  dilated  l>n>ii('lii(ilVi 
can  often  he  trace*!  to  the  very  periphery  of  the  lung,  'i'lu-  muwas 
membrane  Is  red<lenetl  ami  there  is  more  or  less  .secretion.  Tin-  [jaren- 
chyma  of  the  I  -^.g  may  present  the  appearance  of  compression,  (oilapsr, 
or  fibroid  indu  *'on.  In  all  forms  of  bronchiectasis  the  mucous  mem- 
brane is  more  or  less  atrophic  and  infiltrated  with  inflammatory  priNJucts. 
The  cartilaginous  plates  are  degenerate*!  and  often  invaded  liy  vascular 
newly-formed  fil)rous  tissue.  The  ducts  of  the  mucous  glands  art-  liiluteil. 
The  lining  ciliated  epithelium  is  sometimes  intact,  but  more  ufirn 
desquamated  or  in  a  state  of  hypersecretion,  goblet  cells  Mn^r  (juite 
numerous.  Very  rarely,  polypoid  outgrowths  of  the  mucosa  liavc  Ik^d 
met  with. 


3'  ■« 


CHAPTER    XIII. 

THE  LUNOS. 
OOVaiXITAL  AVOMALm. 

Thp  annmaiies  of  drveloptncnt  are  of  little  practical  importance. 

0«mpl«t«  abMBM  of  Iwtli  lungs  htm  been  found  in  acephalic  monsters, 
and  M,  of  course,  a  condition  quite  incompatible  with  life.  Complete 
abserH-r  (afntia)  of  one  lung  and  imperfect  development  fhypApUaia) 
are  occasionally  met  with,  but  still  are  rare.  Agam,  a  lobe  may  be 
rudimentary.  With  some  of  these  defects  bronchiectasis  may  be 
asmciattNl.  More  common  Is  abvonnal  lobttiOB  of  the  lung,  which  is 
rather  more  fre(|uent  on  the  right  side.  In  addition  ti  he  usual  fissures, 
there  may  lie  several  extra  ones  more  or  less  perfect  or,  again,  the  right 
lung  may  consist  of  only  two  lolies.  In  1500  autopsies  at  the  Royal  Vic- 
toria Hosr  i(al  abnormal  iolMttion  was  met  with  71  times;  on  the  right 
side, '>4  times;  and  on  the  left  11;  on  Iwth,  0. 

An  interesting  condition  is  that  in  which  the  right  apex  is  cleft  by 
a  fUsun-  passing  from  above  downward  and  inward.  In  the  cleft  is 
iBualiy  u  fold  of  the  parietal  pleura,  along  the  edge  of  which  the  azygos 
vein  runs.  It  would  .seem  prolmble  that  the  explanation  is  to  be  found 
in  an  ahtiormal  course  of  the  azygos  vein.  In  our  series  we  have 
met  this  (t>ndition  six  times.  A  sapMnnmanry  left  Inng  has  been  met 
with  In  Diirck.' 

Atelectasis  or  ^ndomatosil. — Atelectasb  or  apneumatoiis  Is  a  p. 
sistemr  of  the  foetal  type  of  the  lung  tissue.  It  is  due  to  the  failure  of 
the  alvn.li  to  expand.  This  may  be  caused  by  any  obstruction  to  the 
free  ent  I  nice  of  air,  to  pressure  on  the  lung,  and  to  general  feebleness. 
The  [instnce  of  this  condition  is  of  much  importance  in  medicolegal 
ca.ses.  (  oiif^'enital  atelectasis  is  also  brought  about  by  certai".  -'ntra- 
uterine  iitff»tions,  such  us  hydrothorax  or  pleurisy. 


CIBOULATOKT  DUTURBAHOU. 

.V  coii^iilcnition  of  the  finer  structure  and  the  vascular  supply  of 
the  hiii}.'>  will  throw  considerable  light  upon  the  pathological  processes 
that  atlVci  liicse  organs. 

Tlie  liiri:.'s  receive  a  double  blood-supply,  from  the  right  ventricle 
thr()U);li  ihi  puirnonarv-  artery,  and  from  the* aorta  through  the  bronchial 

'  Munch,  med.  Woch.,  42:  1805:456. 


284 


THE  LUNOS 


arterii'H.  And  while  most  of  the  arteries  in  the  lungs  are  end-artt-rirs, 
we  can  n-a<lily  understand  how  it  Ls  that  obstruction  in  one  set  of  vessels 
<l(H's  not  necessarily  result  in  cutting  off  the  blood  supply  from  the 
affected  part.  Thus  anemic  infarcts  are  unknown  and  necnxsis  or  );an- 
greUe,  as  a  result  of  vascular  occlusion  alone,  b  almast  inijjossiljle, 
unless,  of  course,  both  sets  of  vessels  are  interfered  with  at  once. 

On  the  other  hand,  congestion  and  hemorrhage  are  very  coininon. 
Tliis  is  due  to  the  fact  that  the  capillaries,  which  are  thin-wullid,  con- 
sisting only  of  a  basement  membrane  and  a  single  row  of  cells,  arc  but 
badly  supported,  the  alveolar  walls  in  which  they  run  being  iiiiule  up 
of  a  few  connective-tissue  and  elastic  fibrils.  The  structure  of  the  alve- 
olar walls  is  necessarily  delicate,  in  order  to  allow  of  the  free  iiitcrcliaiifie 
of  gases,  and  this  being  so,  the  capillaries  can  readily  become  ovenlis- 
tended  and  give  way. 

Further,  in  inflammatory  processes,  while  the  alveolar  walls  certainly 
l>ecome  swollen,  congested,  and  infiltrated,  the  inflammatory  priHlucts 
are  poured  out  into  the  alveolar  spaces,  and  thus  the  cardinal  features 
of  a  pneumonia  are  to  be  seen  in  the  alveolar  spaces  rather  than  in  the 
walls. 

A.S  will  readily  lie  understootl  from  what  has  just  l)een  said,  iu  a 
delicate  structure  like  the  hmg,  vascular  disturbances  make  their  appear- 
ani-e  very  t(uickly  and  usually  pro<luce  marke<l  signs.  Finally,  the 
close  relatit)nsliip  l)etween  vascular  disturlmnces  of  the  lungs  and  dis- 
eases of  the  heart  and  bloodvessels  is  sufficiently  obvious. 

Anemia. — Anemia  of  the  lungs  may  be  part  of  a  systemic  olijieniia.or 
may  1h'  partial  and  duc»  to  local  causes.  Thus,  pressure  of  a  |)lenriti(' 
exudate  or  effusion,  or  of  a  mediastinal  growth,  may  lead  to  this  condition. 

In  emphysema,  there  is  always  a  certain  amount  of  anemia  owin;;  to 
the  fact  that  the  vessels  are  occlutled  from  pressure,  atrophy,  and  endar- 
teritis. The  anemia  that  is  part  of  a  .systemic  condition  is  most  marked 
about  the  apex  and  the  anterior  border  of  the  lung.  The  orijans  are 
pale,  colorless,  and  on  section  very  dry.  By  many  it  has  Ix-en  tliou^tht 
that  anemia  of  the  lungs,  such  as  is  brought  alwut  by  congenital  sniall- 
ness  of  the  pulmonary  artery  or  hypoplasia  of  the  cardioviisciii:ir  system 
as  a  whole,  is  a  pcitent  prwlisposing  cause  of  pulmonary  tul>erculosis. 
According  to  Rindfleisch,  the  fact  that  the  apex  of  the  lung  is  the  first 
to  suffer  in  anemia  ex|>lains  why  tuberculosis  so  frequently  starts  in  that 
situation. 

(Edema. — This  is  of  frequent  occurrence,  being  found  at  almost 
every  autopsy— ai/ww/  adema.  The  condition  may  involve  ilie  whole 
lung  or  may  Ik-  confined  to  one  or  more  IoIh's. 

The  linigs  are  somewhat  heavier  and  firmer  than  normal,  pit  on 
pressure,  and  on  section  the  tissue  generally  is  filled  with  a  niilier  thin, 
watery  fluid,  which  can  readily  be  demonstrateil  by  .squeezing;  ilie  \mfi 
iK'tween  the  hands.  When  the  fluid  is  removeil  the  lung  n  ;;.Mns  its 
normal  crepitant  condition.  The  fluid  is  largely  serous  in  cIimii.  iirand 
may  contain  a  few  red  cells  and  leukocytes,  as  well  as  swollen  ( [litlieiial 
cells,  loaded  with  coal  or  blood  pigment,  tliat  have  been  d<'^i|iiamate(l 


HYPEREMIA 


285 


from  the  alveolar  walls.  The  most  frequent  cause  is  the  relaxation  of 
the  vessels  that  takes  place  just  at  the  time  of  death.  This  is  proli- 
ablv  assisted  by  the  toxic  condition  so  often  associated  with  the 
last  hours  of  life.  It  is  rather  curious  that  in  this  form  the  upper  lol)es 
of  the  lungs  are  frequently  most  affected,  and  often  one  more  than  another. 
Whv  tills  should  be  has  never  been  adequately  explained. 

.\  second  form — congestive  adema — is  that  seen  in  connection  with 
passive  hyperemia,  in  which  case  the  posterior  portions  of  the  lungs  are 
most  aifeeted.  Here  the  fluid  is  often  reddish  or  reddish-brown,  from 
admixture  with  blood  or  blood  pigment.  In  cases  of  long-standing, 
chronic  <iHlema  is  not  infrequently  found.  In  this  form  the  fluid  is 
more  viscid,  and  when  the  lung  is  squeezed  the  fluid  does  not  readily 
flow  awiiy. 

A  thin!  form  is  the  inflammatory  adema,  which  is  found  in  the  early 
stapes  of  pneumonia,  at  the  periphery  of  pneumonic  patches,  and  occa- 
sionally in  cases  of  septicemia.  This  differs  from  the  other  varieties 
mentioned,  in  that  the  fluid  is  richer  in  albumin  and  apt  to  contain 
cellular  elements  in  greater  abundance.  This  form  readily  passes  over 
into  catarrhal  inflammation. 

\  fourth  form  is  the  acute  fulminating  adema.  This  comes  on  sud- 
denly, sometimes  in  those  who  are  apparently  in  perfect  health.  Usually, 
however,  the  persons  attacked  are  the  subjects  of  arteriosclerosis  or 
chronic  nephritis.  Allbutt  has  observed  it  in  connection  with  aortitis. 
Cases  often  run  their  course  rapidly,  and  may  end  fatally  in  an  hour. 
In  (iiH  case  coming  under  our  knowledge  pints  of  watery  fluid  pouretl 
out  ot  lue  mouth  for  some  hours  before  death,  and  at  autopsy  the  lungs 
were  completely  waterlogged.  The  condition  has  been  produced  cxperi- 
menlally  by  the  injection  of  adrenalin. 

Microscopically,  oedema  of  the  lungs  shows  little  worthy  of  note. 
The  vessels  of  the  alveolar  wall  are  somewhat  congested,  and  the  alveoli 
contain  a  few  large,  round,  mononuclear  cells  derive<l  from  the  lining 
epithelium,  with  a  few  retl  and  white  blood  cells.  Should  the  oeilema- 
tous  tluid  contain  much  albumin,  although  it  usually  does  not,  the  albu- 
min a|)])ears  as  a  fine  granular  de[>osit  or  in  the  form  of  minute  clear 
pliiliules  pnHlueed  by  the  coagulation  of  the  albumin  in  the  process  of 
hanleiiiuf;. 

Hyperemia. — In  the  production  of  the  various  forms  of  congestion 
of  the  luiif^s,  a  numlxT  of  factors,  mechanical,  chemical,  and  thermic, 
are  coMdrned,  apart  from  the  question  of  inflammation.  Thus  heat, 
cold,  irritating  gases,  anil  other  changes  in  the  respired  air  are  often 
respoibililc  for  the  condition.  Too  great  functional  activity,  such  as 
siimeiinies  arises  from  severe  muscular  strain,  leads  to  marke<l  hy|)cn>min, 
which  ill  some  cases  has  Iktu  so  severe  as  to  cause  death  (apoplexia 
pulmiDi  I!  n,  vnHcularis). 

Of  ihc  t'ornis  due  to  mechanical  causes  might  \w  cited  the  hyperemia 
of  the  liiiii.'s  which  is  found  so  often  in  cases  of  death  from  respiratory 
failure.  IK  h  as  occurs  from  certain  lesions  producing  pressure  upon  the 
Imse  ot  I  lie  brain,  and  in  the  compensatory  forms,  as,  for  instance,  the 


286 


THE  LUNGS 


)' 


!    i 


hyperemia  of  one  lung  which  is  present  when  the  other  lung  is  collapsed 
or  compressed.  One  of  the  main  types  is  that  known  as  hypostatic  eon- 
gattion.  This  occurs  whenever  there  is  obstruction  to  the  fn-c  outflow 
of  blood  from  the  lungs  or  deficiency  in  the  driving  power  of  the  heart 
or  arteries.  As  will  readily  l)e  understood,  the  lower  and  |M)sterior 
portions  of  the  lungs  are  the  parts  first  and  chiefly  affected.  Tliis  form 
IS  seen  in  patients  that  have  been  confined  to  bed  for  a  lengtli  of  time, 
or  where  there  is  degeneration  of  the  muscle  of  the  heart,  sucli  as  is  seen 
in  the  severer  forms  of  the  infective  fevers,  for  example,  typhoid  and 
pneumonia.  Mechanical  olistruction  within  the  lung  itself  niuv  l»e  at 
the  bottom  of  this,  or  the  heart  may  have  given  way  from  chludv  or 
fatty  changes  and  dilatation.  It  is  also  obvious  that  this  coiulition  will 
l)e  aggravated  whenever,  as  so  fretjuently  is  the  case  in  sevi-re  fevers 
the  respiratory  movements  are  weak. 

Deficiency  in  the  driving  power  of  the  right  heart  is  a  potent  cause, 
as  it  allows  the  blood  to  remain  in  the  lesser  circulation  longer  than  it 
should  do  normally.  A  weak  left  heart,  by  lessening  the  power  of  the 
general  circulation,  acts  in  a  similar  way,  but  to  a  less  extent. 

The  most  marked  example  of  the  obstructive  form  is  that  due  to 
insufficiency  or  stenosis  of  the  mitral  valve,  or  to  increased  |)res.snre 
within  the  systemic  circulation.  In  a  marked  case,  the  lung  is  somewhat 
enlarged,  its  consistency  increasetl,  and  its  elasticity  diminislnHl.  On 
section  the  tissue  may  not  \ye  (edematous  but  is  full  of  blood  of  venous 
appearance.     The  color  is  dark  re<l,  or  purple  re<l. 

Being  a  chronic  condition,  there  is  apt  to  Ik*  proliferation  of  the 
fibrous  tissue  in  the  septa  of  the  lung,  so  that  the  tissue  U'comcs  firniii 
than  normal,  the  so-called  cyanotic  induration.  In  cases  of  a  longer 
standing  still,  more  or  less  blood  is  effused  by  diapedesis,  and  the  red 
cells  are  eventually  broken  down,  lilieniting  the  blood  pi};nient.  In 
such  cases  the  fibrosis  is  still  more  marked.  This  condition  is  called 
brown  induration,  from  the  fact  that  the  cut  surface  of  the  Itiiif;  is  of  a 
dark,  rusty  brown  color.  On  stjueezing  such  a  lung,  the  fluid  which  is 
exuded  is  also  of  a  brownish  color,  and  if  a  little  of  it  Ik-  examined 
under  a  microscope  it  is  seen  to  contain  large,  clear,  mononndiar  cells 
loaded  with  brownish  pigment.  These  are  the  so-called  "  heart-failure" 
cells. 

Microscopically,  the  appearances  in  congestion  of  the  limps  are 
characteristic.  The  vessels  are  found  to  Ix"  distended  with  1)Io(h1.  This 
is  extremely  well  seen  in  the  delicate  capillaries  of  the  alveolar  walls, 
which  can  l)e  made  out  to  l)e  filled  with  red  blcxxl cells.  Tliev  arc  over- 
distende<l,  so  that  they  assume  a  beaded  or  varicose  appearance  and 
project  into  the  alveolar  spaces.  An  occasional  red  cell  may  lie  seen 
free  in  the  alveolar  space. 

In  the  chronic  cases,  such  as  those  due  to  a  long-standin;:  valvular 
lesion  of  the  heart,  there  is  in  addition  to  the  appearane(^  iu>t  men- 
tioned a  general  thickening  of  the  fibrous  septi  of  the  lunjr,  which  is.  in 
places,  infiltrated  with  small,  round  cells,  prolmbly  younn  liliroblasts. 
Besides  this,  in  the  alveolar  spaces  there  are  often  consideral!"  iiuml)ers 


i  ; 


HEMORRHAGE 


287 


of  ctlls  of  the  heart-failure  type  just  mentioned.  These  have  the  ap- 
pearaiK'e  of  large  mononuclear  cells,  containing  the  shadows  of  re«l 
wlls,  or  blood  and  coal  pigment.  They  are  derived  either  from  the 
(les(iuiiinate<l  lining  cells  of  the  alveolar  walls  or  are  wandering  cells. 
In  the  advanced  case.,  the  pigment  is  not  confined  to  the  desquamated 
cells,  liut  is  found  in  the  conntctive  tissue,  lymphoid  and  epithelial  cells 
as  well. 

Hemorrhage. — Effusions  of  blood  within  the  lung  substance  may 
affect  the  parenchyma  of  the  organ  or  may  involve  the  various  air  spaces. 
The  iKtter  event  is  by  far  the  more  common,  owing  to  the  anatomical 
peculiarities  of  the  lung  before  referred  to.  As  a  rule,  the  blood  is  de- 
riveii  from  the  pulmonary  ve.s.sels,  but  occasionally  it  comes  from  outside 
the  Itin);  altogether,  as,  for  instance,  when  an  aneurism  of  the  aorta 
hursts  into  a  bronchus. 

The  effused  blood  may  lie  small  in  amount,  taking  the  form  of  petechial 
spots,  varying  in  size  from  that  of  a  pin-head  to  that  of  a  bean,  or  large 
areas  may  be  involved,  even  to  the  extent  of  a  whole  lolje.  The  smaller 
hemorrhages  are  usually  but  imperfectly  definerl  from  the  unaffected  lung 
tissue  and  more  or  less  patchy  in  character.  In  the  case  of  the  largj'r 
areas,  notably  in  infarcts,  the  line  of  demarcation  is  usually  very  distinct. 

With  regard  to  the  ultimate  causes  of  these  effusions,  it  may  be  said 
in  jreiienil  that  the  extravasation  is  due  to  alterations  in  the  vessel 
walls  or  to  the  obstruction  of  the  lumen.  Thas,  in  the  early  stages  of 
loharaml  lobular  pneumonia,  bloixl  may  be  extravasated  in  large  amounts, 
Dwin^'  to  (liape<lesis.  In  a  few  cases,  as  in  vicarious  menstruation, 
it  woulil  appear  that  the  condition  is  due  to  some  defect  in  the  innerva- 
tion of  the  vessel  walls,  for  the  lung  is  in  such  cases  practically  intact. 
.\ny  solution  of  continuity  of  a  vessel  wall  is  also  a  cause,  such  as  may 
result  from  fatty  and  hyaline  degeneration,  ulceration,  or  traumatism. 
.\  >imiliir  condition  of  things  is  found  in  connection  with  lesions  of  the 
[xins,  iiiidulla,  and  occasionally  the  cerebral  cortex. 

Tiif  traumatic  form  is  seen  in  wounds  of  the  lung  produced  by  sh(K)t- 
iii}:  or  stabbing,  or  by  a  broken  rib.  In  rare  instances,  rupture  of  the 
lunjr  occurs  from  severe  strain  without  any  of  these  causes. 

Hv  f;ir  the  most  common  cause  of  the  larger  hemorrhages  is  ulceration 
ur  (Ifircncration  of  the  vessel  walls  in  the  course  of  necrotic  or  tuber- 
ciiiou>  iiiflamination  of  the  lung  substance. 

It  (K( iisionally  happens  that  in  gangrene  of  the  lung  a  vessel  is  opened 
ami  frtf  hemorrhage  takes  place  into  the  cavity,  which  may  eventually 
ilis(li;ir:,'c  into  a  bronchas.  This  Ls,  however,'  a  much  more  frequent 
event  in  diroiiio  ulcerative  tulierculosis. 

In  tli(  ( (lurse  of  the  caseous  and  necrotic  inflammations  which  result 
in  finiiv  formation,  the  fibrous  septa  and  bloo<l vessels,  which  are  the 
most  I.  i~iant  of  the  tissues,  are  laid  l)are.     Thus,  the  i)loodvessels 

'.'"*/" I  projecting  in  loops  from  the  wall  of  the  cavity  or  running 

in  Hhruii.  hands  across  the  space,  where  they  are  Iwdly  supjwrted.  The 
vcsmIs  .in  not  esca{)e,  however,  but  are  the  seat  of  a  panarteritis  and 
emiartc;,!  ..  which  in  some  cases,  but  not  invariablv,  leads  to  oblitera- 


2S8 


THE  LUNllS 


tion  of  the  lumen.  The  vessel  wall  l)ecomps  thickened  tliroii^li  n  ( lininic 
pruduetive  inflammation,  and  from  the  inner  layers  a  tilirinolivaiiiic 
defeneration  sets  in,  which  f(ra<lually  sprca«ls  to  the  periphery-  and  mav 
eventually  involve  the  whole  circinnference.  In  this  way,  the  vessel 
wall  becomes  soft  and  is  no  longer  able  to  resist  the  pn\ssure  of  (he  U(m\. 
Usually  some  part  of  the  wall  gives  way  and  an  aneurism  is  formed 
or  rupture  takes  place.  These  aneurisms  varj-  in  size  from  tlmr  of  a 
pin-head  to  a  cherry,  and  may  fill  up  the  entire  space  of  tlio  <iivitv. 
Rupture  readily  takes  place,  and  the  n-sulting  hemorrhage  uiav  U-  verv 
severe  or  even  fatal.  Often,  however,  death  is  not  brought  alK)iit  liv 
a  single  hemorrhage,  but  by  repeated  attacks,  leading  to  oligemia  anil 
cttche.xia.  Past  mortem,  it  is  not  always  easy  to  find  the  aiiciirisin  or 
ruptured  vessel,  for  when  the  bleeding  has  lieen  rejK-ated  and  prolonged, 
the  vessel  is  often  obliterated  owing  to  pressure  and  inflanimalion. 

Perhaps  the  most  striking  form  of  hemorrhage  into  the  lung  is  the 
hemorrhagic  infarct.  This  is  found  most  frequently  in  the  riijiit  lunj; 
and  in  the  lower  lobe,  but  may  be  multiple  and  occur  in  both  lungs. 

In  a  well-niarke<l  ease,  the  infarct  is  cone-shaped  and  more  or  less 
sharply  defined  from  the  rest  of  the  lung.  It  is  usually  situated  near 
the  pleural  surface,  the  ape.x  of  the  cone  being  innermost.  Tlie  pleuni 
over  the  affected  part  is  elevated,  of  a  dark,  purplish-re<l  color  and  the 
lung  is  felt  to  be  occupietl  by  a  firm  mass.  The  pleura  in  the  earlv 
stages  is  still  (juite  smooth,  but  in  a  case  of  some  standing  is  covend 
with  a  slight  fibrinous  deposit,  due  to  reactive  inflammation.  On 
cutting  through  the  mass,  tli-  affected  area  is  found  to  Im-  solid,  friaiile, 
and  of  a  dark,  purplish-red  or  rusty-brown  color,  'i'hc  tdps  may 
Ih*  quite  sharply  define*!  from  the  rest  of  the  lung,  or  the  infarct  may  U' 
of  a  mon-  patchy  character.  In  an  infarct  of  some  standing,  iliere  may 
l>e  slight  softening  and  th»'  ape.x  and  edges  of  the  cone  arc  xnnenliai 
grayish  in  color,  due  in  part  to  a  deposit  of  fibrin  and  a  iciik(X'ytie 
infiltration.  On  scraping,  the  surface  is  at  first  <lrv  and  ;:niiiular, 
suKse(|uently  mort'  juicy.  We  have  met  with  a  case  of  conipi  :<■  li(|ue- 
faction  of  the  area  with  th<>  formation  of  a  ragged  cavity. 

Microscopically,  the  changes  in  the  affecte«l  tissue  arc  \cr\  plain. 
The  alveolar  spaces  are  filletl  witli  retl  blootl  cells  so  as  to  W  (|iiite  air- 
less. An  occasional  leukocyte  or  thread  of  fibrin  may  also  lie  seen. 
The  alveolar  walls  ait-  thin  and  compresse<l,  the  nuclei  siainini;  l)a(l!y 
or  not  at  all.  The  various  interlobular  septa  are  free  from  ati\  extrava- 
sation. .\bout  the  margins  of  the  infarct,  where  a  certain  .uiionnt  of 
ri'active  inflanunation  is  taking  place,  the  leukocytes  are  more  immerors 
in  the  alvetdar  spaces  and  the  fibrin  Ls  more  abundant.  The  lymph 
channels  alK)Ut  the  p'ripliery  of  the  infarct,  in  ad<lition  ti>  tin'  |RTivaseii- 
lar  and  |H'rilm)nchial  lymphatics,  are  filled  with  reabsorlM'd  MimmI  cells. 

As  the  infarct  ages,  a  characteristic  series  of  changes  takes  place. 
The  extravasateil  cells  gradually  break  down  anil  the  |'i::ment  is 
set  free  in  hrownisli  granular  masses,  (iradnallv  the  •^•-  iibitinn  is 
restortnl  through  the  broncliiil  arteries,  the  alveoli  Ikhoui  iinptied. 
and  the  part  becomes  functional.      Rarely  do  we  have  iii  ■  rosis  and 


■■  i   ■ 


FAT  HM HOLISM 


289 


rii-dtrii'iitioii  as  in  infarcts  elsewhere.  A  ran-  event  is  for  the  centre  of 
ihr  infarct  to  soften  anil  then  InK-omc  al).s()rlN>«l,  pnuhicin^  a  form  of 
iv-t;  iir  thi-  irifurctetl  area  may  In-come  infiltrated  *ith  calcareous  salts 
iiiKJ  a  li:ir<l  ncKlule  Ik"  left.  In  thos*-  cases  where  the  infarct  is  infectwl 
at  tlif  ^tll^t,  or  iH-i'omcs  so  later,  a  septic  pncmnonia  may  develop  with 
the  foriiiiition  of  a  Innj;  alisc-ess  or  a  patch  of  fpinj^wne. 

With  rcjcard  to  the  etiolojjy  of  infan-t  of  the  liinj;,  much  ha.s  lieen 
sritttti.  A  vari«-ty  of  factors  s«-enis  to  enter  into  the  causation.  The 
mo-it  iiii|M)rtaiit  and  constant  is  the  (-onditioii  of  the  l>l(MKlvc.s.sei-,.  As 
a  majority  of  instances  of  lunjj  infan-t  arisip  in  connec-tion  of  valvular 
liNJidis  of  the  heart,  emphysema,  inflammations,  .senile  and  manintic 
niniiitioiis  of  the  general  .system,  we  c-an  look  for  a  main  contrihiitor'- 
(-auM-  in  the  fatty  and  hyaline  dej^eneration  of  the  capillaries  and  smaller 
vessels  which  is  so  often  present  in  siu-h  cases.  A  sudden  disturbance 
i>f  tin  "iIimkI  pressure  of  the  part  or  a  loss  of  the  normal  va.scular  Imlance 
which  should  <'xist  Ix-tween  the  <lifferent  portions  of  a  limg  area  are 
pnverfiil  factors  also,  since  s-.ich  may  lead  not  only  to  degent.ative  changes 
in  the  Vf^^(-ls  themselves,  but  to  actual  rupture  of  their  wall-:. 

Tilt-  most  fref|uently  found  condition  is  a  clot  within  the  main  ve.s.sel.s 
Ifuiiini;  to  the  infan-tcil  area.  The  pulmonary  artery  at  the  apex  of 
the  \v(i|c;(-shaped  mass  is  usually  stoppetl  by  a  thromtjotic  eu  .>lus. 
The  pnhnoiiary  vein  may  be  thromlnxsed,  but  it  may  not  infre(|uently  be 
fret-  frotii  clot,  e.\ce]>t  in  its  terminal  Rimifications.  The  vessels  affecte<l 
may  iqipcar  to  1k>  (omparatively  healthy,  or  they  may  show  fatty  and 
iiilier  cMiiarK-rific  chanjres.  Sometimes  tin-  clot,  f  om  its  condition  and 
apiN-araiKc.  can  Im-  (-Icarly  made  out  to  be  an  ciuIkjIus  which  has  reached 
the  Inn;:  from  some  other  part.  This  is  seen  not  infttH|ueiitly  in  ca.ses 
iif  e-iii<Karditis,  and  when  thrombi  in  the  largt-r  vascular  trunks  have 
iM-onit-  (iisl(Mlj;cd.  In  the  latter  cases  the  tml)oli  may  1k>  so  large  as  to 
ixdmle  the  main  trunk  of  the  pulmonary  vein  and  lead  to  instant  or 
rapiil  death.  The  c-ondifion  of  thi  )mlH>sis  of  the  crural  veins  or  of  the 
uterine  veins  after  childbirth  is  of  imich  importance  in  ti.vs  comiection. 

rile  various  tlu-ories  regarding  the  mcnle  of  formation  of  these  in- 
faret-i  iiavc  already  Ih-cii  discussed  on  page  ;{'.)  et  .swi. 

Ill  eiiiinectioii  with  iiifart-tion  we  hav.-  sj.-oken  so  far  only  of  emlK)li 
that  an  f(iniit-tl  of  blood  clots,  but  on  <M-casi(,i)  other  substances,  such 
a-  fat.  air.  cells  from  tumors,  fragim-nts  of  v.-ssels,  calciireotis  suits, 
ami  p  iiiiHic,  cnt(-r  the  vessels,  although  they  do  not  by  iiny  iiK-ans  always 
ri'-iilt  ill  iiifarclioii. 

Embolism.  Fat  Embolism.- -Fat  embolism  cH-c-urs  whenever  fat  in  aiiv 
f|iiaiitiiy  grains  entrance  info  the  b!(MMl.  ilms,  in  the  ca.se  of  fnu  tun-s  of 
the  ion;;  !»,nes,  cnishing  injuries  to  the  >,.Kly  wall  or  the  liver,  tl  c  iipemia 
"f  <liai..  t< ..  fat  droplets  can  Ik-  found  in  the  (-apillaries  not  <  iilv  of  the 
I'ln^'-.  hilt  1,1  th(-  other  organs  as  well  (sw  p.  .■)4).  A  rapid  melhcHl  for 
llemiiiiMr.iiiiii;  the  condition  is  to  cut  a  thin  .slice  of  tissue  with  a  double- 
''laiieu  kiiir,  .  which  can  then  Ik-  examined  dir»"<-tly  with  the  low  power. 
llie  fat  ill  tlic  larger  vi-ssels  l(M)ks  like  an  elongated  drop  of  some  semi- 
fluidsiih-taiKr,  clear  and  r"fractile.  In  the  smaller  capillaries  the  droplets 


2^)0 


THE  LVSnt, 


liave  a  more  varicasc  appearance,  or  the  tissue  may  lie  treated  with 
Sudan  III  or  osmie  acid,  when  the  fat  takes  either  a  red  or  hrcmnish- 

hlack  stain. 

Air  Imboliim.— Air  embolism  is  apt  to  occur  when  from  any  cause 
a  large  venous  trunk  is  laid  open  to  the  air  (see  p.  55). 


Emboli  c-omposed  of  portions  of  tumors  are  important,  sum 
this  way  that  meta-stases  in  the  lun,js  are  usually  produced. 


•I'  it  is  in 


ii 


\k 


OONDniONS  DOT  TO  DISTUKBlMOK  OF  THE  KE8PIRAT0RT 

FDHOTIOK. 

Atelectasis,— By  this  is  commonly  meant  tie  condition  i'l  which 
t!ie  alveolar  spaces  are  either  part.aily  or  ii>nip"etely  undisffiidfd  hy 
the  air.  The  tenn  "  atelw-ta-sis"  is,  strictly  speakinj;,  only  applicahlp 
to  cases  where  the  lung  has  imdergone  primary  im|)erfect  expiiiision. 
When  complete  airlessness  exists,  " apneumatosis"  is  the  In-ttcr  temi. 

The  c«)ndition  is  cimgcniial  or  ucqumfi.  Before  birth  tiic  liiiij;  is  a 
solid  organ,  the  alveolar  walls  lying  in  close  contact.  Tb'  iiiiii);  epi- 
thelium of  the  alveoli  is  composed  of  small  polyhedral  cells  and  the 
smaller  bronchioles  are  thmwn  into  folds  longitudinally.  'i'liiLs,  iiol 
actual  but  only  potential  air  spaces  exist.  With  the  first  inspirations 
the  lung  Ijegins  to  expand,  the  alveidar  walls  are  thrust  apart,  and  the 
lining  ceils  are  converted  into  flattened  plates.  The  bronchioles  there- 
upon assume  their  pennanent  shajx-.  The  condition  of  the  linifjs  in  the 
newlwrn  is  of  great  importanc-e  from  a  me<licolegal  standp'lnt,  to  deter- 
mine whether  the  infant  has  breathed  or  not. 

A  number  of  caases  may  contribute  to  the  persistence  of  the  ftftai 
cotidition.  Such  are,  general  asthenia  and  muscular  weakness  commnnh 
present  in  premature  children;  weakness,  owing  to  a  syphilitic  or  other 
constitutional  taint;  lesions  of  the  c-entral  nervous  system,  like  eerebrdl 
hemorrhage  or  similar  lesions  of  the  brain;  <lefeoLs  of  development, 
such  as  hyjK)plasia  of  the  lung  and  diaphragmatic  hernia;  finally  external 
cau-ses.  as  compre.ssion  of  the  thorax,  obstruction  of  the  l.roMchi  bv 
foreign  IkkHcs,  meconium,  or  secre'tion,  all  may  play  a  part. 

The  cau.ses  of  the  actjuire*!  fonn  may  be  included  under  the  general 
heads  of  (1)  defwtive  re.spiratory  function  \.:thin  the  liin<;  itself,  and 
(2)  external  mechanical  p.r'.ssure. 

Of  the  first  tvpe  the  comn.onest  form  is  that  found  ni  cue  hectic  or 
moribund  individuals.  Owing  to  weak  inspiratorj-  movements  and  the 
accumulation  of  fluid  in  the  air  passages,  the  lung  ti-ssuc  is  not  i)orf«tlv 
distended.  Conse<iuentlv,  small  areas,  chiefly  at  the  niar^'ins  of  tlie 
lungs,  iKwme  partially  or  wholly  collap.sed.  This  is  aiiioiii;  the  wra- 
monest  conditions  foun<l  post  mortem. 

Another  form  is  that  where  the  bronchial  tree  in  some  jX)iti..M  l)ecoiiios 
(K-cluiled  (obstructive  atelectasis),  as  from  a  foreign  Ixnly,  the  M.rumula- 
tion  of  secre-tion  in  the  lumen,  and  intrabronchial  and  iiitriipulinonar} 
tumors.    The  collapse  in  these  cases  is  brought  about  m  \n>ri  by  the 


ATELECTASIS 


291 


olweriictiiifs  material  acting  as  a  kind  of  valve,  whereby  air  i1(h»  not 
readily  enter  the  affected  portion  while  it  passes  freely  out.  This 
mK-huiiicul  action  is,  however,  not  entirely  ede(|iiate  to  explain  the 
comlitioii,  for  the  whole  of  the  contained  air  c-ould  not  be  got  rid  of  in 
that  way  The  n-sidual  air  is  ahsorlied  into  the  blood  (abiorptioB 
ittlertuii)  and  the  collapw-  thus  lK*coines  complete. 

H.\ . null  pressure  up«>n  the  whole  lung  or  any  part  •)(  it  is  a  very 
frwiueiit  cause  of  ati'lcctnis  (eompretiion  ktelecUiii).  Pressure  may 
lieexerUil  by  fluid  or  air  within  the  pleural  cavity,  an  t'"vated  diaphragm, 
aiR-urisins  or  tumors  in  the  mediastinum,  k\'phosis  and  scoliosis  of  the 
vertelirnl  column,  enlargement  of  the  heart  or  pericardial  cavity, 
thiiki'iiiiig  and  contraction  of  the  pK-ura.  The  effect  is  due  not  onlv 
todirttt  prcssu  •,  but  also  to  tlu'  interference  with  the  proper  respirator^r 
movcmi'iits. 

Fiii.  lis 


Cimpre-i.,,,  .•,,l|a|.-«  „l  tlie  lunu.  Note  the  fai't  that  the  alveiihir  -paceH  are  nbliteraleil,  tlie 
*,'"""'  '"  '""t""-*.     Zeif."  iihj.  1)I>,  iK'ular  N.i.  1       (Knmi  the  Pathological  Laboratory  uf 

.Mi-(illl  t  niwi^ity  I 

Altl((  tasjs  may  affect  one  or  both  lungs,  one  lobe,  or  any  portion 
tlurcof.  When  the  lung  as  a  whole  is  atelectatic,  as,  for  instance,  in 
nvdrothorax,  it  lies  close  to  the  spinal  column,  somewhat  high  up  in  the 
timrax.  ]u  volume  is  much  diminishe<l  and  the  surface  is  thrown  into 
mu-  wriiikl.s.  The  c-onsistence  is  increased  and  the  organ  has  a  leathery 
iH,  the  iioniial  crepitation  of  the  healthy  lung  l)eing  absent.  In  co!.jr 
It  IS  iK,,a!!v  purplish  or  bmwnish-red.  If,  as  sometimes  »-.j,jjcns, 
the  tisMi,.  IS  iseiiemic  from  prtssure,  it  assumes  more  of  a  grayish  or 
■'laty  ai)|)..aiMtiee.  On  section,  the  lung  do  not  crepitate,  and  resembles 
awti.    11„.  jitiWted  part  sinks  in  water.     If  squeezed  below  the  surface 


:ll 


t  -i> 


2!>2 


THE  LUSaS 


of  thf  waUT  a  few  air  liul»l>lf.s  may  sometimes  U'  expres,s«Hl.  In  most 
(•ollapsed  lunjp*  tliew  is  a  teiuleiiey  to  vaseular  stasis,  so  that  ilic  rut 
surfa<-e  is  eoiip-stiHl.  When  only  a  jMirtion  of  a  IoIk-  Is  ••olIapMil,  ih*. 
atfeete*!  part  is  of ..  «hirk  pnrplish-ml  color,  and  somewhat  siiiikcii  Mm 
the  j^ne'ral  level  of  the  liinjf.  The  pleiim  is  sm(M>th  and  flu-  ti^>iw  has 
all  the  elmra<'teristies  already  deserilHtl. 

Mieros<-opieally.  the  alveolar  walls  an-  found  to  Ik-  in  more  or  less 
close  contact,  so  tliat  the  alvt-olar  spacrs  are  ol)Pterat«>4l.  ( KiuMoimllv, 
in  the  infundiliula,  pronps  of  epithelial  cells  can  1h'  niiide  oiii.  Tlie 
cells  lining  the  alveoli  have  n-sinned,  in  fact,  the  eml)ry(»nic  lyiM'.    Tli,. 

bronchioles  are  corrugated  and  the  hlocMlvessels  an-  everywhere  i mstcd. 

Sometimes  small   hemorrluines  and  masst-s   of   l>l(MMi-pigni*Mt  can  lio 

obsiTvetl. 

When  of  lon){  standing;,  ateU-ctasis  is  fn-ipiently  complicated  with  otlur 
conditions.  Thus,  in  infants,  l)n>nchie<-tasis  has  IntMi  oh.s»-rved.  Anain, 
from  the  fact  that  the  atelittatic  portion  is  usually  conjp-stci  while 
the  cause  of  the  condition  is  often  an  inHammatory  one,  infi-ctioii  readily 
takes  place.  Hronchopneumonia,  then-fore,  is  not  an  infrt-(|tifrit  s((|uei. 
In  other  cases,  the  lunj;  un«lerjp>es  a  chn>nic-,  indurative  dmnjrc,  (iwiii(; 
to  pr«>liferati«»n  of  the  fibrous  tissue,  fatty  dejc»-nerati<m  ov  the  aivcohir 
epithelium,  and  In-i-onu-s  pt-rmaiu-iitly  (-ollapsed  and  carnilie<i. 

Emphysema.— Knjpliysema  of  the  lunps  is  one  of  the  (oiniiKtiicst 
pathological  conditions.  '  The  term  "emphysema"  was  orijjiniilly  ap|)lif<l 
to  a  con«lition  in  whic-h  air  is  fomid  in  the  tissues  (interstitial  emphysenu  , 
but  is  very  appropriately  applie»l  to  that  aff»H-tion  of  the  iini>;s  in  which 
thev  are  ovenlistendtHl  and  contain  more  than  the  normal  amount  of  air. 

The  condition  may  Ik-  jjeneralized,  atftHtinj,'  nearly  the  whole  of  Uth 
lungs,  or  may  Ik-  rt-stricted  to  certain  parts.  In  an  advanee<l  ami  typical 
case  of  generalizt-*!  emphysema  the  patient  has  a  characteristic  apfxar- 
ance.  The  neck  is  short  and  thick;  the  chest  is  enlarged  in  all  \u 
diameters,  but  particularly  antero|M>steriorly,  so  that  it  asstnncs  a  liarrcl 
shape.  The  alMlomen  is'  rt-latively  sinikcn  and  the  accessory  nnisclcs 
of  respiration  are  wt-U  (U-velojH-<l. 

When  the  thorax  is  o]H-nj-<l.  the  lungs  art-  more  volinniiioiis  than  normal, 
encroaching  upon  the  canliac  area,  and  do  not  collapse.  Tiic  costal 
cartilages  are  lengtheiM-«l  ami  sometimes  cah-ifiwl.  The  Iniijrs  an' 
considerablv  enlarge<l.  although  fiu-ir  weight  may  Im-  actually  <liinin- 
ished.  The  tissue  is  inelastic  and  much  less  crepitant  tlian  normal. 
retaining  the  impress  of  the  fingers  and  having  the  feci  of  a  t)aj.' of 
feathers.  The  pleural  surface  is  very  pale,  and  the  pigmentation  of  the 
lung  is  not  so  conspicuous  as  it  usually  is.  With  a  hand  Icn-,  or  even 
with  the  naktHi  eye.  small  vesicles,  the  size  t»f  a  pin-head  or  Ic-,  wliiili 
represent  the  enlarged  alveolar  spaces,  can  Ik-  seen  on  the  MiifiKc  In 
ailvanced  cases  tlu-se  vesicles  may  attain  the  size  of  jx-as,  or  c\cii  larpT, 
giving  the  lung  a  bullous  ap|K-arai)c<-  (emphifxt-nm  hullmu).  h'  liic  lar)jiT 
vesicles  can  oftJ-n  In-  tmct-d  the  fragments  of  what  wen-  onj.'inally  the 
alveolar  walls.  ( )n  st-ction,  the  lung  is  jmie  and  dry  and  th.-  lai-i  r  vesicles 
poUapse.    These  can,  however,  be  again  distended  with  watu .    .Associ- 


KSSKSTIAL  KMl'H  VSKMA 


2<W 


attil  vvitli  ihr  iiMHlition  is  astmlly  a  certain  amount  of  chnmic  lintiH-hitls, 
wirli  sonic  thickening  of  the  hninchi  an<l  puhnonury  septa.  Kn)nehiec- 
tasis.  lutwcver,  is  not  often  met  with.  In  h-ss  extn-me  cases,  the  apices, 
thf  iiiitcrior  iMmlers,  and  the  inner  surfacr  near  the  nxit  are  the  parts 
alfM'tc)!.  These  areas  are  somewhat  (listeniie<l  or  inflated  .ts  compared 
with  the  rest  of  the  hing  and  present  the  characters  just  mentioneil. 

.S'vtTiil  classifications  of  emphysema  have  heen  prop<xsed.  The  usual 
imi"  (if  hy|H'rtr(»phic,  atrophic,  and  eom|H'nsator}'  forms,  while  a  iiseful 
('lini<'itl  division,  is  open  to  some  criticism  fnmi  the  [M>int  of  view  of  the 
pthoiojjist.  Perhaps  the  In-st  j{eneral  divisicm  is  into  ititieuUir  ami 
liitrrnliliiil  t'mphysema.  In  the  first  variety  it  is  the  alveolar  spaces  that 
are  liisitiidHl  and  contain  a  surplus  of  air.  In  the  sccoihI,  the  air  is 
pn-sciil  ill  the  interstitial  tissue  of  the  lun^. 

Wsiculiir  emphysema  may  further  1h>  sulMlivide<i  into  (1)  eimential 
or  nuhiildiilidl  emphysema,  and  (2)  cumplemeiiUiTy. 

Isuntial  Emphyuma. — Various  pvdes  of  essential  emphysema  exist, 
which  |)ii.ss  imjKTcepfihIy  one  into  the  other.  Orth  recofjnizes  three 
foriiis:  1 1 )  Simple  emphyMma,  in  which  the  lung  is  simply  inflated  with 
air  to  lis  full  capacity,  or,  in  other  wonis,  is  in  a  permanent  in.spirat«»ry 
|Mvsitiim.  This  form  is  Trauln-'s  Volumen  Pulmonum  Aurtum,  and 
while,  on  anatomical  gmuiids,  it  is  correctly  ditferentiat(><l  from  the 
other  f(i!  IIS  of  emphysema,  it  cannot  Ih"  separate«l  clinically  from  them 
liy  any  (leKiiitc  s'giis.  (2)  Zctatic  emphysenu.  This  is  a  farther  .stage 
ill  whii  h  liic  limit  of  physiological  dilatation  of  the  alveoli  is  over.step|K-d 
and  the  spaces  iHfoinc  enlarged  though  without  actual  atrophy. 

i"he  siruetimil  changes  present  consist  in  dilatation  of  the  alveolar 
spaces  ill  eoiiiicctioii  with  certain  infuiidihula.  The  alveol.  r  walls 
lircoiiie  frnidiially  stn-tclHMl  and  thiiuuHl,  and  the  spaces  tend  t<»  assume 
a  chilmliir  foriii.  Thus,  the  multil<M-ulated  structure  of  the  lung  iK-ccmies 
iini(hsiin|ilific-<l.  (.'{)  Atrophic  emphysema.  In  this  variety,  the  alveolar 
wall>  aii(i|)liy  and  the  vessels  gradually  liecome  ()l)literate<l.  Rupture 
<if  the  air  spaces  is  here  a  striking  feature.  Several  alveolar  spact-s  are 
thrown  into  one,  so  that  actual  hullie  are  the  n-sult. 

In  atrii|iliic  einphyseiim,  the  inicniscopic  changes  are  well  marked. 
The  alveoiiir  walls  are  thiniie<l  and  in  many  casis  hroken.  Thus,  we 
>ee  lar^c  spaces  which  are  clearly  due  to  the  coalescence  of  several 
iiiljiutiit  alveoli,  for  the  remains  of  the  ruptured  walls  can  he  seen  pro- 
jccliiii.'  iniii  the  cavity.  The  hlmxlvessels  an-  .small  and  in  many  places 
olilitcrai<cl.  The  atmphy  affects  first  an<l  chiefly  the  hl(KKlves.sels  and 
tlasti(  li^viic,  the  connective  tissue  lieing  more  resistant.  By  spe<'ial 
preparatimi.  the  lining  epithelium  can  Ik'  n-cogniziHl  on  the  alveolar 
walls.  Ilic  cells  are,  of  course,  forcwl  apart  by  the  pnx-e.ss  of  distension, 
Iml  isolaii  il  ones  can  Ik*  made  out  here  and  there  on  the  walls,  many 
"f  ilicni  faiiily  degenerated.  In  the  infundihida  small  groups  of  these 
ctHs  (■:,•:  !..  totmd.  The  hroiichi  usually  .sliow  .signs  of  chronic  infiani- 
iiiatioii  ami  the  septa  are  infiltrated.  This  is  not  a  feature  of  the  emphy- 
sema, hiiu.  ver,  l)ut  is  due  to  the  inflammation  and  catarrh  which  is  so 
fnipicnt     !  accompaniment  of  the  disease. 


i 


fil 


204 


thk^lvsuh 


OABpltBWtaiy  ImplijMaM.- Complt'iiH-ntiirv  cint>hy!M-nia  !s  ^terwr- 
ally  localiz(>«l  to  otM>  (ir  inori'  l(il>u!<>:s,  liii*  may,  iiiHler  ccrtHin  riniim- 
stances,  affect  the  whole  liiiiK.  Ixm-uI  cinphyM'nia  bt  <|uite  a  coininon 
oumlition,  and  is  ftviiiiently  only  a  teniiMiniry  state, due  not  to  striHiupal 
chani(eN  in  the  lunji,  Imt  bniiiglit  aliout,  for  the  nnwt  |»drt,  by  im'^iiiaritv 
in  the  intra-alvetilar  pre.s.sun>.  'Hiuh,  in  pneumonia,  fibroid  iiiiJiirutidn 
and  in  tulierculcxsis,  where  a  |iorti<»n  of  the  lung  Ijet-omeM  inl|H■r^'ion.s  tii 
air,  the  remaining  air  jwch  an-  mibjecte*!  to  increa-seii  pressure  iiml  in 
con.se«|uence  In^-onie  distemled.  A.s  jwxrn  as  the  cans*'  is  reiiiovjii  iht- 
affecteti  air  sacs  return  to  their  iMinnul  state,  but  in  pn>l<iiif,'nl  or 
repeated  attacks  the  tein|M>rary  may  )(ive  plac(>  to  a  p«-nnanent  ciiniliiidii. 
'Ifle  distension  of  the  alveoli  is  due  to  a  compensatory  pnx'css  hihI  is 
foumi  in  the  nei)(hlM>rhiHMl  of  the  atelectatic  or  consolidate  I  anus  of 
the  \\in^. 

Fill.  HO 


Drnphywrna  of  Itinit.      I."-!!"!  "lij.  N"   7.  willimit  .Kiilnr       The  atnuihieil  nlviH.liir  w^ill  sml  tl« 
rupture  of  several  cif  them  are  well  «lii>wii.      (Fnnii  l!ie  iiilleiliiiii  iif  Dr.  A.  (I    Ni.liill.i 

Interstitial  Imphysema.— Interstitial  emphysema  is  a  n-lativi-ly  unim- 
portant condition.  In  this  fonn  air  is  prt'scnt  in  small  iMads  in  the 
interstitial  ti.ssue.  The  aii  bubbles  resemble  a  string  of  Ix  ads  jiimI  may 
clearly  define  the  various  lobules.  The  bubbles  rarely  attain  ay  size 
and  can  \w  pushe<l  aloiiff  the  septa  with  the  fin>pT.  This  form  may  lie 
present  in  ordinary « inphysema  due  to  ruptun-  of  an  alvitiliis.  in  iiiji'ws 
of  the  lui));,  and  in  those  who  have  die<l  of  suff(K'ation.  Tin  iirtiKoiai 
inflation  of  the  luiiffs  t;f  the  a-spliyxiiitwl  newlnmi  infant  lui-^  !">ii  known 
to  pnxluce  it.  The  wndition  is  usually  met  with  lieneatli  ilir  plfu™. 
but  may  .sprea«l  to  the  hiliis  of  the  lunVs  and  even  to  flu-  iii.ilia.stinal 
tissues. 


I'SKUMONIA 


205 


A  wonl  should  lie  witl  alwut  the  conditioiM  due  to  m  I  aiMK'iated 
with  iMilinoriary  emphysema.  In  udvaiH'e«l  ea-ses  there  is  i .  arly  always 
(•hr«)im'  bniiK'hitw  and  sometimt-n  l>n)nehie<'tH.sw.  Owiti^  to  the  in- 
(wati'"!  intrapuliiionary  pivsMure  the  ri){ht  side  of  the  heart  iH-i-omw 
hvTtfrtrKphijfl,  and  eventually  the  whole  heart  may  l)e<time  hy|M'r- 
iniphiol  himI  <lilate«l  with  evidenees  i»f  valvular  iiKt>m|H'teney,  arte-io- 
sclenxsis  lieinj?  al.s<)  a  not  infr«|uent  ac-eompaniment.  'Hie  ptt-uliar 
chanp'^  in  the  ehest  have  already  lieen  ri'ferred  to. 

In  <«iiiU'  Btniphy  of  the  \»ng,  whi<-h  is  not  prop<>rly  emphywrna  at  all, 
thoii^'li  <iii.H.s«>«l  with  it  l>y  many  writers,  the  thorax  and  iiMle«'«l  tin-  whole 
Ixxiy  is  sniull  ami  shrunken,  the  riUs  close  toffether,  and  very  ohlit^uely 
•iitiiatcd.  Ml  tliat  they  approximate  very  closely  to  the  crest  of  the  ihum. 
'nif  liiiiffs  in  such  (Uses  are  small  ami,  as  Jenner  expn'ss«><l  it,  feel  like 
an  inflated  Img  of  wet  paper. 

nmjkMMATioirs. 

Pneumoni*.— Pneumonia  is  to  Ik*  referretl  to  the  din-ct  irritant 
action  of  micnMirpinLsms  upon  the  lunjr  suKstance.  While,  however, 
crrtain  clinicid  tyix-s  are  ref-ofjnizefl  on  the  (rround  of  the  anatomical 
distrihution  of  the  lesions  and  a  well-<lefine<l  clinical  course,  it  should 
y  niMcnilMTttl  that  there  are  many  intermediate  and  atypical  forms, 
so  niucli  s<j  that  to  the  Iwcteriologist  pneumonia  is  not  u  single  disease 
entity,  hut  ruther  u  multiplicity  «if  pathological  manifestations  dependent 
(in  a  variety  of  causes. 

NiinitToiis  in(|uiries  into  the  etioUigy  of  acute  pneumonia  have  Ix-en 
tnadi-  in  recent  years,  and  almast  all  the  known  pathogi-nic  micrmirgaii- 
isms  have  U-en  provwl  to  l)e  capable  of  producing  pulmonary  inflam- 
mation.' .\mong  these  may  l)e  mentione*!  the  Fraenkel-Weichsellwum 
I»ipl(K(K(iis  of  pneumonia,  Friedlander's  pneumolmcillus,  Streptocix-cus 
pyojjtiics,  StaphylcxHK'cas  alhus  and  aureus,  B.  tulKTcuiosis,  H.  typhi 
alHloininulis.  B  coli  communis,  B.  inflnenziv,  B.  |H'stis,  B.  anthmcis, 
H.  iliplillu'riu',  B.  enteritidis  of  (laertner.  .\ny  one  of  these  alone  is 
alilc  to  cause  the  aflPwtion,  but  mixed  infections  are  common.  To 
imHJiKc  the  disease  it  is  necessary  for  the  Imcteria  to  invade  the  lung. 
and  this  tlicy  do,  either  through  the  bronchi  (inhiiltttimi  or  airogviiic 
piiriiinoiiiii)  or  thro.igii  the  b. "xl  an<l  lymph-stream  {hemdUujetiic 
Iptphoiinilr  piirumimla).  Many  cf  the  germs  alxive  mentione<l  have 
Ufti  found  in  the  buccal  secretion  "f  healthy  people,  so  that  it  is  not 
■^u^|)ri^illJ;  that  inhalation  or  bninchogenic  pneumonia  is  a  common 
iilft'clioii,  lt<s-ent  investigations  go  to  pnive  that  the  lungs  and  p<'ri- 
hnuicliiid  i.diin<ls  play  an  important  role  in  the  protwtion  of  the  organism 
from  iiilVctivi'  agencies  coming  fnmi  without  (see  vol.  i,  p.  2(K)). 

Barthti'  fomid  in  the  healthy  hmg  Ixitli  pathogenic  and  iioii-patlio- 

'  Kiir  I  ■■tiiily  of  the  bacteriology  of  pneumonia,  itee  Curry,  Jmir.  of  Kxper.  M(h1., 

4:  ISiHt:  |i;m. 

'(Vninill.l.  r.  Bakt.,24:lS98:ll. 


2Wt 


THE  LVSiiS 


IP'tiii-  Iwcti-rin  ill  th«-  tru<-h<>ii  himI  lur)p>r  linHM-hi,  thoii);li  ili«>  linim  Imilt., 
iiihI  Hlv«*<»li  wrn-  fni-.  'V\w  Imcti-riu,  of  wIimIi  ihi-  ilipliNiMiiis  wi„  „„^, 
fntiUfiith'  pnvHi-iit,  w<-n>  iiion*  aliiiiHlHiit  in  thi-  liiii^  than  in  ilir  hhhiiIi. 
u  iiiiHiition  of  lliin|(N  <Iih>  |NM.sibK'  to  Km-hI  f;niv.tli  or  to  tin-  iiiliiliitin)j 
niHi  fliiniiuitin);  (Miwcr  of  lh<>  salivii.  'V\\v  lati-r  n-Mi'ttn-lics  of  Ibiii.' 
on  th«'  whole,  (iMiftnn  this  view. 

It  would  a|i|M*ur,  Icmi,  that  Imctcria  iiiav  |ni.s.s  hv  incaiis  of  the  lviii|i|iiiii( ^ 
thmiiKh  the  liiiiK  without  elii-iliii);  anv  iimiiifestation  of  liicir  iiriMiiir. 
Whether  pneiitiioiiiu  is  |inMlii(-«-<l  or  not  iiiiitt  ile|M-n<l,  tlien'fiin'.  uiitiii 
.some  .s4*<-oii(i  v»\\M\  i-ither  inereas4>(l  viriileia-e  of  ilie  iNuteriii  or  ilimiii- 
i.sh«'«l  resi.stiiif(  jjower  on  the  |wrt  of  tlie  <)rpiia.Hin.  In  tin-  ni-c  of  iIh. 
DipliNtNt-us  |ineuinoiiin>,  iiK-rea.<uil  viriileiM-e  is  Hi-anfly  likely  to  In-  hii 
iin|M>rtant  factor,  for,  as  we  kiMiw,  this  jfenn,  when  fn-ely  exiHiM^I  lo  iln- 
air,  rapidly  lo,-  .  its  |Miwer,  and  is  reatlily  killed  out  by  the  prcMiicc  nf 
certain  other  iiiien>or;pinisins.  Any  dipliM-o<-ei,  then-fon-.  in  ihr  itioiiih 
or  respiratory  tnut  iirt-  likely  to  Ik-  .s«»  weakeiusl  that  in  ninny  iiisiiiiur, 
they  an"  iion-patho^enie.  Siiseeptiliility  .s«mis  to  vary  uIm;  in  (litrtrtMl 
individuals  and  rac-s.  Thus,  for  man  the  DipltMSM-ens  piKuiiioniir  is 
rom|Ht.atively  mild,  for  the  majority  of  niM-s,  at  least  in  lieHJihy  ailiilis, 
get  well.  In  the  ease  of  some  of  the  lower  animals,  sikIi  as  inicr  iiiul 
ralihits,  the  inftn-tion  is  very  si'vere,  so  iiiiuh  so  that  when  infertol  tlii'V 
die  fniin  ^>neral  iMU-teriemia  rather  than  pneumonia.  It  iiiny  Ik'  n-- 
niarkisl,  however,  in  imssinj;,  that  the  oftener  ean>fiil  Imctiiiolopciil 
.studies  are  made,  the  mon-  fns|ueiifly  ihi  we  tind  that  piieiiiiioiiiii,  tvcn 
in  man,  is  to  Ik-  repinhsl  as  a  ^eii«-rali/tsl  infeetion  with  ii  lociil  iiiiii:!- 
festation,us  is  tin-  cas*-  also  with  typhoid  fever  and  sonu-  other  iiifrciiiins. 
Any  <-ireiimstaiiee  that  leads  to  a  lowensi  vitality  of  tiie  orpiiiiMii  imiv 
Ih'  a  pi'ilis|M>.sin>;  or  <"oiitril»utor;  cause,  such  as  previous  atl:M  k-.  \\a<\- 
\i\\S,  <li:  .r:es,  alcoholism,  dialx'tes,  Hrinht's  disc-ase,  puliiioiian  Itsjoiis, 
traumatism  to  the  liiiif;,  iMxlily  iiijiii;  ■■*,  chronic  nervous  disordcrM,  himI 
exliaiistin;.'  <M<upatioiis.  Climate,  .sciisoii,  and  aj{e  are  of  soiiir  iiiijior- 
tan'f,  as  atfcctinj;  the  n'sistinj;  |Miwer  of  the  sy-tc-m.  "('jitcliin^' rold" 
d(HS  not  seem  In  have  the  im|M>rtaiice  that  oiur  was  llioiij.'lit.  Tic 
influence  of  traiimalism  is  shown  very  prt-ttily  in  a  case  cited  l>v  i.iicii- 
tello,-'  where,  in  a  |)atient  in  pn-vioiisly  jH'rfc-ct  health,  |iiiciiini>iij,i  tKvcl- 
oiMsl  a  few  days  suhse<|Uently  to  a  si-vere  contusion  of  the  slioiildt  r. 

On  account  of  the  anatomical  structim-  of  the  liinns,  iiilliiiiiinatdrv 
pnKt's.ses  (Kciirriiij;  therein  differ  materially  from  those  incl  wiili  in  tlif 
secretinj;  glands.  The  chief  characteristic  of  pulmonary  inilniniiiation  is 
that  the  inflammatory  pnxlucts  are  |M)ured  out  into  tlie  alvcolai  -\r,m-s. 
while  the  ci-lls  liiiinj;  tliese  spairs  undergo  deffeneration  and  (Ir^ijiiaiiw- 
tion.  Tlic  prcM-ess  may  Ik-  mor*-  or  less  confined  to  the  aivcoliir  walls, 
but  in  many  cases  the  interlobular  septa  an-  involved,  so  dial  an  liiltT- 
stitial  pnxTss  is  at  work  as  well.  The  changes  an-  cxiidativi  ;iiid  dcs- 
cjiminutive   ratiier   tliaii    pareiichyniutoiis. 

'  .\rch.  <lc  iiii'il.  v\\t<'t.  I't  (I'anatom.  pntli.,  May,  IsiHt. 
»  Contralbl.  f.  Hakt..  S:  ISUO:  239. 


r\t:u%ii>\iA 


•M7 


'l%-  iiiMlKHiicHl  |tii-liin'  in  |>iM'iiin<»niH  varit-N  ^-Htly.  Sfmu'tiriH'!*  the 
liM-  i>r  the  )(n>at«-r  |Nirt  of  h  IoIic  is  uffttictl,  hfiMr  tht'  tiTin  lebw 
piiiHiiiiiiniH.  At  (rtlwr  tiim>H  liuMli.M'UM-  i.HC(>iiKtM>«i  In  ihi*  lobiil<><<  lobolar 
piifiiinotiiH  or  to  iiiiiiiiti>  lint  nunwniUH  |iortioti.H  uf  tht*  lottiilcit — 
■tUtry  pnriiinonia. 

'I'hc  iiiftrtion  U  in  many  tuifs  (ifrivitl  fnun  thi*  air  patMai;!*)*,  ami  to 
ATI  iin|Mirtunt  fn^iup  of  th*-M',  in  which  the  pnKt's.s  Mfnis  to  Ixyin  in  thr 
sMiullcr  lin>iH-hiolf>M  bihI  extfrals  to  the  alvifili,  th<>  term  broBchopaw-. 
■tai*  liii^  li«n*n  )(ivcn.  Tht*  nlUaijr  fonn  is  lini*  to  infi^-tion  thn>U((h  the 
ItliNiil  Ntn>uni.  In  cvrtain  other  cum's,  inflammation  l>(*)(iii.'*  in  the  ra'if{h- 
lioriitjr  linsiM's  ami  spnwls  to  the  hm){  by  means  of  the  lymphatics.  An 
ini|)(>rtuiit  tvpe  of  this  form  is  the  s«i-calleil  idtaroffmatie  pa«nm«iila, 
whrri'  tlie  lilsease  lN>)(iiiH  in  the  pleura  a'Hi  extends  as  a  lymphanf{itLs 
ami  iN'rilyniphunKitis  of  the  liuiK  suUstamv. 

Ill  most  viirieties  of  pm  imionin  the  liron<-hi  are  more  or  less  atfecteil, 
ritlur  primarily  or  set-onilarily,  ami  the  |)eriltn>nchial  lymph-^laiHls  are 
Hilary'*!,  succulent,  ami  inflanutl. 

PntuiiKinia  may  lie  arutr  or  rhronir,  (le|M-iKlin);  upon  the  nature  of 
tht' iitr<ii(liiiK  microiirpinism  ami  the  n>sistinf;  |iower  of  the  tis.sue. 

It  is  |M-rhaps  difficult  to  account  suti.sfuctorily  for  the  varialiility  in 
thf  ili>triliutioii  of  the  lesions.  Certain  ({erms  like  the  I )ipl(K-o(rus 
piHiiiiiDiiiie  and  the  l'neumolia<-illus  of  Frie<llander  temi  to  pnHluce  the 
l<  I  ar  variety,  while  others  like  the  pus  jtH-ci,  the  Bacillus  of  influenza, 
Hiiij  the  H  c«ili,  nearly  always  produce  a  loliular  inflammation.  'I'he 
i'X|iliiiiatii>.i  prolmlily  is  that  the  i )ipl(M-«M-cus  pneimioniie,  liein^  relatively 
iioii-iiiiili^iiatit  in  man,  can  only  a<'t  in  the  event  <if  a  lix-ux  rrxinieiiliw 
mimirin  iH'iiiK  fonned,  and  this  in  onlinary  healthy  |M-<iple  is  apt  to  im> 
prrsi'iii  ill  only  one  {Nirtion  of  the  lunj;.  l/iliular  pneumonia,  however, 
while  it  diK's  iH-casionally  d«-vclop  as  a  primary  affectitin,  nearly  always 
iKdirs  in  tlios*'  previously  wciikeiuHi  by  <li.sea.s<-.  It  is  characteristically 
u  "Icnniiial"  infection,  and  as  in  all  <-hroiiic  cum-s  the  lun>{s  an'  uniformly 
Wfiiliciii'd,  not  only  from  def^-nenitive  pnM-esses,  but  also  from  def»'<'tive 
rc>|)irati(>ii,  any  iiifwtive  a^-nts  present  in  the  respiratory  ptissafp's  an- 
likely  Id  exert  ii  (iisseminatc-tl  activity.  The  liemato^-nic  and  lympho- 
IPiiic  fciniis  are,  of  cours4-,  more  easily  understotNl. 

.Viiotiier  iiii|H)rtaut  feature  in  the  diflferentiation  of  the  various  pneu- 
iiioiiiaN  i>  the  chunicter  of  the  exudate.  Fn>m  this,  we  an-  often  enable<l 
til  (leeiile  as  to  the  nature  of  the  infecting;  microorganism.  According 
to  the  .iriiteiiess  of  the  case,  the  inflammatory  pnKliicts  ai  exudative 
iir  iinHliictive,  uiid  either  element  may  pre«lominate  over  the  other. 
In  one  eonunoii  fonn,  the  sfwalled  "fibrinous"  or  "cniupous"  pneu- 
iiMiniii,  liiie  to  the  I )ipl<K'<Kri's  pncumonin*.  the  alve<ili  an-  n\\n\  with  a 
rdllitr  1 1 IV.  jjnmiilar  exudate  of  a  >trayish  color.  When  resolution  is 
coininiiM  iiij;,  tlie  a!ve<ilar  contents  can  Ih"  cxpn-ssj-tl  in  the  form  of  little 
l>lus.N.  I  >.  ill,  f:,nn  due  to  the  Friwllaiuler  bacillti.s,  tin-  htn>»  i.s  <t>nj»fstetl- 
I'H'kiii^'.  juicy,  and  the  cut  surfatr  has  the  ap[x>aranct  of  lieinj;  coated 
with  pl:iiiii.  The  exudate  can  l,e  .scnijied  off  with  the  knife,  ami  is  .so 
vwid  til  It  it  (lejH-iids  in  lonp,  glairj-  strings  from  the  knife. 


ti 


I 


298 


THE  LUNOS 


Aento  Lobar  Pneamonia. — In  luiite  lolmr  pii<>umoniii  (Fracnbl- 
WVichsdlMiutn  diploc-oocus)  the  luiij?  is  usually  said  to  pass  ilir(>M>;li  four 
stages:  (1)  Engorj^'inent,  (2)  re<I  hfjmtization,  (3)  jfray  li<|i:iti/.alioii, 
and  (4)  resolution.  This  is  a  convenient  division  for  pur|M>ses  of  (icscrip- 
tion,  but  it  is  very  doubtful  liow  far  it  is  warranteil  by  the  actiinl  facts. 
The  mode  of  development  of  the  lesions  is  certainly  (juite  varied  and  a 
unifonn  onler  is  not  always  adhered  to.  It  is  not  uncomnion  to  find 
several  of  the  alxive-mentioned  stages  prt'sent  siniultanw)usly  in  die  luiij;. 
There  can  Ik-  no  doubt,  however,  that  the  inflanirnation  lH'j{ins  with  con- 
jj;estion  followetl  by  consolidation.  The  first  two  stages  an*  rarely  cvit 
seen  except  in  persons  <lying  by  accident,  or  in  limited  areas  at  ilic  cd^c 
of  a  crtH'pinjj  pneumonia,  for,  as  might  be  su|)|M)se<l,  the  cases  tliat  conif 
t«)  autopsy  are  in  the  ailvancwl  stages,  in  the  pericxl  of  viKjonjfvmt 
the  condition  is  that  of  a  .simple  active  or  inflanunatory  liyixrcmia. 
The  lung  is  redder  than  normal  and  possibly  slightly  (nlenuitous.  Mien). 
.scopically,  the  capillaries  in  the  alveolar  walls  are  congesti-d  and  varicose, 
the  epithelial  cells  are  .swollen  and  mcasionally  desciuanialcd,  and 
then'  may  Ik-  an  (K-casional  retl  corpu.scle  in  the  alveolar  spaces.  In  tlw 
necond  stage  the  afTectwl  portion  of  the  lung  is  swollen,  heavier,  and 
firmer  than  normal,  pitting  on  pressure,  and  .somewhat  frial)le.  It  is 
inten.sely  n-<l,and  on  .sei-tion  an  ai>uiidant  turbid,  bl<MMl-staiiird  fliiiil  can 
1h'  .scjueezed  out.  Although  the  exudate  ap|K'ars  reddish  and  <'o?ilaiiis 
a  majority  of  re<l  coq)Uscles,  even  at  this  early  .■stage  numerous  leiik(M'ytcs 
are  pre.sent.  Micro.st-opically,  the  capillaries  are  greatly  eonp'sttii, 
the  lining  epithelium  of  the  alveolar  .spaces  is  swollen,  and  tlie  cells 
are  found  in  all  stages  of  pndiferation  and  de.s(|uamutioti.  TIk'  alveolar 
spaces  arc  mon;  or  less  fille<l  with  red  bhxMl  cells,  and  desiiiiainatcd 
epithelial  cells — the  so-calle*!  "catarrhal"  cells — enmeshed  in  filirin, 
but  numerous  leukcK-ytes  can  1h>  .seen.  A  roun(l-<-elled  infiltration  is 
al.so  to  Im'  noted  alM)Ut  the  vcs.scls  of  the  interlobular  .septa.  ( )\viii);  to 
the  .solid  appearance  of  the  limg  and  its  rtnldish  color,  it  was  eom|)arcd 
by  the  older  |)athologists  to  the  liver,  whence  the  term  "  red  liejiatization." 
Imperceptibly  the  <-onditi(Hi  pa.sses  on  into  the  third  atiKjf.  that  of 
gray  hepatization.  Here  the  lung  is  still  more  swollen,  .so  thai  il  shows 
the  impri'.ssion  of  the  ribs,  is  heavy  and  firm  to  the  touch.  'I'lie  [ilenra 
has  lost  its  glassy  appearance,  is  gramdar  and  cloudy,  and  cdvereil  with 
a  varying  anioimt  of  fibrinous  exudation.  In  fact,  every  acute  lol)ar 
pneiunonia  is  also  a  ]>leuropneiimonia.  The  lung  is  (jiiile  airless, 
friable,  and  sinks  in  water.  On  .st-ction,  the  surface  is  gniiiiihir,  aii<l, 
according  to  the  age  of  the  [jok-css,  of  :i  color  varying  from  ilark  nil 
through  the  different  shaih-s  of  reddish-gray  to  gray  or  yelhiw.  This, 
with  the  deposit  of  coal  pignu>nt  .so  often  pre.sent,  gives  the  liinu  a  eiirioiis 
mottled  appearance  that  has  been  ci)mpare<l  to  granite.  The  character- 
istic ashen-gray  color  is  due  in  part  to  the  lcuk<M'ytic  exuiiniioii  and 
in  part  to  the  anemia  of  the  tissue  |)r(HliK-ed  by  the  pre>-uir  of  tiie 
alveolar  contmts  u|)on  the  vessels.  On  .scntping  the  snrl'aii  .  ;i  small 
ainoimt  of  granular  material  can  be  removed.  The  broiiciii"!!  -  of  the 
affected   area   are   usually   blcnkiHl    with    fibrin.     Mici(>s((>|ii(  illy,  the 


ACUTE  LOBAR  PNEVMOhltA 

Fio.  70 


209 


Aiule  Iiilmr  piieuiuimia  (Rray  }i«>|iatiz)itinn).      The  lnwer  lube  is  involved.      (From  the 
Pathulngira)  I^lxpratory  nf  the  itoyal  Victoria  Hi>»4pital.) 


Fig.  71 


J 


Auirc  I   :.,|  |.ii('iinii.iiia.       Leiiz  olij.  Nn.  ",  withniil  tn'iilar.      The  aKeular  spjues  are  filled   witli 
leukocyte!*  and  fibrin.     (Fnmi  the  collcctiun  of  Dr.  A.  (1.  Nirholh.) 


300 


THE  LUNGS 


alveolar  walls  an-  compressed  and  the  capillary  channels  are  obliterated. 
The  exudate  is  made  up  almost  entirely  of  leukix-ytes  and  fibrinous 
threads,  with  an  occasional  erythrocyte  and  catarrhal  cell.  By  \Veij;ert's 
method  the  fibrin  threads  can  be  l)eautifully  demonstrated  u'ld  mav 
sometimes  be  seen  passing  through  the  stomata  from  one  alveolar  space 
to  the  other. 

When  the  fibrin  Ls  lieginning  to  break  up  and  l>ecome  granular,  and  the 
leukocytes  show  advanced  fatty  degeneration,  the  stage  of  remlui'nm  is 
l)eing  initiated.  The  lung  l)egins  to  shrink,  the  pleura  is  relaxed  and 
thrown  into  folds,  and  the  organ  has  a  boggy  feel.  On  .section,  the  tissue 
is  grayish  verging  on  yellow,  and  is  moLst,  .so  that  a  fluid  not  unlike 
pus  can  be  expressed.  On  .scraping,  little  plugs  of  fibrin  and  leukiHvtes 
readily  come  away.  Micrascopically,  the  appearances  an-  not  iiniiive 
the  last  stage,  except  that  the  alveolar  capillaries  are  again  iKHoiniii); 
permeable,  the  fibrin  threads  are  broken  up  into  »  granular  debris,  and 
the  leukocytes  especially  about  the  margin  t)f  tne  clot  show  A^ws  of 
fatty  degeneration  and  .solution  (autolysis).  I,«ter,  regt-neratioii  of  the 
alveolar  epithelium  takes  place.  The  exudation  is  remcwd  cliieflv  hv 
the  lymphatics  but  iil.so  to  .some  extent  throiij:ii  ^expectoration.  The  ivni- 
phatics  are  frwiuently  found  distende<l  with  leukcx-ytic  and  fibrinous 
exudation.  Indee<l,  a  true  lymphangitis  and  jM-rilymphangits  may  iK-eur, 
.so  that  the  framework  of  the  limg  is  profoundly  involved  in  the  iiifiarn- 
matory  process.  Should  the  lymphatics  l)c  damaged  by  previous  disease, 
as,  for  instance,  from  empliy.st'ina,  Hb.sorptioii  is  rendered  so  much  the 
more  <lifficult.' 

As  has  l)een  remarked,  it  is  by  no  means  ntrcssary  for  piiciiniiinia  tn 
pass  regularly  thn)iigh  the  stages  descrilHHl.  Clinical  exj)erieiice  teaches 
us  that  -some  cases  attain  their  acme  very  rapidly  and  subside  in  two  or 
three  days  instead  of  lasting  ten  or  more,  as  is  *Iie  rule.  Sonu-  variation 
in  the  amount  of  exudation  (Kcurs  also.  In  childrt-n,  the  aged,  and  the 
a.sthenic,  the  amount  of  fibrin  pro<luctHl  may  Ik-  small  uixl  tiie  alveoli 
not  greatly  distended,  so  that  the  usual  dry,  granular  ap|M'araii(e  of  the 
lung  is  not  oKserve<l. 

As  to  the  .site  of  the  pneumonic  pnK-c.ss,  acconliiig  to  Ortli,  .")2  \wt 
cent.  (K'cur  on  the  right  side,  ;j;{  |kt  cent,  on  the  left,  mid  !.")  jxr  cent. 
on  lK)th.  When  InHh  limgs  an*  involve<l  it  is  common  to  find  the  pnness 
less  advanced  in  one  than  in  the  other.  One  lung  may  Ik-  in  the  sta<;e 
of  gray  hepatization,  while  the  other  .shows  merely  engorgement  or  mi 
hepatization.  The  portions  of  the  lung  uninvolvetl  in  the  consulidation 
are  not  fn-e  fn>m  pathological  change.  They  are  usually  iiiiidi  con- 
gested and  there  may  Ik-  local  emphysematoii.s  dilatation  of  tlie  alveoli 
of  a  coinpen.satory  character. 

With  regard  to  the  distribution  of  the  lesions  in  the  lung,  tin  lower 
IoIh"  of  the  right  lung  is  the  one  most  frtniuently  affwted,  nt\i  in  this 
the  lower  IoIh-  of  the  left  limg.     The  tendency  is  for  a  wlinlc  Ii>1k'  to 


'  For  a  Htiidy  of  (he  liiHtologiral  »|>|X'aruiiceH.  we  I'nitt,  .Jour.  Boston  ~ - 
.Me<l..Sci.,  4:1<J00:1H;j. 


Ill'  ilip 


ACUTE  LOBULAR  PNEUMOXIA 


m\ 


Ih'  iiivolvwi.  Atypical  forms  are,  however,  not  infretjuently  met  with, 
as,  for  iiiMtantf,  the  "central"  pneumonia,  where  the  prtx-ess  liegias 
alK)iit  the  hihis  and  is  most  in  evidence  in  the  centre  of  the  lung.  In 
otliir  cases  the  disease  may  he  localized  to  a  small  area  in  the  apex  of 
tix'  luiij; — "apical"  pneumonia.  The  presence  of  such  a  focas,  by  the 
wav,  should  always  raise  the  suspicion  «jf  tul)ercul(vsis.  A  curious  form 
is  tiif  so-i-alled  "creeping"  pneumonia,  in  which  the  consolidation 
presents  various  stagt-s  of  ilevelopment,  i»t  one  part  resolution  lieing  in 
pn)j;ress,  at  another  fresh  pneumonic  infiltration.  This  confonns  to  a 
wcil-kiiowii  clinical  type. 

It  is  the  rule  in  young  antl  otherwise  healthy  persons  for  resolution 
to  take  place,  hut,  ajMirt  from  a  lethal  tennination,  certain  other  results 
may  follow.  Not  infrtHpiently,  tulK»rculasis  is  superadded  an«l  the 
(use  progn'sses  instead  of  resolving.  Rarely  the  exuclate  dries  up  within 
llic  alveoli  into  a  granular  caseous  mass,  so  that  the  condition  resembles 
iiias.siv('  tuln-n-uUxsis.  Again,  secondary  infection  may  take  place,  and 
if  pyogenic  or  putrefactive  microtirganisms  l»e  present,  alxsccssj  or  gan- 
f,n\w  may  result.  Further,  there  is  a  close  relationship  between 
alvsccss  of  the  hnig  ami  ga  .grene,  for  the  one  may  initiate  the  other. 
Willie  it  nuist  1m'  admitted  that  the  pneumix-occus  is  capable  of  producing 
a  stipi.iirative  and  necrosing  pnx-ess,  it  is  probable  that  this  is  a  rare 
event.  -N'o  doubt,  owing  to  the  close  resemblance  l»etween  a  pneumonic 
exiwlatc,  when  undergoing  li(|uefaction  and  absorption,  and  pus,  two 
<litfercMt  conditions  have  In-en  confuse<l.  (Jangrene  is  said  to  he  more 
fre<|nciit  than  abscess.  Here  the  lung  is  converteil  into  a  foul,  pulpy 
mass  of  (lark  greenish  color.  When  softening  has  taken  place,  irregular 
cavities  with  shaggy,  necrotic  walls  are  seen.  A  line  of  demarcation  is 
not  usually  formed,  (iangrene  is  specially  apt  to  supervene  in  thase 
cases  where  there  is  putrid  bn>nchitis  and  bnmchiectasis,  where  the 
circnlation  is  \v.)ov,  and  in  caws  where  a  hemorrhagic  exudate  is  a  promi- 
nent feature.  The  most  common  setjuel,  however,  is  fibroid  induration 
of  tlie  lung.  Here,  with  the  signs  of  «lelaye<l  or  absent  resolution,  the 
exudate  iHcoines  organized  by  a  prwess  similar  to  that  occurring  in 
a  tlironil)Us.  The  affitttnl  part  is  enlargtnl,  verj-  finn  and  heavy,  cutting 
witli  some  difficulty.  The  color  is  rtnhlish  or  reddish-gray,  mixed  with 
ilie  lihiek  of  the  coid  pigment  .ind  the  septa  are  pmminent  as  bands 
of  j:nivisii-wiiife  ap|K'arjince.  Ihiis,  a  jH-culiar  marblnl  appearance  is 
the  result.  'I'he  })leiira  is  also  greatly  thickene«l.  If  the  patient  live 
loiij;  enough  the  exudate  is  absorlMHl  and  the  limg  .shrinks  into  a  har»l, 
irre^'uhir.  fii  irons  ma.ss. 

Acute  Lobular  Pneumonia  (Oatatrhal  Pneumonia,  Bronchopneumonia). — 
Tills  iniin  differs  somewhat  from  lobar  pneumonia  in  that  the  exi'date 
tends  to  lie  ciitarrhal  rather  than  fibrinous.  The  process  Is  as.sociated 
«itli  liroiicliltis,  and,  indeed,  almost  always  starts  with  inflammation  of 
the  siiiidlir  bronchioles,  which  .spreads  to  the  adjacent  alvi-oli  (bronchitis 
and  p(iiliroiuhitis).  This  is  the  "capillary  bronchitis"  of  the  older 
writer-  'I'Ih-  fxudate  is  at  first  .serous  and  c-ontains  ii  few  erythrocytes, 
but  iium  numerous  white  wils,    A  striking  featiire  is  the  great  ttbundknce 


If 

■;j:''. ' 

1 

■    1   ' 

302 


THE  LUNGS 


\ 


of  the  s()-fall<Hl  "catarrhal"  cells,  large  monoiiucU-ar  cells  with  clear 
protoplasm.  These  are  belicve<l  by  many  to  lie  swollen  and  <les<|imiiiHit'(l 
epithelial  cells  from  the  alveolar  walls,  and,  while  they  are  pn-sctit  in 
all  fonns  of  pneumonia,  they  are  six-cially  numerous  in  the  loliiilar 
variety. 

(July  ex<t'ptionally  d(H-s  this  disease  (K-cur  as  a  primary  atr('cti(jn. 
As  a  rule,  it  is  a  si-quel  of  bronchitis  or  a  complication  of  the  iiifcctive 
fevers,  such  as  measlt-s,  scarlatina,  wh(X)ping-coug!i,  diphtheria,  influ- 
enza, typhoid,  and  variola.  It  is  generally  met  with  in  the  yoiiii);  or 
agi"*!,  or  in  those  del>ilitate<l  from  any  cause.  Particularly  is  it  lialilc  to 
happen  in  the  lK'<lri<ldcn  and  those  siitfering  fn)m  congestive  coiiditjons 
of  the  lungs  (/ii//xw/a//r'  pneumonia).  A  class  of  cases  worthy  of  .s|K-<'ial 
note  is  tliat  due  to  the  inhalation  of  infc<-tivc  material  from  the  nioiitli  and 
upfHT  air  passagt's  (^aspiration  pneumonia).  This  is  met  with  after 
operations  U|M)n  the  nose  and  mouth  and  in  certain  nervous  diseases 
with  involvement  of  tin-  vagus  nerve  (ragu.i  pneumonia),  'i'he  niien>- 
organisms  at  work  here  are  the  same  as  in  the  lobar  form,  but  there  is 
a  greater  tendency  for  the  pyogenic  ccKci  to  Ik*  conccrnwl.  Tiic  disease 
usually  afftH'ts  i)oth  lungs,  but  may  involve  onlv  one,  or  even  a  single  IoIk- 
or  portion  thereof.  The  affected  organ  is  heavier  than  normal,  sonie- 
what  congesttnl,  and  in  its  sui)stance  can  Ik-  felt  areas  of  increased  con- 
sistence. These  ar»'  friable,  of  a  rtnldish-gray,  gray,  or  grayi.sh-yeilott- 
color,  contrasting  somewhat  with  the  rest  of  the  lung.  In  otlier  cases  the 
whole  or  the  greater  part  of  a  IoIh'  is  consolidate<l,  but  irregularly  so, 
pointing  to  the  origin  of  the  condition  in  the  coalescence  of  isolate*! 
fiK'i.  Oil  jjressure,  a  turbid  bhxMl-stained  fluid  can  Im'  cx|)ressed,  in 
which  may  Ik"  seen  small  particles  of  a  more  gray,  grayish-yellow,  or 
purulent  appoarance. 

T'  i'  often  represent  the  contents  of  the  bronchioles.  From  the 
sporadic  distribution  of  the  consolidated  areas,  the  term  "spK'nizalion" 
has  iK'en  given  to  tiie  condition.  As  in  the  lobar  fonn,  lM)tli  red  and 
gray  stages  are  recognized.  On  section,  tiie  lung  as  a  whole  is  markedly 
hypereniic.  The  smaller  bronchi  and  brt)nchioles  slu  w  inflannnation 
ami  are  filled  with  exudate.  In  the  alveolar  spaces  the  exudate  consists 
mainly  of  serum,  a  few  red  cells,  abundant  leuk<K'ytes,  and  "caiarrhal" 
cells.  These  catarriial  cells  fre<|uently  contain  pigment  anil  liiicteria. 
Fibrin  is  not  a  striking  feature,  and  in  this  the  lol)ular  differs  nmlerially 
from  the  lobar  forn  .\t  most,  a  few  of  the  alveoli  at  the  peri|)liery  of 
a  consolidatiil  patch  may  contain  a  few  threads  of  fibrin.  Conseiinently, 
granulation  of  the  lung  is  absuit.  It  is  worthy  of  note  that  ])ricMni()nic 
infiltration  may  supervene  upor.  the  previous  collapse  of  a  piilniDnarv 
lobule.  The  explanation  is  simple,  since  bronchitis  and  oi)>tni<  tion  of 
the  bronchial  lumen  lead  alike  to  collapse  and  bn)nchopneum()iii:i. 

In  the  form  due  to  the  presence  of  foreign  bo<lies  in  the  bi-oiiclii  or 
!'>  the  iiiludatioM  of  infective  material,  the  exudation  may  I'ecome 
j)urulent.  Such  a  condition  usually  leads  to  a  diffuse  purulciii  infiltra- 
tion of  the  lung  and  eventually  abscess. 

Like  lobar  pneumonia,  the  lobular  form  presents  .several  variiiiinns  in 


SEPTIC  OR  PURULENT  PNEUMONIA 


303 


its  toiirse  and  development.  It  is  a  serious  affection,  since  it  nearly 
always  attacks  those  of  low  vitality,  or  complicates  other  grave  disease. 
.\  fatal  termination  is  therefore  quite  frequent.  When  risolution  does 
ocfiir,  it  takes  place  quickly,  for  a  relatively  small  area  of  lung  sub- 
stance is  involvetl,  and  the  lymphatics  are  less  interfere<l  with.  In  certain 
tust's,  when  the  inflammatory  prcx-ess  has  originated  in  an  area  of  old 
(il)n)i(i  or  castnius  pneumonia,  the  secri'tion  tends  to  l)ecome  fatty  and 
finally  inspissateil,  so  that  the  affectwl  area  remains  coasolidated  and 
ap|M  iirs  somewhat  gelatinous  with  yellowish  specks.  This  condition  was 
callctl  by  Virc-how  "chronic  catarrhal  pneumonia."  Occasionally 
iiksccss  and  gangrene  of  the  lung  may  result.  This  is  the  case  in  aspira- 
ti(.  pncuii.onias,  in  the  weak,  and  thase  with  general  circulatory  dis- 
mrl)aiKr.  In  another  class  of  cases  local  areas  of  induration  result 
uitli  l>n)iichiectttsis.  An  important  result  is  a  secondary  infection  with 
the  tiilM'nIc  liacillus,  so  that  a  miliary  or  (uscous  bronchopneumonia 
results. 

Septic  or  Purulent  Pneumonia.— The  characteristics  of  this  form  are 
its  ftreat  intensity,  a  purulent  exudation  into  the  alveolar  spaces  and  into 
the  interstitial  tissues,  and  a  tendency  to  destruction  of  the  lung.  Ex- 
pectoration in  some  <"i.ses  is  profuse,  and  the  sputum  may  contain  el&stic 
lis.sue  all '  Mther  fra^nients  of  lung  substance.  The  process  is  rarely 
primary,  ln.t  usually  (x-curs  as  a  st^iuel  (»r  complication  of  some  other 
comiiiion  It  is  due  to  the  action  of  pyogenic  microl)es  that  reach 
the  hiMj;  through  the  air  passages,  the  blooclvessels,  and  lymphatics. 
The  ty|H'  of  the  bmnchogenic  form  is  the  so-called  "aspiration"  pneu- 
monia. .Ucording  to  the  virulence  of  the  infecting  agent  a  simple 
catarrlial  pneumonia  may  l)e  the  first  result,  leading  eventually  to  sup- 
puration or  rapid  destruction  with  gangrene.  One  or  both  lungs  may 
l)e  affected  and  the  lower  lol)es  are  the  seat  of  election.  According  to 
the  character  and  amount  of  the  aspirated  material,  scattered  foci  of 
infihration,  separated  one  from  the  other  by  comparatively  healthy 
lunj;  tissue,  may  1>-'  seen,  or  a  diffuse  and  c()nfluent  condition.  The 
atfectwl  lung  is  ush.illy  congested  and  (edematous,  and  the  abscesses  can 
fre(|uently  l)e  recognized  on  the  surface  as  nodules  of  a  reddish  or  reildish- 
yeilow  color,  over  which  the  pleura  shows  some  cloudiness  and  injection 
On  set  tion,  the  nodules  referred  to  are  .seen  to  Ik;  due  to  a  more  or  les 
foinphtc  consolidation.  The  centre  is  apt  to  1h>  broken  down  and  c< 
posed  of  thick,  yellowish,  or  blood-stained  pus.  About  the  affecied  ai 
there  is  ;;iiicrally  a  zone  of  intense  hyperemia.  The  tissue  Ls  very  friabl. 
and  if  tlic  proc-css  lie  of  some  standing,  cavitation  may  lie  observed. 
Sometimes  gangrene  supervenes  and  then  the  affected  pairt  is  of  a  dirty, 
greenish  color  with  a  foul  odor.  The  bronchioles  are  often  plugeed 
with  exiuhite.  ^ 

Micr(H((,|)ically,  the  parenchyma  of  the  lung  is  intensely  congested. 
1  he  siiinlliT  iibsccsses  ,-ire  (•ompvscd  of  an  inten.se  intra-alveol'ar  and  itilcr- 
stitial  hiikocvtic  infiltration,  forming  a  local  celhdar  focus,  the  centre 
"f  which  stains  bmlly  and  contains  leuk(x-ytes  in  all  stages  of  degenera- 
tion and  debris.     In  the  neighborhood,  the  capillaries  of  the  alveolar 


mi 


■il' 


!i 


f 


Si  -'i.  wa-^icsiS:^ 


304 


THE  LVXaS 


walls  are  miioli  con^^'sttHl,  ami  there  is  a  certain  amount  of  (imI* ma  and 
des(|uamation  of  the  lining;  cells,  toother  with  s<»nie  <lia|M-(lesis  of  the 
ret!  and  white  cells.  Fiv<iiiently,  little  clumps  of  Imcteriu  cfii  he  st-cn 
in  the  centre  of  the  mass.  Staine*!  with  hematoxylin,  these  ar»'  ii  |>uri)lf. 
black  color. 

MataiUtie  or  Ssptie  Imbolie  Pn«ninoiiia.  Metastatic  or  septic  cinltoli,. 
pneumonia  is  nion-  common  than  the  last  form,  and  is  the  ty|M-  of  pnniltMit 
pneumonia.  It  is  hemato^-nic  in  ori^^in  and  due  to  the  loilpni.'  i,f 
multiple  infwtinn  aj^-nts  in  the  vessels  of  the  lunj;.  It  is  conn.  U 
met  with  as  a  nianifestaticm  of  jj^-neral  septicemia,  and  nvsults  from  sidi 
romiitions  as  osteomyelitis,  tJiromhophlciiitis,  septic  arthritis,  septic 
endometritis,  muli^nunt  endcK-urditis,  erysipelas,  and  the  like.  In 
ca.ses  of  infan-tion  of  the  lun^,  when  due  to  an  embolus  containini; 
pyoji;enic  micn>orpiiiisms,  suppuniti(m  will  result.  In  otlur  casfs 
clusters  of  bacteria  arc  found  obstructinj;  the  capillaries,  and  thus 
bring  about  the  condition.  It  is  not  likely  that  ^>rms  are  ever  in  the 
bl(KHl  in  such  (juantities  a.s  to  form  emboli,  but  it  is  more  pr<)l)al)ic  that 
one  or  two  bei-ome  entangled  in  the  lining  cells  of  the  vessels  and, 
Ix-ing  strong  enough  to  overcome  the  defensive  power  of  the  cells,  pro- 
liferate there. 

B  )th  lungs  are  usually  uniformly  affected,  but,  exi-eptionally,  onlv  a 
few  lobules,  ciiieHy  those  of  the  lower  IoIk's.  The  abscesst-s  appear  as 
multiple  mMlular  swellings  l)eneath  the  pleura,  varying  in  size  from  that 
of  a  pin-head  lo  a  cherry  or  even  larger.  The  areas  are  usually  more  or 
less  spherical  or,  if  the  condition  have  originau-d  in  infarction,  irrej.'iilarlv 
wedge-shajKHl.  The  overlying  pleura  is  congested  and  clomly  and 
generally  covered  with  fibrinopurulent  exudation.  On  section,  the 
lung  is  filled  with  inflammatory  foci  in  all  stages,  from  simple  consolida- 
tion or  purulent  infiltration  to  actual  iibscess  and  excavation.  The  color 
vari«>s  from  re<ldish-yel!ow  to  yt-llow.  In  the  earlier  stages  there  is 
not  much  destruction  of  tissue,  but  softening  .s«K)n  cK'curs  and  the  hiiij; 
has  the  apjM'armice  of  a  l(M)se,  sjwngy  matrix  fille<l  with  a  thick,  reildish- 
yellow  purulciit  fluid.  Se<|Ucstration  of  the  tissue  is  not  nnconnnoii, 
and  in  ailvanciil  stages,  on  washing  out  the  pus,  the  abscesses  are  re- 
veale(l  as  cavities  with  dirty,  nwrotic  walls,  surrounded  by  a  /one  of 
intense  iiiHaniinatory  hyperemia.  In  cases  which  have  lasted  some  time 
the  cavities  may  Ik-  iKHUidcd  by  a  rather  dense  layer  of  infiltration  walliiij; 
off  the  abscesses  more  or  h'ss  completely,  the  so-called  "|)V(ij;eiii(" 
membrane.  In  certain  cases  of  intense  infection  gangrene  supervenes. 
Microscopically,  the  picture  is  much  like  that  in  other  forms  of  ^ii[)piini- 
tive  pneumonia,  with  the  exj'cption  that  the  prwess  is  more  loealized. 
The  minuter  abscesses  show  merely  collections  of  small  round  cells, 
l)Ut  the  larger  ones  stain  badly  in  the  crntre,  owing  to  necrosis.  (Kdenia, 
congestion,  and  hemorrhage  in  the  neighlM)rh(M)d  are  marked  Icaiiires. 

Besides  the  bnnichogenic  and  hematogenic  forms  just  described,  hnal 
.suppurative  and  gangrenous  inflammation  may  (H-cur  in  the  hini:  as  the 
result  of  trainnatism. 

l*erhap.i  niorv'  frt'cjucntly  than  in  any  othw  organ  .sec<)n«hn7  -uppura- 


CHROSIC  PSEUMOSIA 


305 


lion  is  met  with,  complicating,  for  instance,  fibrinous  pneumonia,  chronic 
tilorative  tulierculosis,  actinomycosis,  and  e(;hin(K;(xx?us  disease.  Buhl 
has«ltscril)ed  a  purulent  peribronchitis  that  may  lea<i  to  septic  pneumonia. 

BepUe  Pnenmonift  by  Ixtenilon.— Another'  important  form  of  septic 
pm-imionia  is  that  arising  by  extension.  Ab.sce.s.ses  of  the  liver,  sub- 
phn-nic  alxscess,  and  suppuration  of  the  lymphatic  glands  may  extend 
to  tin-  lung.  Frequently,  the  infection  is  by  "way  of  the  pleural  cavity  and 
lymplmtics  (;)/cMro5f?n/r).  This  gives  riw  to'a  suppurative  interetitial 
lyinpliangitis,  and  is  said  to  be  most  common  in  children,  especially  in 
coniHMtion  with  empyema.  In  this  case  the  subpleural  Ivmphatics  are 
(iilatt'd,  varicose,  and  of  a  yellowish  color.  On  section,  the  lobules  are 
found  to  \ye  .st>parate<l  from  each  other  by  broad  succulent  yellowish 
bands  representing  the  connective-tissue  septa.  The  pnx'ess  niav  go  on 
to  tlu>  extent  that  portions  of  the  lung  tissue  are  sequestrated  and  cast 
aS (pnnimoniH  dimH-runn  of  Ziegler).  The  lung  tissue,  as  a  whole,  except 
in  tlu-  iieiglilM)rlioiKl  of  the  affected  lymphatics,  departs  but  little  from 
the  normal.  As  a  rule,  if  rec(»ver}-  take  place,  the  affec-ted  tissue  remains 
somewhat  thickened. 

Chronic  Pneumonia.— This  is  characterized  by  the  overgrowth  of 
(■onnpctive  tissue  in  the  lung,  so  that  it  l)ecomes  hard,  traversed  bv 
Khrous  bands,  and  more  or  less  shrunken.  The  condition  leads  to 
destruction  of  the  alve<»lar  spaces,  sometimes  with  bronchiectasis,  and 
always  to  marked  impairment  of  function.  As  already  mentioned,  it 
may  be  one  of  the  methcMls  of  termination  of  ordinary  lolwr  pneumotiia, 
and  may  also  foll(»w  catarrhal,  tulierculous,  and  syphilitic  disease  of 
till'  Imi};,  and  fre(|iiently  passive  congestion  or  atelectasis.  This  may  Ik- 
callwl  1 1)  the  secondaiy  fibroid  or  indurative  pneumonia  (2)  or  it  may  fol- 
low the  iidialation  of  various  kinds  of  dust,  and  is  then  termed  Jmeu- 
monokoniosis;  (.J)  lastly,  it  may  arise  by  the  extension  of  chmnic  pleurisy 
to  tilt'  lung  substance — p'ourogenetic  fibroid  pneumonia. 

Thf  iiuluration  following  upon  onlinary  acute  pneumonia,  when  of 
the  lobar  type,  takes  the  form  of  a  generalize-d  substitution  of  the  sporigv 
iissiic  hy  (onipact  fibrous  bands,  while  the  pleura  and  the  interlobular 
septa  arc  thickciiwl  as  well.  When  due  to  lobular  pneimionia,  the  fibrous 
tissue  jnoduction  follows  the  course  of  the  bn)nchial  tree  (peribmiichial 
hlm.id  pucinnonia).  The  hmg  is  gr.>atly  increased  in  weight,  has  lost 
Its  s|).iiij.'y  f(rl,  and  is  (piite  hard.  It  cuts  firmlv  and  is  of  a  gravish- 
white  olcr,  mottled  with  black  from  the  inhaled  c-oal  dust.  Sometimes 
Miiall  areas  of  necn)sis  not  tmlike  caseation  mav  In-  seen.  In  advanced 
•ases  the  pleura  is  thickened  and  the  lung  is"  greatly  distorte<l.  The 
two  layers  of  the  pleura  are  usually  matted  together  'and  the  tissues  of 
the  rm.liastiniim  may  Ih>  indurate*!.  Not  infre<|iientlv,  contraction  of 
the  hhroiis  tissue  leads  to  deformity  of  the  chest,  dr<M)ping  of  the  shouhler, 
and  s(.,ii,,sis.  Microscopically,  the  condition  is  seen  to  l)e  due  to  an 
nnpert.ei  nl.sori)tion  of  the  exudate  within  the  alveolar  .snares  and 
lieoveinmvvth  of  connective  tissue, so  that  not  onlv  are  the  septa  of  the 
iim^'  till,  k.Mcl,  but  the  newly-formed  fibrous  tissi'ie  gmws  out  into  the 
alvti-h  ,, „. i  thus  tends  to  obliterate  them.     The  affected  alveoli  are  small 


300 


THE  LVXGS 


collapited,  or  rompre-ssed,  and  often  all  that  can  be  made  nut  is  an 
irregular  cavity  contuiiting  a  few  catarrhal  cells  or  a  leukocytic  cMKiiitiim 
in  various  phases  of  degeneration  and  al>sorption.  Small  IniikIs  of 
fibrous  tissue  project  into  the  cavity  of  the  alveolus  and  may  even  fonii 
polypoid  excrescences.  The  bronchi  are  either  compressed  so  that 
they  are  thrown  into  longitudinal  folds,  or  are  rendered  dilnt<Hi  ami 
irregular  from  traction.  Here  and  there  in  the  fibmiis  tLs.sue  nrf  lar>;p 
masses  of  inflammatory  leukocytes  and  young  fibroblasts,  poiniiup  to 
a  continuous  proliferative  process.  Greatly  contructetl  alveoli  mav  !)»■ 
found  almost  devoid  of  lumen  and  lined  by  an  epithelium  whicii  is 
almost  cubical  in  type. 

Fio.  72 


Chronic  in^lurative  pneumonia,  sliowinfl  great  thickening  of  the  alveolar  waiU  iin<l  di^titrtion  of 
the  alveoli.     Zeitw  obj.  DI),  without  cwular.     (Knim  the  collecti()n  of  I*r.  A.  (i.  Ni-'Ih-IU.,' 

Ill  cases  tlue  to  passive  congestion  the  fibrosis  is  never  .st>  t'xtrcine, 
and  there  is  considerable  deposit  of  bUxxl-pigment  with  dilatation  of  the 
veins,  while  the  alveoli  contain  numerous  catarrhal  cells  filled  with 
pigment.  The  lung  has  a  brownish  color  (hrown  induratinn  i.  An 
important  variety  is  that  due  to  the  inhalation  of  dust.  Hut  a  small 
part  of  the  dust  that  we  commonly  inhale  reaches  the  lungs,  miuI  wiiat 
finally  gets  there  probably  does  not  reach  the  termination  of  tlio  lironchial 
tree,  but  is  carrietl  into  the  lung  by  means  of  the  phagocyits.  With 
regard  to  the  events  that  follow,  much  depends  upon  the  natnic  of  tiic 
dust  inhaletl.  All  kinds  lead  to  a  certain  amount  of  bronciiiiil  iiiiiatioii 
and  inflammation,  and  when  carrietl  along  the  jK'ribroiuhial  Ivinpliatics 
into  the  substance  of  the  lung,  are  deposited  in  the  alveolar  walls  and 
the  deeper  layers  of  the  pleura,  where  they  lead  to  catarrhal  iiillaniiiiation 
and  leukocytic  infiltration.  The  more  irritating  kinds  of  diisr.  -luh  as 
stone  or  iron,  may  lead  to  much  more  extensive  lesions.  The  jiartii'li's. 
Ijcing  sharp,  penetrate  the  walls  of  the  bronchioles  and  tiie  ahmli  ami 
lead  to  marked  inflammation  with  proliferation  of  the  coiimi  livi  tissiif. 
Thus,  it  is  common  to  sec  in  the  neighl)orhood  of  the  brom  !ii  ami  in 


TUBERCULOSIS 


307 


the  alvfolur  walls  more  or  less  rounded  nodules  of  considerable  hurd- 
nes.s  tliat  are  composed  of  connective  tissue  enclosing  a  granular  detritus 
with  (lumps  of  pigment.     In  advanced  cases  the  peribronchial  glan<ls 
are  pnatly  eniargecl  and  full  of  gritty  material.    Occasionally,  the  pig- 
ment  may  pa.ss  the  lung  and  be  deposited  in  the  glands  about  the  lesser 
ciir\atiirp  of  the  stomach  and  the  hilus  of  the  liver,  and  mav  even  reach 
the  liver  ami  general  circulation.     Among  the  forms  of  dust  that  are 
inhalwi  may  lie  mentionf  a  -oal  dust,  stone  dust,  kaolin,  iron,  wool,  flour, 
tolwcct).  iron  o.xide,  and  ultramarine  blue.     When  coal  dust  is  present,' 
the  condition  is  called  anihrncoais.    This  condition  is  found  in  the  limgs 
of  all  those  pa.st  the  age  of  infancy,  and  is  more  marked  in  those  living 
in  the  cities.    Coal  dast  is  relatively  innocuous,  and  all  we  see  is  scattered 
ptchts  (.f  black  pigment  with  comparatively  little  fibrosis.    Sometimes 
small,  rDiHiiled  nodules  with  a  black  centre' are  met  with,  the  so-tailed 
"anthrafotic  tul)erc-les."     It  i.'  the  rule  for  the  peribronchial  glands  to  be 
enlari.'ed  and  contain  coal  pigment.     In  coal  mmers  the  lung  is  uniformlv 
infiltrated  with  coa',  is  heavy,  and  has  a  grittv  feel  on  cutting.     In 
such  cases  the  expectoration  may  be  black.    I  n  cas^s  of  pneumonokoniosis 
(liic  to  stone  dust  or  particles  of  steel,  fibrosis  mav  be  very  marked 
In  the  stonemason's  lung  {chalicmia)  the  lung  is  heavv  and  "filled  with 
a  crayish,  gritty  material.     Sideroaia  is  the  name  applied  to  those  cases 
due  to  the  inhalation  of  iron  or  steel,  such  as  is  seen  among  needle  grin<lers, 
tile  makers,  and  founders.     The  results  of  pneumonokoniosis  are  not 
unlike  those  of  the  secondary  fibroid  pneumonias.    There  is  the  same 
induration  and  deformity  of  the  lung,  together  with  deforraitv  of  .the 
thorax  and  dislocation  of  the  mediastinal  tissues.     Calcification  has  Ijeen 
obsoned.  and  true  bone  formation.    In  rare  cases,  suppuration  and 
lavuatioii  has  been  met  with.     It  should  \ye  noted  that  the  presence 
of  dust  within  the  lung  predisposes  to  tulx?rc"!"sis. 

Pleurogenetic  Fibroid  Pneumonia.— Pleurogenetic  fibroid  pneumonia  is 
due  to  an  extension  of  pleuritic  inflammation,  wherebv  both  the  pleura 
and  the  .-epta  leadmg  from  it  are  infiltrated  with  inflammatory  pr.Klucts 
and  show  Hl,r.,u.s  hyperplasia.  This  condition  is  also  frequently  com- 
plicated with  collapse  of  the  lung. 

Tuberculosi8.-This  disease  may  present  Iwth  acute  and  chronic 
manife.tutio.is,  and,  as  its  name  implies,  is  characterized  by  the  forma- 
nnn  o  tiilHrcles  or  sjiecific  granulomata  in  the  lungs.  The  disease  is 
'ausetl  l,y  the  H.  tulK-rciilosis,  first  descriljed  by  Koch  in  IKSI  This 
inif  r.M,r>,'ams.„  is  constantly  present,  and  conforra's  to  all  the  reciuirements 
".  K<«l, ,  law-  as  to  siH-cificity.  The  search  for  this  bacillus  in  the 
jmm  „  now-  one  of  the  routine  practices  of  clinical  msearch.  Some 
'limni  tv  |„,  l«rn  iihported  into  the  subject  owing  to  the  discovery  of 
>;Mral  t.rms  of  acid-resisting  bacilli  that  inorphoh>gicallv  an.l  tii.Vt.H 
fialy  are  M,„ilar  to  the  tubercle  bacillus,  some  of  which  are  met  with 
•Wrt  MiiuMr  .  ircuiii^iaiices.  Such  are  the  smegma  bacillus  f..un.l  in 
^a^es  of  ;.M-„'rene  of  the  lung  by  Pappenheim  and  Fracnkel,' and  bv  one 


'  Berl.  kliii.  Woch.,  .53:  ISOSrSsO. 


h 


-     :    i  . 
- 


ao6 


THK  LUSt.S 


i  -m'  :i 


4\ 


•;r 


x\ 


of  lis  (A.  G.  X.),  the  butter  ttaeilliis  of  Moller,  the  tiinothy-frniss  liiuillii;, 
the  iMicilhis  uf  Lviiiu  Ilabinuviteh,  uimI  certain  .streptuthri\  fonib 
(le.scribe«i  by  Floxiu-r.'  Some  «»f  th»^»c  «an  pnxhice  ipiinuloiiMtii  in  the 
tissues,  so  thill  the  resembl<<nce  to  tite  true  B.  tulHTCulosis  is  closr.  ("an'- 
ful  culture  experiments  alone  will  differentiate.     We  have  to  nciijrnizp 

now  that,  an  there  is  u  colon  i,rn)uu 
y'">-  '-I  of  Imcilli  including;  a  ffwut   niimlNr 

of  allied  fonns,  m>  there  is  a  mUr- 
culosis  or  acid-fast  )in^)Up,(iiii(iiiiiiii^ 
si'veral  fonns  <lifferin>j  in  viriiicnd' 
^  and  in  minor  cultund  [M-4'tiliiirities. 

With  reganl  to  the  modfs  of  in- 
>*i     ^        ^  •'''<''  fection,  it  may  Ik-  said  at  once  tlint 

tnlx'n-ukxsis  is  practically  never  in- 
herite«l.  Some  few  aulluiitiialfd 
cases  an'  on  rt-cord  of  the  tninsniissioii 
<)fthe  specific  l>aeillus  from  nioihrr 
to  offspring  thniu^h  the  placctital 
IiKmkI,  but.  such  cases  arc  so  r.iiv 
that  (lirtH-t  inheritance  may  Ik>  dis- 
misse<l  as  an  unini|)ortiiiit  factor. 
At  most,  we  can  say  lliat  tlicrc  is 
an  inheritanct*  of  the  soil,  in  that  in 
certain  individuals  there  is  a  weak  nsistinj;  jxiwer  of  the  tissncs  towani 
the  tuln-rcle  Imcillus,  so  that  when  infection  takes  place  (htrc  is  (;rowth 
of  the  bacillus  within  the  Innly  with  all  its  c«)nse<|ueiice,s.  Tlie  prliiKt 
ricr  of  infection  are  various.  It  used  to  Ik-,  antl  in  many  (|uartfrs  still  is, 
accepted  by  clinicians  and  pathologists  that  tulx-rculosis  of  tlic  ltiii),'s 
is  bronchogenic  as  a  rule.  It  shouhl  Ik-  mentioned,  however,  that  hy 
certain  obser\ers,  notably  Hibl)ert,  Aufrecht,  and  Baunijjartcn.  a  ninre 
t)r  less  successful  attempt  has  l)een  made  to  disprove  this.  HiljlnTt,' 
while  not  denying  alwolutely  that  infection  may  take  place  by  inhalation, 
iH'lieves  that  pulmonary  tulK'rculo,sis  is  u.sually  hematojicnic.  in  the 
sen.se  that  the  peribronchial  glands  are  infi-ctwl  throiifjli  at'rial  tnuis- 
mission  by  way  of  the  buccal  muco.sa,  and  that  when  they  Imak  down 
the  pnMlucts  of  the  destructive  inflammation  are  diseliarpd  into  the 
bl(KKl  and  so  reach  the  lunp.  I3aumgarten'  goes  still  fartlur.  ami  holds 
that  the  glands  also  are  inva<led  hematogenously.  The  expciiint'iits  of 
.\ufrecht'  would  .seem  to  prove  that  it  is  imp)ssible  for  bacilli  to  n-ach 
the  terminal  brfinchioles  and  alveoli  through  inhalation,  atid  |x>st- 
niortem  evidence  also  sup|M>rts  this  cotitention.  It  would  scciii  |)rol)ahlf 
that  we  will  have  to  give  up  the  view  that  the  bmnchi  are  the  (ii  -i  >n  lu  tnre- 
to  l)e  attacked,  and  adopt  a  nKxIified  inhalation  theory  soincwii.it  similar 
to  Kibbert's,  admitting  an  infection  through  the  blood  or  !yni|ili-stream 


'I'ulierculou^  r*l>utUMi  r<luiiieil  liy  (labljctt'-s 
ineMioii.  ■fiiheri'lp  hui-illi  arf  i«eeii  a^  red 
r<Ml.;  all  elrne  ix  r«ttiined  hlile.      (.XMxttt.) 


'  .Fohns  Hopkin.H  llo-sp.  Hull.,  8: 1S07: 12S.      '  IXnit.  inwi.  Wik-Ii..  I'"  ':  N".  IT 

'  Wicn.  nifd.  Wocli.,  .N'ovi'IiiIkt  2.  liMll. 

'  .Xiilri'chf,  Pathologic  luul  TlKTupie  dur  Lungonschwimlsuclil,  \\  !•■  ;.  l'"is. 


TVBERCUWSIS 


300 


from  ilic  mouth  awl  n«»!«'  and  ilie  up|)rr  n>.spirHtorv  paxsaKc^.  In  this 
(•ontitf  lion  Uavi'iH'l'  has  shown  nfently  that  tnlifrculouM  matprial, 
wIh-ii  injteste*!,  frH|UPntl,v  rrarhi^^  thf  ton.silt  ami  prrihronchiai  fclaiHls. 
In  sDiiic  cases  the  hings  have  iNfoine  •MH-oiHlarily  affected  from  tuberruloiis 
(lka^<'  of  th"  inti>stinal  traet.  This  is  rare,  at  least  in  this  coiuitrv. 
alilii>ii}.'h  a  , .  rently  nn)re  c-otnrnon  in  Gn'at  Hritain.  In  12tM)  autopsies 
Ht  ilif  l{o\..l  Victoria  Hospital.  ' '  treal,  active  tuljen-.ilous  lesions  of 
nne  kimi  or  another  were  fonn.  .i..i  times;  in  only  three  of  these  was 
ihe discns*'  obviously  primary  ti  the  intestim*,'  aithf>U)(h  this  soune  of 
(iriitin  ^ih'MumI  prol>al>le  in  six  mon*. 

ill  ntw  iristunces  the  lungs  have  Ih-cu  infM'te«l  in  cuses  of  primary 
tiiUrc iilosis  of  the  skin.  TJie  skin  is,  however,  a  n-latively  unfavoralile 
medium  fi>r  the  >;rowth  of  the  tul»erfle  liacillas,  prol>ably  owin;;  to  local 
temp<rntim-  conditioi  <  and  the  nature  of  the  epithelium,  so  that  the 
(li>puM'  does  not  «)ften  liecome  ){enera'.  The  bovine  strain  of  the  organ- 
ism, liowcver,  when  invading  the  human  subject  in  this  way,  is  apt  to 
rise  to  widcsprj-ad  and  virulent  infection. 

.\fttr  II  careful  consideraJon  of  the  methcMis  of  infection  of  the  lung 
we  art'  rcducwl  to  three:  (1)  the  aerogenic,  (2)  the  hemaiogenic,  and 
i.{i  \\\c  lymphogenic.  Fre<|uently  tw-  (»r  even  all  three  methods  may 
lie  ciiiiiliini-d.' 

The  first  method,  if  tul>erculcxsis  of  the  bronchi  lie  an  essential  lesion, 
wiiiild  ap|Har  to  Im-  rare,  except  in  those  cases  where  a  lobe  of  the  lung 
N  Mtcmdarily  iiivolvcsl  by  the  inhalation  of  infective  excretions  fnHu 
s<imc  other  part  of  the  respiratory  tract.  Such  cases  do  not  represent 
the  frt(|iitn(y  of  inftrtion  through  the  air,  as  it  is  possible  for  Iwicilli 
to  pass  through  an  intact  bnmchial  mucosa  and  lodge  in  the  deeper  struc- 
tures. A>  iK'fore  liinte<l,  we  must  distinguish  In-tween  aerogenic  and 
linm(hoj:iiiip  tulicrculosis.  The  di.st>ase  usually  arises  from  the  inhala- 
tion (II  drii  I  sputum,  but  also  infective  material  from  tulM-rciilous  cavities 
orcasfdiis  [Mrilironchial  glands  may  lx>  aspirated  iiit(»  the  air  passagt>s. 

\\  hell  the  liacilli  are  inspired  they  l)ecome  entangle<l  in  the  mucus 
at  certain  parts  of  the  bnmchial  tree,  where  they  .set  up  irritation. 
•fiuliriiij:  fniin  clinical  experienc-e,  i)ronchitis  is  a  fref|uent  result,  but 
pistmorttiii  studies  suggest  that  this  is  simple  and  not  caseous,  for 
priiiiarv  .asinxis  bronchitis  is  rare.  As  a  rule,  the  Iwcilli  are  picketl 
up  liy  the  phago<ytes  and  carried  through  the  lymphatics  to  the  recesses 
of  the  hiiii;.  Thus,  a  lymphogenic  distributioti  of  the  infection  is  (luite 
eommoM. 

Inaiiothtr  set  of  cases  infection  is  through  the  bItMxl,  as,  for  instance, 
'hen  a  caseous  gland  discharges  its  contents  into  the  pulmonary  artery, 
or  when  the  recej)taculum  ch\'i  or  the  thoracic  duct  are  invaded. 


■li:n'i,.l   AiiKT.  .lour.  Med.  .Sci..  1  .'U :  1  !H)7 : ■»(}<•. 

•  Xich.  i:-  Mniitrenl  Mo<l.  Jour..  .11 :  !<)(»2-.127. 

r  :i       rv  pmkI  con.siilcration  of  the  nio»le»  oi   infection   in   »ulH>rciil(isis.  see 

^:il:i    ;:\  niMirt  on  the  Helation  of  llovine  Tuberenlosis  to  the  I'ul.lic  Health. 

I''!  ■     \2ric.  Hiireau  of  Anininl  In.lustrv,  Hull.  \'i 

al^iA,  Ii, 


I'.E. 

r.  s. 


!  (  kailer,  .Montreal  Me<l.  Jour.,  .30: 1901 :  90.5. 


.«:  KHtl:  Washington; 


I 


IP; 


310 


THE  LUSM 


WlH-n-vrr  till'  Itarilli  Ixmine  lod|i^  is  u  finnw  for  the  c|pvel<»|imrni  of 
■  tiiU'rciiloiM  IfsiiHi,  aiHl  the  iiumlier  of  thfse  will,  of  (>«>iir<u',  iIiin-inI 
very  much  oti  the  amount  of  infective  material  reaching  the  iiiin;,  m\ 
the  character  of  the  phagocytes  ami  lymph  current.i.  'llie  niiiitoiniiiil 
picture  frefjuently  prcNhice«i  is  that  of  a  liN-alizeii  l>ronchopncuni>iiia.  In 
adults  the  site  of  nretlilection  i;;  just  lielow  the  apices,  prolwlfly  Uthii^. 
the  excursion  of  the  lung  is  slighter  at  these  |M>ints  arnl  the  niovi  llu■lll^ 
of  fluiiN  and  gases  are  cons<>(|uently  slower.  At  first,  the  pnich  of 
infiltration  i-  snudi,  somewhat  gelatinous  in  nppearance,  ami  iniixT. 
fectly  defin  t>m  the  healthy  tissue.  At  this  stage  the  ve.s.s«-ls  of  (he 
alveolar  walls  re  congested  and  a  cellular  exudate  is  thrown  out  jniit 
the  alveoli.  Ti.e  vess«>ls  gradually  liecome  hlix-ketl,  owing  to  i.ndifcra- 
tioii  of  the  endothelium,  and  the  picture  speedily  changes  us  the  ccntn. 
of  le  area  hreaks  down  and  l)ecomes  caseous.  A  shar|>ly  defined  nixliiif 
thus  results.  This  may  heal,  l»eing  finally  represented  hy  a  fihmus 
scar  with  some  puckering  of  the  apex,  or  a  fibrous  ntnlule*  {•ontaininj! 
east-ous  or  calcareou.s  matter.  Should,  however,  the  pro<rs.s  ciiiitiime. 
as  fr»H|uently  happens,  the  bacilli  are  carried  aUing  the  lyniphiitics  of 
the  neighlxtring  sepu,  and  secondary  ftx-i  are  the  result.  The  original 
nodule  gradually  increases  in  size  through  continued  ieifiitration  ami 
proliferation,  until  coalescence  takes  place  Iwtween  it  and  the  summmliiiK 
nodules.  The  dis(>ase  may  spread  rapitily,  es|)ecially  in  children,  until 
the  most  distant  parts  of  the  lung  Ijecome  involvetl.  '  Where  the  Irsions 
real  li  the  surface  the  pleura  is  inflamed.  The  |>eri  bronchia  I  glnnds  art 
liable  to  be  infe\.  ted  early  in  the  disease.  Quite  frefjuently  auti)-iiiftttion 
takes  place  in  cases  where  a  ca.seous  oKscess  discharges  into  a  hi^Hichiis 
or  into  a  vessel.  Aspiration  of  infective  sputum  will  bring  alwiit  the 
same  result. 

The  linig-substance  between  the  tuJ)ercles  may  show  little  or  no  clmnj.'e, 
but  in  their  immediate  vicinity  there  are  always  congestion,  iiiH.M'ru.it. 
infiltration,  and  cell-proliferation.  The  tulxrcles  are  coniiinnily  sur- 
rouiule<l  by  a  zone  of  simple  pneumonia,  which,  in  turn,  rapidly  Inwiiies 
caseous.  In  the  progressive  form  the  original  focus  may  attain  oiii- 
si«lerable  size,  and,  owing  to  the  interferenc-e  with  the  ciniilation  ami  the 
toxic  action  of  the  Imcilli,  undergoes  caseation  and  colli<|iiativc  iiccrosis 
A  ragged  cavity  is  the  result.  Even  in  the  more  chronic  caxs,  where 
there  is  n-  ♦^'xyihs  tissue,  this,  in  turn,  may  become  ca.^enib.  The 
cavities  !rcum.scril)ed  and  filled  with  soft,  piiriforin  material 

confaininj"  -l  calcareous  particles  with  slmxis  of  ti-^-iie.    In 

many  cases  ti.  >mes  lined  with  pyogenic  membrane  iir  Uiundeil 

by  a  fibrous  wall.  .  ..s  of  tissue  are  not  infrequently  foiiinl  liaversin); 
these  cavities,  and  repn-sent  the  original  interlobular  septa  <>f  the  luiij;. 
In  tlie  strands,  bloodvessels,  sometimes  showing  uneurisinal  liilatations, 
may  lie  found,  the  rupturi>  of  which  lea<ls  at  times  to  fatal  In niorrlia^e. 
.'^niall  cavities  may  gnuluaily  contract  and  their  contents  Imm.,,,.  inspis- 
sated, so  that  a  cheesy  and  calcareous  nodule  surniundetl  bydi  i  •  fibrous 
tissue  results.  The  larger  cavities  may  contract,  but  seMiKi  JK-con.;" 
obliterated.     When  free  communication  exists  l)etweeii  a  (.i\ii\  and  a 


311 


TUBERCULOSIS 


hniiicliiii  it  U  a  rommori  thing  to  AimI  a  rtitHiition  of  tabaraitou  I 
yMunoiiia  in  the  other  lobes  or  in  the  upptisite  \\iug.  'I1iu  Li  <liie  to 
the  aspiration  of  the  infe<-tivt>  prothicts,  a  {mK-eMH  that  Li  ri'iulered  eair 
bv  (-oii^h  or  forred  iaspiration,  iuhI  Uy  UNlily  activity.  Here,  in  the 
eariiiT  stajjei  of  the  profe.Hi,  snwll  isolateii  tiihen-lei  fom  along  one  or 
more  hranohes  of  the  bronchial  trw,  which  eventually  co;*lescc  and  pro- 
duce liirjre  ami  perfectly  ilefined  cafw-oui  nia.i.ies  .turroumled  by  a  zone 
of  simple  pneumonia.  The  course  of  the  dLieaie  defiendi  on  the  nature 
of  till'  iiiffftion.  Many  caws  ore  examples  of  mixwl  infection  with  the 
Iwcillus  tulH>rcuiix<ti.i  and  pyogenic  micnMtrganLsnLS.  Thi.i  a.i[M>ct  of 
the  siil(je<t  has  reeeivetl  coaiideralile  attention, 'notably  from  Ortncr' 
ami  Sprenglcr.' 

Fw.  74 


•  awiitiun    itiihrrFuluufi)    in   llie   lun«.      Area  ut   caMatiim  to  the    right;    the    hInrMlves.wIt 
inju-tel  to  -lii.w  ilie  avanrularity     !  the  net-rotio  |iart.      I^ili  i>l>j.  No.  3.      (Froi.i  Ur.  A.  O. 

Xiili"ll-'  lullectiim.) 


Ill  a  iiMKlerately  severe  form  of  secondary  tul)erculous  bronchopneu- 
monia, a  local  cellular  exudation  and  proliferation  take  place,  followed 
hortlv  l.y  tiie  formation  of  a  caseous  nodule,  ^^'hen  such  an  area  is 
examined  niicrt)scopically,  one  sees  at  the  periphery  of  the  caseous 
mass  an  exudation  of  fluid  into  the  alveolar  spaces,  diapedesis  of  leuko- 
fvtcs,  swcllinj;  and  desquamation  of  the  lininjj  epithelium,  and  occu- 
sionallv  threads  of  fibrin.  The  alveolar  walls  show  rountl-celled  infiltra- 
tiiiii,  Hiiil  the  lymphatics,  not  only  the  perivascular  and  peribronchial, 
liLii  ai-ii  the  interalveolar  and  interlobular,  are  more  or  less  blocked  with 

'  !iii'  I.imgentu))erculo8c  als  Mischinfcction,  Wwn,  1803. 

■  I'linKMituberculose  u.  Mischinfection,  Zeit.schr.  f.  Hvg.,  18:  1S94:  343. 


II 


312 


TUt:  LUAGS 


inflainmntnn-  prcKhicts.  As  tin-  pnx-e.ss  ex'.eiuls,  !•!!  tin-  manifcsiations 
si'fii  in  thf  iiripnal  fm-iis  are  rt'patt-*!.  The  decree  of  involvcimnt  of 
the  blocKlvessels  in  the  neighiMiHKKxl  of  tiie  tulHTcles  is  a  nuiiiir  of 
some  importance.  (Jenerally,  owinj;  to  proliferation  of  the  lininj;  cikIo- 
fliehnni,  they  InTonie  more  or  less  ocehuietl.  Thus,  the  tul)ri(  Ic  is 
avascular.     It  sometimes  hapjH'ns,  however,  that  erosion  of  the  vessel 


Fui.  75 


I.efl  IiliiK.  .«u|)Pri..r  l.ilje.  niiil  upper  piirt  of  l,.wer  InVie.  Ilie  former  rniitiiiriiiiit  :>  miiiiNr  "f 
••"ninmni.-iiling  cnvrni-,  t.nmglit  iilx.ul  l).v  lulH-rculous  iiiKlenitirui,  rasention.  uii.l  ma,  ii:in..ii  .if 
till  .ciitent.- tlirnugli  the  tirmiilii.  .1,  aneiirismal  ililatation  of  an  artery  ^.pallnillK  ""'•  mown. if  a 
large  ravity;  U.  eninniuniealion  with  aiioilier  cavity:  C  >'.  Iliiikerie.l  ami  a.lli.r.iit  \Aeura 
Iwtweeti  the  two  involve.)  lobes.  Tlie  pleura  over  both  lobes  is  tlii.keneil,  un.l  al  !!..■  aiilii|i.y 
the  cavity  had  been  .ihliteraleil  by  universal  adhesion.  I),  the  pointer  from  the  h-tl.'i  /)  l.u.l-  l.. 
a  small  itr.iu|)  of  tulieples  in  whi.h  ,„«eation  is  just  beginniiiK;  A',  a  fu-e.l  group  .1  luMT.le-, 
farther  advmiied  than  at  />       .  Uare  ) 

walls  takes  j)lace  and  hemorrhajre  results.  .Vpiin,  a  caseous  fuc  iis  may 
ero<le  into  a  lar^e  vessel  and  lead  to  a  miliary  dissemiiialidn  nf  the 
hacilli  throujfhoiit  the  iKnly. 

As  We  meet  with  this  form  of  tulK-rciilosis  post  mortem,  tin  liiiiir  is 
more  or  le,ss  adherent  to  the  thoracic  wall,  is  increas«>d  in  wi'^Ja,  the 


TVBERCl'LOSIS 


313 


upiKT  lolx-  liirRely  caseous  witli  iniiltiple  cavities,  while  tulMTculoiis 
ihhIiiIo  are  scutteml  here  and  tliere  throughout  the  rest  of  the  Iuikt.  The 
hroiiclii  are  usually  inflaineil.  The  cavities  that  are  so  frefjuentiv  found 
ill  tills  form  of  tuU-rculosis  are  prcNluced  In-  the  softening  and  sul)se<|uent 
ivaciiiitioii  of  the  c-ontents  of  a  caseous  ft)cus,  or  at  times  hy  the  enlarge- 
imiit  i)f  a  hronchiectatic  cavity  through  necrosis  of  its  walls.  Their 
mimlxrs  and  size  vary  considerahly.  Sometimes  a  single  cavity,  the 
size  of  a  walnut,  is  found  near  the  apex,  or.  af-.in,  n  •..•!.-)le  IoIh-  mav 
be  coiivcrfeil  into  a  thin  shell.  It  is  not  urn  c  nioii  to  fisv!  f',-  upper 
part  of  the  upper  lohe  riddled  with  cavities  .  "  vai  ving  i/e,  '<  .nmuni- 
catiiig  more  or  less  completely  one  with  the  .jtl„i'.     Dcp^'n-I ng  upon 


Klo,  7fi 


hl.r.i|.|  ,ri.lun.t],.ii  „f  ll,e  hiiiK  in  tuteri'ulcsi^.  The  alvenli  are  .lo«troveil  nnil  ri-|.la<-e(l  li.v 
tilTo.,.  ti-u,  U,.u,„lKelle,i  infiltration  i,  markeil  at  the  lower  part.  Zei-»  „l.j.  l)|)  without 
-ular.       I  rn„i  il,o  folleriion  of  the  Hoyal  Victoria  Hospital.) 

[lie  (liioiiifity  of  the  prcKTss.  the  walls  are  either  rough  and  shaggv, 
iiiii'd  In  a  pyogenic  inemhmne,  or  smooth  and  fihrous.  The  walls  are 
uftin  im  oiilar  fn)m  the  presence  of  the  fihrous  septa  of  the  lung,  which 
are  iii.Mv  irsistant  than  the  rest  of  the  lung,  .so  that  an  imperfcctlv  Kku- 
lateti  (avity  is  the  result.  The  cavities  contain,  besides  air,  a  niixfure 
')  striiMi,  ,,„s  fells,  ca.seous  matter,  and  detritus,  (H-casionallv  bliKxI. 
"ne  or  III,,!,.  „f  the  cavities  may  communicate  with  the  bronchi,  which 
>li'm  II ,,  n,tion  and  other  inflammatory  change.  In  the  older  regions 
nt  tlif,  i„aM.  considerable  fibroid  induration  mav  be  met  with. 

H(si,|,s  ih,,  ,.„„„„„„  f„r,„  „f  tul)erculoiis  invo'lvcmcnt  just  dcscrilH-d. 
«iii(ii  i„,nh,  |„.  ,.„rm.t|y  terme<l  the  caseofibroid  varietv,  or  chronic 
Bicerauve  tuberculosis,  there  are  several  conditions  arising"  in  the  same 


K«g*_ 


Id 


I  ' 


F  I 


iCn^:' 


314 


TlIK  Lvxas 


way  that  an-  worthy  of  attention.  Not  infre(|uently,  a  fil)roi(l  or  cal- 
careous  fotnis  in  the  lung,  or  a  partially  healed  cavity,  for  a  ioiii;  time 
giving  rise  to  no  .symptoms,  will  suddenly  start  into  activity  and  rapjdlv 
invade  the  rest  of  the  lung.  In  one  form,  minute  miliary  (iiU'rcleis 
are  prtxlueed  along  the  course  of  the  bronchi,  and  a  picture  not  unlike 
the  hematogenic  miliary  tuU-rculosis  is  the  result.  This  li.is  Ixn-n 
termed  dissemiiuted  miliary  tuberculous  bronchopneumonia.  In  other 
c  ■'es  the  f(X'i  lu'come  rapidly  larger  and  coalesce,  showing  iiltic  or  no 
tendency  to  fibrosis,  so  that  caseation  and  softening  |)r(K'cc(i  ;i])ace. 
This  is  the  caseous  nodular  or  lobular  bronchopneumonia.    Again,  n  whole 

Fio.  77 


Tuliemiii.ii^  pneuniunia  (acute  pneumonic  phtlii^is).     (Frum  the  Pathuliit(i<-:il  l.al><Tut<rry 
of  McGtIl  I'nivereity.) 

IoIk',  or,  indee<l,  a  whole  lung,  may  liecome  rapidly  anil  iinil'nrmly  iii- 
vo1v(h1,  owing  to  the  coalescence  of  the  various  foci,  an<l  wv  i,Tt  llie 
caseous  lobar  pneumonia  or  acute  pneumonic  phthisis.  Tiiis  i-  ilic  form 
that  has  l)een  called  i)y  clinicians  "floritl"  phthisis  or  "galhii)in<;  con- 
sumption." Here  the  affected  lobe  or  lung  is  uniformly  (iMiMiiiiiatcd. 
very  heavy,  with  a  thickcnetl  and  ailherent  pleura.  On  mi  limi,  it  i< 
dry,  granular,  ami  caseous,  and  with  it  may  la-  small  areas  of  ravitation 
near  the  aix'x.  The  con.-lition  is  not  ntiiikc  lolxir  pncnino'ii.!.  cxcep! 
that  the  infiltnition  is  denser  and  the  exudate  white  and  caMnus  rather 
than  gray  and  fibrinous. 


UE}rA  TOO  EMC  T  UBERC  ULOSIS 


315 


Anotlier  type  is  the  chronic  fibroid  taberculosis,  a  disease  that  often 
lasts  for  years.  Here  tissue  proliferation  is  in  excess  and  leads  to 
iiuiuration,  contraction,  and  defomiity  of  the  lunj;.  The  organ  is  trav- 
erstnl  by  numerous  bands  of  fibrous  issue,  with  some  caseation  and  old 
contracting  cavities.  The  parenchyma  of  the  lung  is  greatly  damaged, 
Ix'ing  substituted  in  great  part  by  compact  fii)rous  tissue.  In  the 
parts  less  affectetl  the  alveoli  are  emphysematous.  This  form  may 
atfect  tlie  upper  lolje,  which  may  form  a  very  small  appendage  to  the 
rest  or  the  lung,  an<i  may  contain  partially  contracte<l  cavities  and  cal- 
careous noihiles.  Tlie  i)roiichi  are  often  dilated.  The  pleura  is  also 
preatly  thickened  and  is  adherent.  After  a  time,  owing  to  contraction, 
(ieforinity  of  the  chest  wall  sets  in  with,  sometimes,  dislocation  of  the 
heart.  This  form  frequently  arises  from  old  apical  disease,  but  is 
occasionally  pleurogenic. 

Fio.  78 


Miliurv  tuljficul..»i.  of  the  lung.     7M*n  obj.  IJI),  without  ocular.      (From  Dr.  A.  G. 
NicholN*  cullertion.) 

Hematogenic  Tuberculosis.— Hematogenic  tul)erculosis  may  l)e  part 
and  panel  of  a  generalized  systemic  dissemination  of  the  infection, 
or  iiiiiy  Ik"  confined  to  the  lungs  alone.  The  s|)ecific  bacilli  are  conveved 
totlic  liiii^rs  i)y  the  blood  stream.  The  condition  often  arises  from 'the 
ilisc  mrL'.M)f  a  suppurating  lymph-gland  into  a  vein  or  from  tuberculosis 
m  the  ii.i^rlilMtrlKMxl  of  the  receptaculum  chvli  and  thoracic  duct.     As 


a  rule,  the  tuljercles  are  numerous  but  minute  (miliary  tuberculosis). 
A  .ii);-  jilFcctcd  in  this  wav  is  dark  red  fmm  hvpcremia  and  sc 

«-ha*    :   ..  ^i t        ^        .  ..  '  « 


some- 


what l.(  ivitr  than  normal.     In  the  earlier  stages,  tlie  tubercles  can  l)e 
felt  raihn  tlian  seen  as  minute  shotty  granules.     Later  they  are  noticeable 


1^ 


^i  M 


1 

flif 


3U) 


THE  LUSGS 


Fio.  79 


as  small  pin-point  dots  of  a  pniyish  color,  IxK-oming  in  time  niM-oiis. 
In  the  generalized  systemic  infection  the  tiiU'rclcs  are  numer  as  and 
uniformly  scattered  throughout  the  luiijfs  and  on  the  pleurae.  In  other 
cases  they  are  confined  to  one  lung  or  to  one  l()l)e.  They  mav  often  In- 
seen  at  the  periphery  of  a  large  case«-us  focus.  The  lung  is  less  cre|)itant 
than  normal  and  the  lm)nchi  Hiv  Ktldened  and  inflnin'  i. 

Owing  to  the  small  size  of  the  lesions,  they  fonn  a  convenient  fonn 
for  the  stutly  of  the  <leveIopment  and  minuter  structure  of  the  'vpieal 
tuliercle.    The  Imcilli  usually  lo<lge  in  the  capillaries  ■  i  the  alveolar 
walls.     Here  they  become  entangle<l  in  the  endothelial  cells  lininj;  the 
vessels,  which  po.ssess  phagocytic  powers,  an('  proliferate  thorc.    The 
irritation   pro<luce<l    leads   to   inflammatory  hyix-remia   and    the  out- 
pouring of  leukocytes,  chiefly  lympho- 
cytes, not  only  into  the  interstices  of 
the  alveolar  septa,   but  also  into  the 
alveolar  spaces.      Accompanyinj;  this 
there  is   oedema,    exudation  of   Huid, 
and    des(|uamatiun    and    proliferation 
of  the  cells  lining    the    alveoli.    The 
cells   lining   the  capillar       also    pro- 
liferate, so    that    scxuier  oi    later  ol)- 
struction   of  the   luinina   takes  place. 
As    the    di.sea.se    progresses,    another 
type  of    cell    makes    its    appearance, 
somewhat  larger  than   the   leiikcH-vte, 
with  a  single  pale    nucleus    liie  .so- 
called     'epithelioid"  cell.     The  e.xact 
origin   of    these    is    not    settled,   luit 
they  are  prolmhly  derived   from  the 
proliferation    of    the    fi.\e<l    inesmler- 
mic  coimecfive-ti.ssue  element-.    Thns, 
a     typical     tiil)en'le     consists    in    a 
Kxalized   collection  of   lymphcK'yttv.  with,  toward  the  centre,   a  ninn- 
IxT  of   epithelioid    cells,  f.ccompanieil  by  the    usual    signs  of  InHam- 
mation,    viz.,    hyperemia,    exudation    rf    fluid    .sometimes    eontainini; 
fibrin,  and  catarrh  of  the  cells  lining  the  alveoli.     As  the  (undition 
progresses,  the  central  portion  of  the  tuln-rcle  brt-aks  down  or  ci-eates. 
In  the  more  chronic  forms,  large,  multinucleate<l  cells-  giant  (clls— 
make   their  appearance  at  the  jieriphery.     Any  that  may  I    nc  lieen 
present  in  the  central  portion  are  u.suaily  destroyed  in  tiie  (a-eating 
process.      The  tiil)ercle   increases   by  the  gradual  involveineni  "f  the 
peripheral  cells  in  the  ca.seating  process.     It  usetl  to  Ih'  tlumirlii  that 
giant  cells  were  characteristic  of  tulxTculosis,  but  we  know  now  that 
they  are  present  in  many  forms  of  ctironic  inflammation  and  wlieri'vcr 
foreign  matter  is  being  absorl)ed.     In  fact,  there  is  nodiing  dmrader- 
istic  in  the  structure  of  the  tul)ercle  as  a  whole,  except  in  the  preijon- 
derance  of  lymphocytes,  the  caseation,  and  the  presence  of  tin    pecific 
bacilli.     Both  plasma  i^ells  and  " Mast-zellen"  are  met  widi  in  ii jKreles, 
but  are  efpially  non-specific. 


Sflienmt ic  rt>preM'rilati<in  of  a  tuhen-le 
a.Kiiint  cell  with  nermtic centre  an<l  null 
tiple  nuclei  periptierally  arranKed;  6,  epi- 
ttieliuiil  cells;  c,  lynipliocytet*. 


PSEUlKITUBERy  SIS 


317 


III  tlif  more  chronic  i.  irms,  or  where  the  resisting  power  of  the  individual 
is  ^tronj;,  there  is  a  new  formation  of  eoiiiiective  tissue  which  tends  to 
wall  in  the  focas.  This  may  be  so  well  marked  that  firm  shottv  masses, 
the  -v/x'  of  hemp  seeds,  with  relatively  little  central  caseation  mav  be 
priMluced.  This  is  the  chroiii'r  miliary  tuberctdosia,  or  the  chronic  granular 
tiilwrriil(>.ii.i  of  the  \'ienna  school. 

PMudotubercnloiii  (see  also  p.  319).— This  term  has  l)een  emploved 
to  tlisijrnatc  a  condition  do.sely  resembling  tulxjrculosis,  but  due  to 
micntorpinisms  other  than  the  Ixicillus  of  K<xh.  The  lesioas  found, 
like  those  of  tul)erculasis  proper,  may  be  ca.seous  granulomata  or 
abscesses.  The  etiology  of  the  condition  is,  curiously,  most  diverse. 
Perhiij)s  most  of  the  cases  have  l)een  due  to  Imcterial' microorganisms 
allipfl  to  the  streptothrices  or  to  certain  hypomycetes,  but  some  have 
lieeii  due  to  animal  parasites,  or  even  to  foreign  Ixxlies. 

One  form,  the  pseudotulierculosis  of  rtxlents  (tut}erculnae  zoogleitiue), 
is  found  in  guinea-pigs,  rabbits,  hares,  and  mice,  but  occasionallv,  also. 
in  cliickens.  An  orgjinism  has  been  isolated,  which  seems  to  lielong  to 
the  same  class  a.s  tlie  l>acillus  of  hemorrhagic  septicemia.  Two  cases 
■iff  r([H)rtcd  where  this  form  of  the  disease  has  l)een  traasmitted  to  man. 
Tlif  tvi.lciice  is,  however,  somewhat  inmnclusive.'  Some  few  cases, 
also,  have  l)ecn  descrilied  in  which  p.seudotul)erjulosis  in  man,  though 
not  of  the  lungs,  has  l)een  caused  by  germs  not  identical  with  the  Bacillus 
psciidotuiK'rculosis  rwlentium,  but  only  differing  fmm  it  in  minor  points.' 
Prtisz'  and  Kutscher*  hr.ve  met  with  cases  due  to  organisms  resembling 
the  Ikk  illiis  of  diphtheria.  Eppinger*  has  reported  a  case  of  pseiido- 
tiiUn niosis  due  to  a  cladothri.x,  and  Flexner,"  one  apparently  due  to  a 
form  of  streptothrix. 

\\\  irittTfsting  form  of  the  affection,  found  in  pigeons  and  transmissible 
to  man,  has  l)een  descrilje<l  by  Chantemesse.'  The  organism  at  work 
lurt-  is  the  Aspergillus  fumigatus.  We  have  found  this  also  coi.  aon  in 
(piite  yonnfj  chickens.  A  number  of  cases  affe<-ting  the  lung  in  man 
liavf  Ih'cii  rcjwrted. 

.\ii  oivanism  producing  a  rare  and  curious  disease  of  the  skin,  found 
m  .^oiitli  America  and  California,  alliiHl  to  blastomycctic  dermatitis, 
lias  Urn  known  to  invade  the  internal  organs,  including  the  lungsj 
PhhIik  ill;;  .('sions  resembling  those  of  tulx'rculosis." 

-^' "-'   'I'P  animal   parasites   that    mav   cause    pseudotuln'rculosis, 

«•■  may  nuiuion  the  eggs  of  the  strongylus,  which  have  \wen  foimd  bv 
■M  rxl.ii'  in  the  lungs  of  hogs,  sheep,  and  goats. 

Mnall,  (i.ad,  foreign  iMnlies  can  also  produce  notlules  if  they  enter  the 

'  Ma.ss.1  ami  .Mrnsi,  Hev.  HaumiJ.  JahresI).  :  l.S9.i. 

'  Wnile,  Zifjjicrs  Ht-it.,  32: 1902: 52ti. 

'  I.iibarsch  u.  ( ».st<'rta({  Ergobnisse:  1 :  1890:  7.'l3. 

'  (Vnlralhl.  f.  Bact..  17:  189.5:  83.5. 

'  Ziesicr's  licit.,  tl:  lS90:  287. 

'  .Jour,  of  Exper.  .Me<l..  3:  1898:  43.5. 

'  Ht'v.  Cemralbl.  .'.  I'ath.,  1 :  1890:  .581. 

'  <  •phuls  and  .Moffi--   Pliila.  Mwl.  .lour.,  .5:  19(10:  U71. 

'  .Munch,  iiml.  Woch.,  35:  1898:  lllK). 


318 


THE  LUa'GS 


II 


:  11 


lung,  as  has  been  shown  by  Cruvei'hier'  antl  Waldenbiirg.'    TulHTtles 
of  this  order,  due  to  coal  dust,  are  cpiite  common. 

Syphilis. — Syphilis  of  the  lung,  apart  from  the  congenital  form, 
is  rare,  and  does  not  always  manifest  itself  in  a  characteristic  wav. 
it  is  at  times  impossible  to  differentiate  it  from  non-specific  forms  of 
inflammation.  No  doubt,  many  of  the  cases  of  bronchitis  and  pneu- 
monia attributed  to  s_\-philis  are  more  correctly  to  be  regarded  as  com- 
plications or  examples  of  mixed  infection.  Syphilis  is  met  with  in  the 
form  of  gummM  and  diffuse  intentitUl  flbrosii. 

Gummas  are  rare  in  acquired  syphilis  and  arc  not  common  even  in  the 
lungs  of  newborn  syphilitic  children.  The  gummas,  which  are  usually 
quite  numerous,  when  present,  are  in  the  earlier  stages  grayish-red  or 
grayish-white,  somewhat  translucent,  and  form  nodules  of  all  sizes  up 
to  that  of  a  hen's  egg,  surrounded  by  an  area  of  congestion.  I^ter, 
they  undergo  a  process  allied  to  caseation  and  become  opaque  uliite 
and  more  or  less  walled  off  by  coiuiective  tissue.  The  contents  of  the 
granuloma  may  liquefy  and  be  discharged  into  a  bronchus,  or  apiin 
may  become  inspissated  and  calcareous.  Healed  gummas  an-  to  !« 
distinguished  from  old  tubercles  and  aliscesses  only  with  the  greatest 
diflBculty.  Clumnias  are  more  common  near  the  hilus  of  the  hnif;  than 
elsewhere.  Microscopically,  they  only  can  be  distinguishetl  from 
tubercles  by  the  absence  of  the  tubercle  bacilli. 

In  the  second  type  the  lung  becomes  the  site  of  a  more  or  less  dif- 
fused and  extensive  cellular  infiltration,  togi'ther  with  hyj)erplasia  of  the 
connective  tissue  and  proliferation  and  desf(uamation  of  the  alvi-oiar 
epithelium.  To  any  one  who  has  seen  the  extraordinary-  niinilier  of 
spirochietes  present  in  these  cases,  this  markeil  inflammation  is  not 
surprising.  The  alveolar  walls  In-come  greatly  thickcne<l,  and  iafjife 
areas  arc  converted  into  a  M>mewhat  fibrous  mass,  in  which  compressed 
air  spaces  and  groups  of  cells,  representing  the  proliferate!  and  des- 
(|uamated  epithelium,  can  be  n.-ognized.  The  blocxlvessels  ari'  thick- 
ened so  that  the  lung  is  pale  and  anemic,  an  appearance  that  has  jriven 
to  the  condition  the  name  of  "white  pneumonia."  Diffuse  pnrmiionia 
of  this  type  may  l)e  combined  with  giuiimas.  Virchow,  folhiwed  hy 
Pankritius,'  has  described  a  form  of  induration  starting  from  the  hihis 
of  the  lung  as  of  syphilitic  origin.  Dthcrs  mention  a  form  siaitinj;  from 
the  pleura  and  interlobular  septa.  Heuter'  has  demonstratcil  the 
presence  of  the  Spirochwta  pallifia  in  the  lung  of  a  ciiihl  ilyini;  of 
hereditary  syphilis  with  "white"  pneumonia. 

Actinomycosis. — This  disease  may  affect  the  lung  primarily,  iiut  it 
is  more  common  for  it  to  originate  in  actinomycosis  of  thi'  mouth, 
pharynx,  or  oesophagus,  by  inhalation  or  by  extension  from  the  anterior 
m<Hliastinum.  Occasionally  the  disease  is  metastatic,  as  in  a  la'-e  we 
saw  in  which  the  primary  lesion  was  in  the  liver. 

'  Traite  "Anat.  path,  gi"-!!.,  4:  lS<i2. 

'  Tulwrculosis.  Pulmonary  Phthisis,  and  Scrofulosis,  Berlin,  Isi.'i, 

'  I'el)er  LunRensyphilis,  Hcrlin,  ISKl. 

•  Zeit.  f.  Hyg.  u.  Infect.,  r,4;V.Hm-  4i). 


PARASITLS 


319 


Miilti|)l<  uHJiiles  of  11  iniliarv  t.v|)e  arc  mi-t  with,  or  there  mav  be 
laiyc  ana>  of  infiltration  formed  bv  the  fusion  of  several  >tranu!omas. 
Not  iMfrc(|iientiv,  the  affec-tion  eonfonns  to  the  type  of  a  bronchopneu- 
monia. Clinically,  the  tJisease  may  resemble  brr»nchitis.  there  beinj; 
a  (li-(liar>:e  of  fetid  muct>-pus,  containing  at  times  the  characteristic 
Niil  -hur  irrains."  I'mier  the  microscope  these  are  found  to  be  the 
speci  ic  ray-fungus.  In  more  chronic  cases,  signs  of  consolidation  and 
t-avitation  of  the  lung  may  Ix-  met  with,  so  that  the  disease  is  not  unlike 
chronic  tul)erculosis. 

In  the  metastatic  form,  the  lungs  are  riddled  wi.S  small  abscesses 
wntaining  creamy  pus  and  sum>undc«!  l,v  an  inh  mmatorv  areola 
When  young,  the  granulomas  are  grayish  or  gravish-red  in  color  and 
sumniiided  by  a  pneumonic  zone,  or  what  amount^  to  a  vascular  granu- 
lation tissue. 

In  long-standing  cases  the  nodules  arc  more  or  less  completely 
walled  off  b\  ^brous  tissue,  the  interlobular  septa  are  thickened,  anil 
there  are  all  the  signs  of  a  diffuse  fibrt)us  hvperplasia  with  alveolar 
catarrh  and  inflammatory  exudation.  The  lung  mav  eventuallv  be 
wnverti-d  into  a  contracted  no<lular  mass  full  of  cavities  and  riddle*! 
with  sinuses.  The  disease  occasionally  spreads  through  the  thoracic 
wall  an.!  mvades  the  pectoral  muscles,  or,  again,  mav  spread  through  the 
diaphragm  to  the  alMlommal  viscera.  The  mediastinum  and  pericardium 
arc  lial)le  to  Im-  involved. 

fflanders.— This  is  rare  in  man.  and  is  almost  invariablv  contracted 
from  annuals  suffering  from  the  disease.  The  affection  takes  the  form 
of  inultiple  cellular  nodules  of  a  grayish  or  vellowish-white  color  varving 
in  <ize  fr..m  a  nullet-scH-d  to  a  pea.  In  other  cases  ther^  is  IoImiV  or 
I'llmlar  pneumonia,  or  a  <liffuse  purulent  infiltration,  with  abscess  forma- 
mm.  I  he  affection  can  only  Ik-  recognized  bv  the  presence  of  the  mullein 
reiKtioM  .inring  life,  or  the  detection  of  the  B.  mallei  in  the  excretion 

Parasites.-  Apart    from    the    bacterial    fonns    alreadv   mentioned 
n      •';  '1«;  H-  tul)erculosis.  DiplcK-occus  pneumoiuR".  pvogeiiic  cocci 
K.  mallei    H.  anthrac-is,  and  the  Actinomyces,  vegetable'  parasite^  are 
rart'  and  few  of  them  are  of  importance. 

\arinM,  forms  of  mouhls,  .such  as  asjK'rgilli  an.l  the  thrush-fungus. 
Have  Urn  (leMTikHl.  1  hey  are  liable  to  Ije  found  wluwver  .lestruc- 
""II  "t  the  lung  substance  is  going  cm  or  where  there  is  stagnation  and 
'l'vnmp„M„„n  of  secTction.  Some  are  accidental,  while  others  must  be 
re^ir,.,  a^  pathogenic.    A  P„cumonom;jro.,h  a.pcr,,m!„„,  as  it  has  l^'en 

™"'  ''■;  .^I'/YV  *"';:  ,'>«'"  <iescrilH>.l  by  \-irc-how.  Dieulafov.  Chante- 

n  h.i.'lan.l  hy  Hoyce,  Arkel,  and  Hinds,  and  bv  Pearson  and  Ravenel' 


Pn.un:  ■M,-i,vci>>H  Asjiereillimi.  Jpna*l<H«). 

■  ttii  I.  ,  ir  1  :i<,K.rpllosc'  che^  Ics  animaux  et  chez  Ihommo.  1S<I7. 
In*   i'nl,  S)c.  I'hila..  new  scries:  HI:  I'.XK):  10. 
N.,™, ''"»''','"'■*"'"■  '^'■"'■'''  ""  Pulmonary  As,«.rgillosis.  .\lll,utt  an.l  Itolleslons 


i 


i 


If     !: 


320 


THE  LUXaS 


Tlu'  (li.MMist-  is  met  with  in  hinls,  honws,  hikI  cattle,  hiit  (Ht'n^ionallv 
nttncicH  iiiun.  The  lesions  pnNltieeti  resemble  tlicxse  of  tulK'niiJnsis  i.sw 
ulnne). 

Of  the  aniniul  parasites,  the  most  important  is  the  ErhiinHarrm. 
KehiniK-iH-c-iis  disease  may  In*  primary  or  swondary.  The  linij;  mav  lie 
inva(i«>(i  from  the  liver.  Karely,  infection  takes  place  throiijili  the 
hepatic  vein,  the  inferior  vena  cava,  and  the  rijjht  heart.  The  ( ysi  mav  lie 
sin^fle  or  multiple,  and  may  reach  the  size  of  a  man's  head.  The  cavitifs 
nre  fill(>d  with  clear  fluid  containing;  the  characteristic  luxiklris,  or 
a^iin  may  suppurate.  When  healing  takes  place,  the  Hnid  is  to  some 
extent  aKsorlKNl,  and  calcareous  deptxsit  may  take  place.  Occasioiiallv 
the  cysts  may  rupture  into  a  l)n>nchns,  the  pleural  cavity,  or  the  aixlornt'ti. 
nislcK-ation  of  the  neighlMiring  organs  is  likely  to  wx-ur. 

The  Cynticrrcun  relliiloxie  is  ran-.  The  Strnmjyliut  lotujiriKiimitM, 
ilonnn  lem,  CercnmoiKiit,  axvidia,  an<l  jtsorwi perms  have  iKt-ii  met  with. 

A  rare  hut  im[Nirtant  affwtion  is  that  calle<l  by  Stiles'  "  Viimqimi- 
mimi»."  This  is  due  to  a  tn-matotle  worm,  the  "lung  fluke"  or  I'ara- 
gonimus  Westermannii.  It  is  most  connnon  in  Asia  and  Africa, 
although  some  few  cases  have  lieeii  met  with  in  America.  Tlie  iliseasc 
affects  the  tiger,  cat,  ilog,  and  swine,  and  sixty-six  cases  in  man  have  Ijwn 
collci'ted  by  Stiles.    The  infection  is  prolwhly  through  drinking-water. 

The  most  striking  symptom  is  hemoptysis.  The  parasites,  wliich  liKik 
not  nnlik*'  small  almonds,  fix  themselves  hy  their  suckers  to  tlic  mucosa 
of  the  bronchi  anil  burrow  their  way  through  the  lung,  so  dial  a  scries 
of  intercommunicating  cavities  are  pnxluced.  These  may  (•ommiiiii- 
cate  with  a  bronciuis.  The  bronchi  are  much  inflamed  and  the  liirif; 
tissue  near  the  cavities  is  much  congestwi.  The  cavities  contain  liroketi- 
down  lung  tissue,  ova,  hematoidin,  and  the  parasites.  The  disease  tends 
to  run  a  chronic  course,     llei'overv  is  the  rule.' 


RETROGRESSIVE  METAMORPHOSES. 


Atrophy  of  the  Lungs.  — This  is  a  comparative!''  uiiiiii|Mirtant 
<'()i)dition. 

The  form  known  as  senile  atrophy,  sometimes  called  "atropliii  cniphv- 
sema,"  has  already  l)oen  n-ferred  to.  It  is  to  Ix"  regardc«l  a>  :i  physio- 
logical involution  rather  than  a  pathological  prcK'css.  Kiii|)hyseina 
may,  however,  be  assoc-iatetl  with  it,  and  is  generally  due  to  a  (•iiiiimiiitaiit 
<-lironic  lironchitis  which  is  found  in  so  many  old  jhtsoiis. 

Besides  this,  a  certain  aniDunt  of  1(m-b1  atrophy  is  found  in  a  varieK 
of  conditions,  such  as  emphysema,  atelwtasis,  and  indurative  jininnionia. 

Uokitansky'  also  recognizwl  a  form  of  atrophy  due  to  iiiaciivitv  of  the 
lung  in  cases  where  the  pleura  presents  marked  thickening. 


'  rroc.  Path.  Soc.  I'liila.,  I .  liruarv,  1001. 

'  For  iletuils  of  pathological  utiatotiiy .  .see  Katsiirada,  Ziegler's  IV'it  r . 

M^hrb,  3:  ISOl:  47. 


:',KK1:30«. 


PROr.RKSSlVE  MKTAMOHPHOSES 


321 


Degenentionf.— Pattjr  D«niMntiOB.~'rhi.<«  affects  chiefly  ihe  alveo- 
larptidiithflium  and  the  walls  of  the  bliioc  I  vessels.  It  Ls  fouml  in  pni.son- 
inj;  by  ars«-nic  atul  phusphonis,  aiMi  Ls  met  with  a.H  a  secondary  mani- 
ffstaiioii  in  a  jfn-at  variety  of  inflammatioas  ami  new-j^wths.  The 
ihanirt-  is  \n^t  w-cn  in  the  epithelial  cells  lining  the  air  spaces,  which  are 
•wollt'ii  and  desf{Uamated. 

HTtline  1  3(«i«ntioB.--Thi.s  also  affi-cts  the  alveolar  epithelium 
aiHl  the  waLs  of  the  lihxMlvessels.  It  Ls  fouml  chiefly  in  tuberculous 
;iii<l  >y|(liilitic  uffectioas  of  the  lunj;.  The  .soH-alled  corpora  amylacea 
have  Ix't-n  ref»'rn>d  to  elsewhere  (vol.  i,  p.  H4H). 

Amyloid  Dic^am.  This  is  singularly  rare  in  the  lunfjs.  Only  in  the 
riifht  ixtfiisive  c-<»mlition  of  disseminated  amvloid  dLsea.se  do  we  find 
ihe  \f>M-U  of  the  hinfr^  affj-^ted.  Occasionally,  in  ca.ses  of  .syphilis, 
wirli  imlurdtion  of  the  lnnjp<  and  marked  ..myloid  degeneration' of  the 
iirpiiis,  tlif  condition  Ls  met  with. 

Calcveooi  Deg«n«ration. — This  is  seen  usually  in  the  form  of  concre- 
ti(iii>..>lcl  tul)«>rculous  f(Mi,aml  in  tumors.  A  rare  condition  Ls  a  deposit 
if  lime  <alts  in  the  alveolar  walls,  l)l<MKlves.sels,  or  septa  of  the  lung. 
This  ha-  U-cn  uttrihuted  to  a  lime  nietastasLs,  where  the  blood  is  loade<l 
with  silt-  (ierivwl  fnmi  the  skeleton  (see  vol.  i,  p.  S.")2). 

Pneumoaomalacia.  — .\part  from  that  form  of  gangn-ne  of  the  lungs 
liif  ti.  i.iHainmation  or  to  the  germs  of  putrefaction,  there  is  a  form 
;iiial.><rims  to  myomalacia  of  the  heart  and  encephalomalacia.  Small 
;in-as  an-  -♦•cii  which  are  softened,  shagg\-,  and  nc<-rotic  looking.  The 
jiatihi-  liine  a  reddish-bn»wn  color  and  are  devoid  of  any  putrid  odor. 
The  ( (tiiilition  seems  to  l»e  a  simple  necro.sLs.  It  Ls.  of  c'lurse,  rare,  as 
will  rtailily  U-  uiidersfwxl  when  we  consider  how  easy  it  is  for  anv  dis- 
iwl  [xirtioii  of  the  limg  to  l)ecomc  infected  by  germs.  .Some  cases  are 
■liie  to  jiultiioiiary  eniiM)lism;  others  are  met  with  in  dial>etes. 


PROGRESSIVE  METAMORPHOSES. 

Hypertrophy.  ^  We  miLst  l)e  careful  not  to  conclude  that  becau.se 
'<  luriL'  i-  .iilarged  it  is  lu-pertrophic,  for,  unlike  other  organs  which 
t»loni'  to  the  >rnMip  of  epithelial  glands,  the  luii^  do  not  tend  to  undergo 
livpcnniiiliy.  Owing  to  its  anatomical  structure,  when  (mm  anv  cause 
a  |x.ni.>ii  „{  the  lung  is  rendered  functionless.  the  rest  Ijcctjmes  eiilarged. 
It  i>  trii.'.  y.t  not  from  hypertrophy  but  from  emphysematotts  dilatation 
't  the  air  -pares.  Still  the  lung  does  .seem  to  have  a  certain  amount  of 
r-nemnitiNe  power,  for  cases  are  on  record  where,  in  the  event  of  com- 
plete at  r..|.hv  of  one  lung,  the  other  enlarged  so  much  as  to  fill  not  onlv 
''!ie  ph  iiml  cavity  but  to  encroach  upon  the  other,  and  this  in  the  absene^ 
"f -uft.  iMit .  inphysema  to  account  for  the  enlargement. 

B^i'ip  iliis  fonn.  which  is  rare.  h>-pertrophy  of  the  miLscle  fibers 
'  ""If  '  ■  'UUiWi'T  bi^>tKhioIes  has  \yeen  obscn"i-«l  in  ca.si\s  of  i)rowii 
iiHlurari. .  ,(  ,i,e  lungs.  This  Ls  pmliably  to  be  attributed  to  the  catarrh 
"  the  hr,,:<hi,  which  Ls  asually  present  in  such  cases  and  should  be 
'ia»^|  u  :ri;  ;h^.  hvpertrophies  due  to  increased  work, 
.'1 


322 


TIIH  WXdS 


miA 


Tumort.— Primary  tumors  of  the  \ium  art*  compsrativclv  rarr. 
AnioiiK  tht>  Ikmukii  p^wth.s,  ftbromM,  Upomai,  ehondromu,  uixl  oitMmu 
have  Inrii  olwervwl.  Not  all  the  eases  reported  as  "osteomas,"  iKmcvtr 
are  to  In-  ref^anletl  as  true  tumors.  Many  are  examples  of  ussificaiion 
(levelopin)(  in  hypeq)lastie  eoiiiieetive  tissue  arising;  from  chronic  iiiflam. 
mution  (metaplasia).  Hil>lM-rt  has  deserilMtl  assification  in  cwmm 
an-as,  and  we  have  met  with  the  same  i-ondition  ourselves,  ('art-  shoiiM 
also  Ite  taken  not  to  confuse  the  ealeifieation  that  takes  place  in  old  tiilirr- 
eulous  and  other  inflammatory  f(K-i  with  tumor  formation.  ('Iiitiidnmia 
is  also  Hire  and  ari-ses  fn)m  the  Sronchial  eartilaKes,  and,  imhsIIiIv, 
from  emhryonie  "n-sts." 

D«niioida.  I  )emioids  are  (H-casionally  met  with.  AIInts  has  dcscriU'd 
a  ease  in  which  ther«'  was  a  j-ystic  tumor  c«inmiunicatinK  with  a  l>n>n(liiis. 
For  years  hairs  were  discharfi^-<l  in  the  sputum. 

AdraoiM.  -  Adenomas  derived  from  the  perihn>nehial  nnicons  jtiaiKls 
have  In-en  dcscrilK'«l  hy  Chiari,'  hut  aiv  very  rare. 

Ssreonu. — Primary  sarcoma  is  al.so  rare.  Iian)(laret'  has  ni-onled  a 
case  of  spin<ile-cellt*<l  .sarcoma  of  the  left  lung,  and  Reymonil'oiit'of  the 
n)un«l-ccllc<l  variety.  Ltfinphimtrvomn  is  not  .so  uncommon.  Ix-ns  fre- 
(|uent  are  the  cases  thut  arise  in  the  mediastinal  tissues  and  the  lymph- 
glands  at  the  r<H)t  of  the  lung.  It  is  interesting  in  this  coinu'ctioii  to 
note  that  chronic  irritation  from  <-ertain  kinds  of  dust  .seems  to  Ih'  an 
exciting  cause,  for  Ancke*  has  |)ointe<l  out  how  fre<|uent  sarcoma  of 
the  lung  is  among  the  miners  of  the  Schneelwrg  district.  \cry  intt-nst- 
ing  and  important  ar*-  th«).se  new-growth.s — the  eniiothrlloimix  that  an' 
intermediate  in  strui-:  l)etween  the  sarcomas  and  the  ciini nomas. 
They  <lev  lop  sup.  i  fir  :,  In-neath  the  pleura,  orat  the  hihis  of  tin- Imij: 
in  the  lymph-<hannels.  The  ai)errant  growth,  however,  s(H)ri  jmis-k^ 
In-yond  the  lymphatic  ve.s.sels  and  invades  the  adjacent  tissues,  forming; 
larger  or  smaller  ncxlules,  arrangeii,  in  some  cases,  alM)Ut  the  l>n)iKhial 
tree  like  a  string  of  lR>ads. 

A  very  rare  form  of  primary  gmwth  is  the  simple  melanotic  tnmoi 
(tumeur  melaniipie  simple)  descrilx-d  by  Cornil  and  Uaiivicr,'  whidi 
may  take  on  malignant  action. 

Oareinoma. — Primary  carcinoma  of  the  lung  generally  affects  In  prefer- 
ence the  right  side,  and  is  either  nodular  or  diffase.  Then-  nre  thm' 
main  types,  in  which  the  new-growth  starts  from  the  hnwichi,  the  alveolar 
epitlieliimi,  or  the  p'rihn)iichial  mucous  glands.  The  first  form  i< 
compose«l  of  columnar  cells,  while  the  .second  is  made  up  of  Hattemil 
plates  in  which  celUnesLs  may  .sometimes  Ik-  .seen.  It  is  clianicteristic 
of  careinomus  in  this  situation  that  they  rea«lily  .soften  or  iKt-oiiif  heiiicir- 
rhagic,  so  that  they  are  not  unlike  ca.seoiLs  tul)en'ulous  masses.     In  sueli 

'  ViTHcliicilcnr  Ti'inori'ii.  I'mncr  iniil.  Wooh.,  ISS.'l. 

'  Mill!.  (Ic  l;i  MOO.  aiiiit.  lie  Paris.  S»t.  V :  Turn.  VIl ;  Kasr.  22:  |>.  .V.l! 

^  Ihi.l.,  p.  2.'>li. 

*  Uisnert.  Miincli.,  1S«4. 

'  Tiiineurs  meianiqucs  simples,  Manuel  d'hiHtol.  path.,  2:  IHS2:  I  I". 


CARCIXOMA 


323 


cases,  when  tho  <-nn(rnU  an*  (ILscharKnl  through  a  hruiK'hiu,  ravities 
an-  thf  ifsult      Mftastates  appear  to  lie  relativply  inrn>«|iient. 

SeiiMMlary  growths  are  miirh  more  pommon.  ami  are  generally  due  to 
mali){nurit  emiNili  that  get  into  the  venous  cireiilation,  an  event  that 
««silv  (K-curs.  The  first  to  Im-  nientione<l  is  the  rhoudroimi,  which, 
when  foiitMl  in  the  lungs,  is  m-arly  always  si-eorMlary.  Oirteitld  chondromtu 
myximii*,  lipimyxomu,  have  also  l)een  met  with.  Besides  the.se  are 
ihewmowM.  including  pigmenttnl  forms,  and  all  varieties  of  mreinonuu. 
In  the  <a.s«-  of  the  latter  the  primary  .seat  is  nearly  always  in  the  stomach 
or  tnanuna.  An  interesting  and  not  uncommon  form,  in  our  experience, 
of  secondary  caninoma  is  that  in  which  small  canceroas  nodules  are 
formed  along  the  course  of  the  pleural  lymphatics,  .so  that  a  distinct 
network  is  produced. 


U  '■ 


CHAI'TKIl    XIV. 


THK  IM.Kl U.K. 


Hi 


f 


TilK  pk'unc  an-  siu-s  (iMniH)^*-!!  of  a  lliiii,  nith«T  1«mis«',  cniintiiivf- 
lissiir  ini-iiihranr,  ('oiituiiiinf;  iiiimcniiis  hliMNlvcsHt-ls  anil  i-lasiii  lilirillii'. 
Thi'V  an'  <'(ivi'r»'<l  \t\  a  siiij;!*-  la_v«T  of  flattfiu-<l  inoiKiiiiiilcar  kII,  tin 
eiiilotht'liuin.  Tlu*  pU'iiriv  an-  not  vitv  lialtlc  to  Ik-  affcctitl  hy  |iriiii;ir\ 
(li.st'us*-,  liut  owin^  to  tlu'ir  <'los«'  assiM-iation  witli  tli<-  \\\i]fi>  urc  frc- 
(|U(>ntly  inv(>lvi>«l  hy  contiKiiily  or  t-xtcnsion.  Not  only  so,  luit  iiiasnuicli 
as  tlif  pli'unil  .sacs  arc  lyinpli-spaccs  having;  ctiniinniiicaiinn  iiKirr  nr 
less  clos<>ly  with  the  |MTicanlial  and  |H-ri(oncal  cavities,  intliiMiinalnrv 
|iriK'css«'.s  originating;  in  cither  of  tlu-sc  rcpons  readily  cxtcml  in  tln' 
|>lcnra>.  Disea.sc,  therefore,  of  the  lun^s,  |M>ril)ron<-hial  and  iin'iiiii^tiiiiil 
f;lands,  u-sopha^ns,  aorta,  thoracic  duct,  stomach,  liver,  and  tliiira<'ii' 
wall  may  rapidly  involve  the  pleura-.  Conversely,  lesions  of  tin-  |)|(iirir 
may  exten<l  to  tlx-  contiguous  parts.  In  the  disseniination  nt'  iljsia^r 
the  inoveinents  of  the  ineinhrane  incident  to  respiration  play  an  iiii|«irtiiiil 
part. 

ANOMALIES  OF  DEVSLOPMENT. 

Perhaps  the  most  common  anomaly  is  an  infolding  of  tiir  mriiiliraiii' 
at  the  upper  part  of  the  <'avity  assiK-ialed  with  the  a|>ical  fis^inv  dF  tlir 
lunjj  iK'fore  refernMl  to.  Alonj;  the  free  lM>nUT  an  alinonnal  ,i/\i.'ii^  viin 
fre<piently  runs,  i'artial  defect!  of  the  pleunv  are  found  a^scK  iaidl  with 
congenital  diaphragmatic  hernia.  In  monstrous  Itirths  the  |)lc'iira  iiiav 
Im>  absent  altogether  or  redundant,  in  the  rare  conp'nilnl  iniphynf 
the  Inn);,  the  pleural  cavity  may  Im-  Hlletl  with  fat  mixed  \mi1i  ,i  iiiiicnid 
connc-ctivc-tissut-  substance. 


OIBOULATORT  DISTURBANCES. 

Hyperemia.  Active  Hyperemia.  Active  hy|H-remia  iiinuN  as  mi 
accompaniment  of  congestion  of  the  lunj;  pn>|M'r,  and  mI-h  I'nuri  a 
sudden  relaxation  «)f  tension,  such  as  takes  place  ilnrinj:  ilir  ii|Hraiioii 
of  thoracentesis.  In  the  latter  event  the  vc-mIs  not  infn'i|iiriiily  ;;ivr 
way  and  hemorrhaj;e  results. 

Pusive  Hyperemia.  Passive  hyperemia  is  found  in  all  T  in-  i>f  fli- 
strnction  to  the  fjreatcr  or  lesser  circidation. 

Hemorrhages. — Multiple  lipmorrhaj;es,  ecchymoses,  u\u\  iicifchia' 
art?  common.    They  are  found  especiully  in  cases  where  tin  n  lias  Utn 


I'SKVMoTllnH.XX 


:v2^ 


marknl  inU-rfrn'mf  willi  M-Mpinilion,  iw  in  di-utli  l>y  siiff«»tatMMi.  Sim- 
ilar iiijiiiiftslnlioiiH  urt'  ii«t  with  in  kidnty  tiiul  iMiIrt  affMtioiw,  in  fhc 
inffiiiiiiis  and  into.xiiution.s,  ncnou.s  cii.stu<i«'.<*,  ami  in  the  hcniorrliaKic 

(liilllK'SCS. 

ddema.    <l<xJi>tnu  of  the  pU-ura  is  indiMtiiiguishahly  a.s.H«icia«ecl  with 
(rdi'tiiii  uf  the  Imif^H. 


ABHOIMAL    ITATU    OF    TBI    PLIUIAL    O.VniIS. 

Hematothor»x.~^-\Vhfn  l>l(io<l  is  effused  into  the  pleural  cavitv,  the 
(iMiiliiioii  is  lullcsl  heinatuthonix.  It  is  .somewhat  rare  for  the  sae  to  eon- 
laiii  pure  hicMxl,  for  the  fluid  is  >{enerally  mixwl  with  transudation  or  the 
pnidiK  ts  of  inflammation.  The  afft-c-tion  is  liroujjiit  alniut  hy  ruptun- 
cf  iIk'  vessels,  uiid  is  not  infntjuently  met  witii  in  rupture  of  tulx-reulous 
anil  triiiinretious  cavities,  in  certain  fonns  of  inflammation,  and  in  carei- 
iKHiia.  <  )flicr  caii.s«'s  that  should  Ih'  meiitii>r  -^l  are  the  bursting  oi"  an 
aiuuriMu  into  iIm-  cavity,  fracture  or  ca-'       'f   he  rihs,  and  stah  wound.s 

1)1  till'  (ilf.St. 

Hydrothorax.-  Hydrolhoni.\  is  a  c ,f  transude*!  fluid  in  the 

pleural  ciivity.  This  oicurs  hy  prefei.  -c  on  tlu-  rijjht  si<le,  although  it 
iiiay  !«■  I.ilatcral.  The  reason  for  this  is  .said  to  Ik*  that  most  people 
liouiMMi  ilic  ri>,'h(  siile,  or  else  that  fli.-re  is  pressun>  of  a  distended  right 
laart  on  tli<-  veins  of  that  side.  When  pleural  ailhesion.s  are  pre.sent, 
the  ctfi^ion  may  Ik-  sacculatc*!. 

Tiic  lliiid  is  usually  pale,  s|i-.iw-<()lor«-<l.  alkaline,  the  sjM-cifie  gravity 
yarviiij;  1,.  twcen  l(KK»  and  1012,  or  a  little  higher,  and  conudns  no  flakes. 

^'"'  '" ""  "f  albumin  varies  fmm  2.7S  jxt  cent.  (Hop|)e-wSevler)  to 

4.07  ...  f  (viit.  (.Shen-r).  MicroMopicutIv,  there  are  a  few  leuk(Rvte.s 
ami  ..Min.niiat.sl  cells  from  the  pleural  endothelium.  The  pleural 
siirfi-.r  i>  still  siiuH.th,  but  may  Ik-  slightly  .scxiilen,  and  in  long-standing 
•"IMS  tl„.  membrane  l)eeomes  turi>id.  in-arly,  aii.i  somewhat  thickenetl, 
ottiiii;  lo  r.vcrgrowtii  of  the  comiectivc  tissue.' 

Small  (|iiiiiitities  of  fluid  may  Im-  jxmred  out  into  the  eavitv  <hiring 
ilii'  cicaili  agony,  but  the  larger  collwtions  are  found  in  nephritis,  un- 
wiiipiiisiKd  heart  lesions,  laxlular  cirrhosis  of  the  liver,  hvdremia,  and 
poisoiiiii;;  with  (jirljoii  mono.xide. 

Chylous  and  Puudochylous  Hydrothorax.-Chvlous  and  pseudo- 
(  u  (Mi>  liy.ln.thorax  are  due  to  rupture  or  .)l).struction  respectively 
oftlie  tlioracic  duct  aUne  its  |)oint  of  entrance  into  the  pleural  cavity. 
1  If  HiM.l  IS  opaque,  milk-white,  and  contaits  granules  and  lymph 
MK    Im  (liyloiis  fluid  fat  globules  are  also  present. 

!Miiall  <  c.ll.rtions  of  fluid  in  the  thorax  are  of  no  significance,  but  the 
arKiT..,,, ,  |,,„1  ro  compression  and  eoll;,ps,>  of  the  lung  and  dislot~a- 
"""iif  III.  iaiglilM)ring  structures,  such  as  the  heart  and  diaphragm. 

mumothorax.-\Vhen  the  pleural  cavity  contains  air,  the  condition 
Merin,.,!  |.i„..iinothorax.  Owing  to  the  nature  of  the  e.xciting  causes,  the 
anettioi,  h  accompanied,  m  the  vast  majority  of  cases,  by  inflammation, 


f-l       \ 


320 


THE  PLEURM 


so  that  the  cavity  contains  scruin  or  pus  aa  well  as  air  {hijdrnpnvumh 
thorax,  pyopinimothitrax).  Pneumothorax  is  rare  as  a  prirnarv  dis- 
ease, ami  is  usually  «lue  to  a  lesion  of  the  lung  or  pleum.  The  most 
frequent  cause  is  the  rupture  of  a  tulx'n-ulous  fix-us  in  the  lun>;  diiriiii; 
cough  or  other  strain.  Occasionally,  it  follows  the  ruptun>  of  a  gan- 
grenous or  suppurating  area.  It  is  said  that  it  may  also  lie  cauwil  hv 
the  giving  way  of  an  emphysematous  bulla.  It  may  l)e  reganlcd  as 
certain  that  it  never  occurs  from  the  rupture  of  a  healthy  lung.  Air  mav 
also  enter  the  pleura  as  the  result  of  stab  wounds  of  the  chest,  fractuwi 
ribs,  thoracentesis,  or  from  the  stomach,  a>sophagus,  and  bowel.  In  the 
last  case  the  usual  condition  found  is  a  malignant  growth  in  the  visciis 
which  attaches  it  to  the  diaphragm.  An  empyema  may  also  ennle  its 
way  into  ihe  lung  and  discharge  into  a  bronchus. 

Pneumothorax  «lue  to  perforation  has  been  divided  by  Weil  into  three 
varieties:  (1)  Open  pnenmothoru,  in  which  air  passes  freely  in  and  out. 
(2)  Ventiktad  paenmothonx,  in  which  there  is  an  oblicpie  or  valve-like 
opening,  so  that  air  enters  readily  but  cannot  escape.  (3)  OIoMd 
pnenmothoru,  where  the  opening  has  become  cx-cludetl.  In  nianv  cases 
the  fistula  becomes  closed,  and  at  autopsy  it  is  frequently  impossible  to 
find'  the  point  of  rupture. 

Laennec  was  |)erhaps  the  first  to  describe  pneumothorax  without 
perforation.  Although  for  .some  time  doubted,  it  is  now  abundantly 
demonstrated  that  there  is  such  a  thing  as  non-perforative  or  euentiil 
pneumothorax,  caustnl  by  the  growth  of  ga-s-pniducing  microorftunisms 
in  the  pleura.  ('a.ses  due  to  the  B.  coli  have  In-en  rec-orded  by  H.  Mav 
and  A(iolf  (Jebhart,'  and  in  other  cast-s  the  B.  Welchii  has  iMH-n  found]' 

The  result  of  pneumothorax  will  depend  very  much  on  the  cause  and 
on  the  persistence  or  otherwi.se  of  the  communication  with  the  outer 
air.  So  long  as  the  fistula  remains,  the  lung  is  completely  collapsed 
unless  this  result  lie  prevente<l  by  the  presence  of  adhesions.  In  case.s 
where  a  valvular  opening  is  present,  the  pleural  cavity  liecomes  j;railually 
inflated  with  air,  .so  that  the  lung  is  c-ompre.s.se<l,  the  heart  pushed  over 
to  the  opposite  side,  the  diaphragm  <lepresse<l,  and  the  whole  side  of 
the  thorax  distended.  In  cases  of  pneumothorax  without  infection,  the 
wound  may  close  and  the  air  is  then  gradually  alxsorlx-d,  so  that  llie 
lung  resumes  its  normal  condition.  A  fnhe  pneumothorax  is  nut  with 
post  mortem  owing  to  seIf-<ligcstion  of  the  walls  of  the  stonnich  and  the 
diaphragm  and  a  con.se<]uent  di.seharge  of  gas  into  the  pleural  cavitv. 
('a.ses  with  -serofibrinous  inflammation  or  empyema,  pnividiil  they  arc 
cure<l  at  all,  generally  leave  traces  in  the  ,shapc>  of  pleural  thicl;<iiiii):  and 
adhesions. 

lOTLAMMATIONS. 


I  >' 


Pleurisy. — Inflammation  of  the  pleura  (ptouiisy  or  pleuhtisi  is  only 
orrasionally  n  primary  infection,  and  usually  originates  in  (lipase  I'f 

'  I)eut«.  Archiv  f.  klin.  Med.,  61  :  1898  :  323. 
»  NichoUs,  Urit.  Med.  Jour.,  2  :  1897  :  1844. 


EXUDATIVE  PLEURISY 


327 


the  Iiinj;  or  the  n(>i)(hlM>rin|r  cavities.  The  tvpo  »f  <Iisea.sc  varij-s  coii- 
sklcniltly  ivcconling  to  the  nature  of  the  infeetiiif);  ai^nts.  These  are 
almost  invariably  bacterial,  since  the  lung,  «iwin>t  to  its  association  with 
(Ik  outer  iiir,  always  contains  bacteria.  Pleurisy  may  Iw  partial  or 
roraplftf,  the  exudate  free  or  .sacculated.  Frecjuently,  pleuri.sy,  par- 
ticjlarly  when  left-sided,  is  combined  with  pericarditis.  It  is  iiot  un- 
common also  for  several  serous  membranes  to  be  progressively  involve*!, 
a  condition  for  which  certain  Italian  observers  have  propose*!  the  term 
"polyorrhomenitis."  According  to  Taylor,'  the  course  of  involvement 
of  the  Mirious  serosje  is  as  follows:  (1)  Peritoneum  involve<l  first  with 
extension  to  the  pleura,  usually  the  right;  (2)  the  pleura,  then  the  peri- 
toneum; (3)  the  pleura  of  one  side  and  then  of  the  other;  and  (4)  one 
pleura,  then  the  peritoneum,  and  finally  the  other  pleura.  According 
to  the  course  of  the  inflammation,  we  may  recognize  exudative  and  pro- 
ducUtr  pleurisy.  These  fonns  may  exist  independently  but  it  is  not 
uneoumu)n  for  exudative  pleurisy  to  develop  into  the  productive  v»riety. 

Exudative  Plenriiy. — Exudative  pleurisy  is  met  with  oc-casionallv  in 
persons  of  low  vitality  or  as  a  manifestaticm  of  the  rheumatic  infection. 
It  is  vcrv  common  in  pneumonia,  tul)en-ulosis,  infarction,  an«l  in  new- 
prowtlis. 


Fill.  HI) 


Vtii-  -,,..i,l,r„„,„.  pleurisy.  Zuss  .,l>j.  ni).  nrular  Nil.  1.  Idling  .triiiiil*  i.f  .nl.rin.  l)elwwn 
•ii'ii  irill.riimitory  Ipukiifytei.  art-  piiiupkIipiI,  tar  well  wen  on  the  surfaic  nf  (lio  Iumk.  (Knim 
ilif  lalli.l.  ,.,  ul  l.:il»,mti,ry  „f  Mi'Cill  rniv<Ti.ity.) 

llie  iXMiiatioii  nuiy  Ik-  fibrinous  (plavic),  serofibrinous,  fibrino- 
piiriiltiii.  |iiinilcnf  or  hemorrhagic. 

'  »riti»li  MeUicul  Journal,  2  :  1900  :  1«»3. 


328 


rilf  PLEUUJB 


m 


nbrinotu  Pleuiiiy.—  In  tin-  jUmnoiui  form,  or  wimt  is  .suinctinicN  calli  i| 
"dry"  plfurisy.  the  pltMirti  is  <)ptt<|iio,  slii,'luly  turbid,  and  upon  it  is ;, 
d(>lii-ute  layer  of  fibrin  which  vm\  reiulily  Ik-  scrufMHi  off.  Microsc.>|)i(al|v, 
the  pleura  is  <wleniatous;  tiie  vessels  of  the  pleuni,  IkHIi  bhxKl  arid  ivn'^ 
phatie,  and  the  sui>jaeeut  layer  of  the  Iiui};  are  eon^estjil,  wiili  sotia. 
perivastiilar  leukueytasis;  not  infre(|tiently  meshes  of  fibrin  ean  be  made 
out  within  the  layers  of  the  eonneetive  tissue  of  the  pleura.  Ipon  th,. 
.surfuc-e  the  exudate  is  seen  to  eonsist  of  delicate  interlacing  fil)rilla.  of 
fibrin  with  .some  leukocytes.  Oci-asionally,  the  fibrin  is  fuse«l  toj^Ttlicr 
into  hyaline  n)as.ses.  By  appropriate  methods  of  staining,  Iwctcria  iiiav 
Ih?  demonstrated  in  the  exudate.  In  the  early  stajjes  it  is  not  alwavs  ea.sv 
to  detect  the  presence  of  pleurisy,  since  then-  may  be  merely  u  trifliiij; 
cloudiness  and  turbidity  of  the  membrane,  but  in  more  advancinl  cases 
the  fibrin  forms  a  definite  layer,  even  amounting  to  a  membrane. 

Seroflbrinous  PUurisy.— Very  few  pleurisies  remain  «lry  for  loiip  and 
there  is  usually  a  more  or  less  abundant  outpouring  of  fluid  into  the 
cavity  (serofiln-inowi  pjeunntj).  The  .senim  exudetJ  is  of  a  yellowish  color, 
clear,  or,  if  mi.xetl  with  cells,  somewhat  turbid.  The  fibrin  is  usiiallv 
abundant  in  the  fi.ssures  of  the  lung  and  in  the  dependent  or  ixtstcrior 
portions  of  the  pleural  cavity.  It  is  often  curdy,  whitish-yellow,  and 
forms  shaggy  masses  adhering  to  the  lung  and  thoracic  •walls.  In  many 
ca.ses,  Uxxse,  friable,  rather  gelatinon.s-looking  cK)ts  art>  produced.  The 
amount  of  exudation  varies  from  a  few  cubic  centimeters  to  sevcrul  liters. 
The  specific  gravity  is  almast  always  above  1025.  The  fluid  coajjidates 
readily  on  the  application  of  heat,  and  often  spontane()iislv'"\vhen 
removejl  from  the  Ixxly.  The  exudntion  differs  from  the  fluid  of  hvdn)- 
thorax  in  In-ing  of  higher  .specific  jTavity,  containing  more  albumin',  .rui 
also  more  uric  acid,  cholesterin,  ami  sugrir.  Micro.scopicallv,  it  contains 
leukoc-ytes  and  bliMxI  c-ells,  bacteria,  somewhat  swollen"  endothelial 
cells,  and  shreds  of  fibrin. 

UTien  the  effusion  Ls  large,  the  lung  is  more  or  less  completelv 
compressetl  and  atele<'tjitic,  lying  in  the  upper  part  of  the  pleural 
cavity  clase  to  the  spine,  unless  previously  existing  adli<"iions  limit 
its  movements.  When  free,  the  fluid  moves'  on  posturing  the  patient. 
The  airle-ss  j)ortion  of  the  lung  is  tough,  lacks  crepitation,  and  is  of 
a  dull  gray,  grayi.sh-brown,  or  blue  black  color.  The  heart  may  l)e 
dislocate*!  to  the  side  and  the  large  thoracic  vessels  compress  d.  The 
diaphnigm  is  depre.sse<l  and  the  intereostal  spaces  may  Imlire.  In 
large  right-.sidi>d  effusions  the  liver  is  pushed  down.  When  liealing 
takes  pla(r,  the  fluid  |M>rtions  are  absorlxnl  by  the  lyujplmtics.  ilie  (il)rin 
breaks  down,  In-coines  granular,  and  in  its  turn  i.s  carricil  nit.  I'hus, 
few  signs  «)f  tmuble  may  remain,  except  jxxssibly  a  slight  ihiikeninj; 
()f  the  pleura.  Xot  infrtniuently,  the  connective  "ti.ssue,  li(»«(  \er.  pro- 
liferates, grows  out  into  the  fibrinous  layer,  and  leads  to  adhesion  of  tliose 
parts  which  are  in  contact.  The  union  is  at  first  intiniair.  l.iit,  as 
the  lung  regains  its  function,  the  adhesions  are  pulie»l  upcii  mi  that 
velamentous  stran<ls  are  pro(iuce<l.  These  are  very  eoniinonlv  found 
between  the  lolies  and  about  the  upper  lobe  posteriorly.  The  ,i  lliesions 
may  \w  partial  or  lead  to  complete  obliteration  of  the  pleural  ^p.ae. 


CHRONIC  OR  t'RfJUVcriVt:  I'LEI'RISY 

Pnnilent  Plenriiy.— Serofibrinous  pleurisy  o<x-asioimllv  ilevelops  into 
a  purulent  or  filtrinojnindent  one  (rmpi/c'mn).  Here  the  exudate  is 
mor.'  cloudy,  yellowish,  and  contains  aburKjimt  leiikwytes.  There  Ls 
often  iiiort'  or  less  fibrin,  but  it  temls  to  diminish  lx>th  absolutely  and 
relatively,  as  lioth  less  is  prcxlueed  an«i  what  is  present  Ls  gradually 
digested  by  the  action  of  the  pas  corpuscles.  Empyema  is  rarely  a 
primary  affection,  except  in  children.  It  sometimes  Ls  met  with  in  pneu- 
monia, especially  that  form  due  to  influenza,  but  occurs  perhaps  most 
commonly  from  the  rupture  of  a  tuberculous  cavity  in  the  pleura  or 
follows  abscess  and  gangrene  of  the  lung.  A  subdiaphragmatic  abscess 
may  discharge  into  the  pleura  as  well  as  cancerous  or  other  ulcers 
of  the  .esophagus,  stomach,  or  bowel.  When  putrefactive  germs  are 
present,  the  pus  is  often  dark  colored,  decompased,  and  verv  foul  smell- 
ing. .•^ome  of  the  bacteria,  notably  the  Diplococ-cus  pneumoniffi  and  the 
B.  typhi,  which  usually  poMluc-e  a  simple  inflammation,  are  competent 
to  pnxiuce  pus,  either  from  an  increase  in  their  virulence  or  a  diminution 
in  the  resisting  power  of  the  patient.  As  a  rule,  however,  when  a  simple 
pleurisy  l)ccomes  purulent,  it  is  due  to  secondary  infection  with  pus- 
prod  iitiiig  organisms. 

Iniess  relieved  by  surgical  interference,  the  <-on.sequences  of  empyema 
are  apt  to  be  serious.  The  patient  may  <lie  of  exhaustion,  am  vioid  disease, 
or  septicemia,  or  the  pas  may  burrow  through  the  lung  and  d'ischarge  into 
a  bronchus,  with  the  formation  of  pyopneumothorax.  The  pus  may  also 
disse*  t  its  way  beneath  the  parietal  pleura  and  point  externally,'  thus 
finally  discharging  (empyema  necenaitutis).  The  usual  site  for' this  is 
near  the  lower  end  of  the  ste:  num.  The  pus  mav  also  discharge  into 
the  o-sophagus,  stomach, peritoneum,  pericar»liuin, or  nmliastinum.  Em- 
pyema, as  a  rule,  unless  recognize«l  and  treated  earlv,  usually  leads  to 
peat  tliK  kening  of  the  pleura  and,  in  pn.tracted  cas^s,  to  deformity  of 
the  ( hcst.  In  some  cases  the  pleura  IxHomes  so  infiltrated  with  lime  .salts 
that  It  IS  converted  into  a  dense  calcareous  cuirass. 

HemoiTlugie  Ptouriiy.— Hemorrhagic  pleurisy  is  not  rare  as  a  secondar\' 
fompliiation.  It  is  found  in  debilitated  p^rsoas  or  thase  suffering 
from  -cMrvy  and  the  hemorrhagic  diathesis.  It  is  common  in  tuber- 
(Ulos,.  and  carcinoma  of  the  pleura.  In  one  variety,  which  is  strictly 
ronipanibic  to  pachymeningitis  hemorrhagica,  there"  is  a  formation  o'f 
a  va^  iilar  granulation  tissue  upon  the  surface  of  the  pleura 

Chronic  or  ProdnetiTe  Plenriiy.-Chn)nic  or  prxHluctive  pleurisy  is 
ivmmun.  It  may  exist  as  a  late  manifestation  of  an  acute  simpl'e  or 
purul.„t  ir.Haniniation.  or  may  begin  insidiously  as  a  primary  affection 
with,.,,,  exudation.  The  comlition  leads  to  great  thickening  of  the  pleura 
»m>  n,„r,.  or  less  extensive  adhesions.  The  lung  is  coated  with  a  firm 
»niti-ii  nr  whifish-gray  membrane  which  mav  Ik-  one  or  more  centimeters 
"lick,  Alurosc-opically,  it  is  composetl  of  somewhat  interfacing  fibrils  of 
"'""""'';  '"■*»♦'  *"h  areas  of  coagulation  necrosis,  and  in  the  dwper 
uvT.  .1. « Iv-formed  capillaries  and  perivascular  leukocytic  infiltration.  In 
^me  c.„  s  the  membmne  is  very  thick,  pearly  white,  ktid  of  a  firm  carti- 
"•^nou-  .. insistence  {Zuckergms).    This  form  is  rar*  as  a  primary  dis- 


i 


I' 


330 


THE  PLKVR.F. 


hi 


1 1  ' 


'w ;  i 


ease  of  the  pleura,  but  usually  is  due  to  a  chronic  inflammation  extciKlini; 
from  the  peritoneum  or  from  the  |N>ricanliuin.  Kawnhacli'  has  iMiintcd 
out  that  chronic  pleurisy  may  cxten<l  to  the  liver  capsule  causiii);  con- 
traction of  the  orfnan  and  to  the  pericardial  sat-,  which,  in  time  iKcotnos 
obliterated.  The  cartila^^inous  appearance  is  due  to  extensive  hvaline 
degeneration  of  the  connective  tissue.  In  such  ciuses  the  luiif;  nsiiallv 
shows  some  atrophy,  but  when  adhesions  have  not  taken  place  it  nmv 
be  considerably  i-ontracte<l  and  deforme<l.  In  other  ca.ses,  partii  ularlv 
those  connected  with  pneumonia,  the  lung  itself  participates  in  the  pri). 
liferation  and  l)ecomes  imlurated.  In  long-standing  ca.ses,  cuicarcoii.s 
masses,  and  even  plates  of  cartilage  and  Ixine,  are  formetl  in  the  pleura. 
The  di.sea.se  has  been  known  to  follow  simple  pleuri-sy  and  tulHTciilosis. 

TabercnlosiB. — Exceptionally,  tuln-rculosis  of  the  pleura  is  met  with 
as  a  primary  manifestation  without  discoverable  di.sea.se  elsewlicrr. 
Such  ca.ses  are  difficult  of  explanation,  but  the  Imcilli  probably  rtarh 
the  sac  through  the  blcMnl-stream  or  the  lymphatic  .system.  A  coiiimon 
form  Is  that  in  which  the  pleura  is  affecte«l  as  a  part  of  a  general  niiliarv 
dissemination  of  the  di.sea.se.  Here  the  membrane  is  stiKldtnl  with  pin- 
point tubercles,  with  possibly  slight  surrounding  congestion,  but  without 
exudation  or  adhesion,  so  that  the  inflammatory  manifestations  are  of 
the  slightest.  Mast  frequently,  tuberculasis  of  the  pleura  is  an  e.vtension 
from  the  lung  or  peribronchial  glands,  and  it  has  U-en  fouml  to  iMMKca- 
sioned  by  tulierculosis  of  the  peritoneum,  the  ribs,  and  the  spinal  cohimn. 
In  tul)er?  dIous  bronchopneumonia  it  is  not  unc-ommon  to  find  clusttTs  of 
tubercle.^  ..pon  the  pleura,  .somewliat  cU  vated  alune  the  general  surfaci-, 
and  covirwl  with  a  delicate  layer  of  fibrin.  In  other  ca.so.s,  a  more 
abundant  exudation  takes  place,  frinjuently  of  a  .serofibrinous  charactpr, 
and  with  some  admixture  of  blood.  The  surfac-e  of  the  lung  is  covcrfd 
with  a  layer  of  blood-stained  fibrin  that  may  be  rea<lily  rcniovni.  On 
scraping  it  off,  one  can  make  out  tulK>rcles  on  the  under  surface.  Wliin 
the  disease  is  of  long  standing,  .several  layers  of  ca.seating  tubercles  are 
formed  in  the  exudation  which  is  c-onverttxl  into  a  thick,  clieesy,  and 
brittle  membrane.  Another  common  form,  sometimes  combined  with 
the  la.st,  is  that  where  a  more  or  less  extensive  .adhesion  of  tlie  pleural 
surfaces  takes  place.  In  the  adhesions,  which  are  due  to  the  orjrain'za- 
'ion  of  the  exudate,  Isolated  or  confluent  ca.si-ous  tuln-rclcs  are  piiKluced, 
leading  to  marked  thickening. 

A  purulent  tul)erculous  pleuri.sy  also  exists  and  is  due  conimonlv  to  the 
rupture  of  a  cavity  into  the  pleural  .sjmce.  He.  >,  no  doubt,  a  mixed 
infection  is  at  work. 

A  word  should  l»e  .said  here  alM>ut  a  peculiar  form  that  is  (.unnion 
in  cattle  and  has  l)een  met  with,  though  rar»'ly,  in  man-  the  so-i-alhi 
"grape  disea.se"  or  "Perlsucht."  In  cattle,  the  di.sea.se  is  ln(|nenlh 
found  not  only  in  the  pleura,  but  in  the  lungs,  lymph-glands,  peiieardiuni, 
peritoneum,  and  liver.  As  it  afl'ccts  the  pleura,  th('  di.sease  [indents  a 
very  striking  and  characteristic  ap[)earance.     The  tul)ercles  \,ir    sonie- 

'  Die  Krkrankungpn  des  UruRtfellii,  N'othnogel,  14:  18St4:  I :  Is. 


::•  i 


TUMORS 


:«i 


wliiit  in  size  nnd  take  the  fonn  of  wurts  ami  jiolypdid  excr;soence.s,  often 
boiiml  one  to  the  other  by  fibnms  Immls,  .so  that  they  have  been  lieen  eom- 
pami  to  pearls  on  a  string.  At  first  they  are  of  "a  gray  or  grayish-red 
color  but  sooner  or  later  degenerate  at  the  eentres,  In^-oming  opaque, 
yelJDW,  and  brittle.  They  may  finally  calcify.  Ho<lenpyl  regards  the 
minute,  lenticular,  pearly  dots  sometimes  found  on  the*  pleura  a.s  of 
tuberculous  nature. 

Syphilil.— Syphilitic  induration  of  the  lung,  already  referred  to, 
commonly  leads  to  tl>'ckening  of  the  pleura.  I^incereaux'  has  de.scribe<i 
a  pleitrlth  gununona.     It  is  excessively  rare. 

Leprosy.— This  is  foun«l  in  the  form  of  granulomas  of  varying  size 
upon  the  pleura. 

Foreign  Bodieil.— These  are  rare  except  bloo<l  and  pus  a.s  already 
mentioned.  Foreign  IxKlies  may  l»e  introduced  from  without,  or  maV 
l^in  entrance  from  the  stomach  and  nesophagus.  llarelv,  detached 
portions  of  tumors  may  Ik-  found,  or  se<|uestra  from  the  lui'ig. 

f»nsitM.~'-vh!nococcii.<i  cyntu  are  found  Inith  priniarilv  and  second- 
arily. P-iortviprrnM  have  also  Ijeen  met  with.  The  .1  mceb'a  coli  is  found 
in  ciisps  where  an  amoebic  abscess  of  the  liver  has  ruptured  into  the 
pleura. 


PROORESSIVK  MBTAMORPH08S8. 

Hypertrophy.— Hypertrophy,  if  it  can  l)e  regarded  as  occurring 
at  all,  is  po.s.sibly  that  form  of  enlargement  of  the  pleura  that  occurs 
when  the  volume  of  the  lung  is  increased. 

Tumors.— Tumors  are  primary  and  secondarv.  The  primarv 
henijrn  growths  are  flbroma,  lipoma,  oiteonu,  and  angioma.  Lipomas 
originate  in  the  subserous  fatty  tissue  of  the  intercostal  spaces,  but 
Rokitaiisky  has  descril)ed  a  branching  lipoma  (lipomn  nrborescem), 
■itartinjr  at  the  free  etlgc  of  the  Imse  of  the  lung. 

Thf  most  important  malignant  growth  is  the  endothelioma,  which  is 
found  in  the  pleura  more  fre(|uently  than  elsewhere.  This  may  (K-cur, 
a.s  m  a  case  coming  under  our  own  observation,  in  the  form  of  minute 
flatten.ll  no<lules  of  miliary  t\-pe,  but  more  fref|iientlv  Inrge  scattered  or 
eoakw  iiig  ncKlules  of  whitish  color.  (K-casionallv  connected  bv  fibrous 
t>an.k  are  produceil.  The  growth  leads  to  considerable  infiltration 
atul  tliK  keiung  of  the  pleura,  and  is  usually  accompanied  bv  a  -senms  or 
heinorrhajrK-  pleurisy.  Sometimes  large,  .^ft,  solitarv  tuniors  are  pnj- 
(iuee.!,  but  generally  the  tumor  has  more  the  characteristics  of  a  hard 
ran.  IT  .MicroM-opically.  it  consists  of  a  dense,  fibrous  stroma,  in  which 
ari'  iu>t,  ,)f  cells  of  an  endothelial  type.  When,  however,  the  tumor 
IS  soft  .11.1  rapidly  gn)wing,  the  resemblance  to  sarcoma  is  somewhat 
<l<)se.  I  li.-  growth  originates  in  an  overgrowth  of  the  lining  cells  of 
tfirp..  I:;,  ...tid  may  gradually  e-Uend  to  the  lung  and  Ivmphatic  glands. 

Vmm-y  sarcoma  is  usually  of  the  spindle-celled  variety  and  liegins  in 

'  Traits  de  la  Syphilis,  187.1 :  320. 


332 


THE  PLEURA 


the  subpleural  connective  tissue.  It  Is  shuI  to  be  coinmun  in  cliildn-n. 
It  may  extend  to  the  lung  and  lead  to  pressure  upon  the  brachial  |»lfxiis 
and  axillary  vessels,  as  in  a  case  examined  by  one  of  us.* 

Secondary  tumors  invade  the  lung  by  metastasis  or  by  direct  cxtciisioi.. 
The  most  common  are  those  due  to  carcinoma  of  the  thyroid,  niuniina, 
stomach,  and  oesophagus. 

'  Stewart  an    Adami,  Montreal  M«l.  Jour.,  22:  1S93-1M:  IKm. 


CHAPTER   XV. 


THE  MKDLVSTISLM. 

Thk  nicHliastiniim  is  that  portion  of  the  thorax  which  lies  between  the 
two  pleunr,  bounded  in  front  by  the  sternum  and  behind  by  the  verte- 
bral column.  The  anatomists  generally  divide  it  into  two  parts— the 
siiptrior  mediastinum,  lying  alxive  the  pericardium;  and  the  inferior 
n«-«lia.stinum,  which  i.s  further  suMividwl  into  three,  the  anterior,  median, 
and  posterior  me«liastina.  The  anterior  mediastinum  is  bounded  in 
front  hy  the  sternum,  laterally  by  the  pleura,  and  behind  by  the  peri- 
cardium. The  fKxsterior  is  boundwl  in  front  by  the  pericardium  and 
nM.ls  of  tlie  lungs,  laterally  by  the  pleurne,  an<l  pixsteriorly  by  the  spinal 
(■olmiiii  from  the  lower  lH)r«ler  of  the  fourth  dorsal  vertebra  downward. 
Tlic  mi<l(l!e  mediastinum  is  the  remaining  space. 

Pallioiogically,  the  mediastinum  interests  us  on  account  of  the  great 
niinilHr  of  important  organs  which  it  contains  and  its  intimate  relation- 
ships witii  other  parts.  All  the  viscera  of  the  thorax  with  the  exception 
of  iIh"  lungs  and  pleura>  are  to  be  found  within  it. 

Tht'  superior  me«liastimim  contains  the  origins  of  the  sternohyoid 
and  sternothyroid  muscles  and  the  lower  en''n  of  the  longas  colli;' the 
transv.rsi-  part  of  the  aortic  arch;  the  innom  ■  ite,  left  carotid,  and  sub- 
clavian arteries;  the  vena  cava  superior,  the  innominate  veins,  and  the 
eft  superior  intercostal  vein;  t!ie  pneumogastric,  cardiac,  phrenic,  and 
left  rcTurn-nt  laryngeal  nerves;  the  trachea,  oesophagus,  and  thoracic 
duct;  the  thymus  gland  and  lymphatics. 

The  anterior  niecliastinum  contains  the  origins  of  the  triangularis 
stcrni  iiiusc-les,  the  internal  mammary  vessels,  some  areolar  tissue,  and 
some  lymphatic  channels  and  nodes. 

The  iniddle  mediastinum  contains  the  heart  and  pericardium,  the 
asirnding  aorta,  the  superior  vena  cava,  the  bifurcation  of  the  trachea, 
the  piilnionarv  arteries  and  veins,  and  the  phrenic  nerves. 

The  posterior  mediastiimm  contains  the  descending  limb  of  the  aortic 
arch,  tlic-  ciescending  thoracic  aorta,  the  greater  and  le-ser  azygos  veins, 
the  pneumogastric  and  splanchnic  nerves,  the  oesophagas,  thoracic  duct 
and  some  lymph-nodes.  ' 

In  the-  consideration  of  disorders  of  this  part  of  the  body,  we  need  deal 
»^th  only  a  few,  but  they  are  of  not  a  little  importance.  T'le  affections 
of  the  tracliea,  bronchi,  oesophagus,  heart,  pericardium,  vesseb,  and 
ner^,•s  are  more  conveniently  described  elsewhere,  though  it  must  not 
'H-  toijiMtten  tiiat  the  mediastinum  is  often  secondarily  involved  in  dis- 
luse  oi  these  structures.  In  this  place,  therefore,  we  shall  confine  our 
Rinarks  cliiefly  to  the  areolar  connective  tissue,  the  lymph-nodes,  the 
ttiyiniis  frhiiid,  and  the  various  ailments  affecting  them. 


IM 


ii\ 


334 


THE  MEDIASTISVM 


OOXOBXITAL  AKOMiXIXS. 

The  medittfltina  will,  of  fourst*.  Ih>  motliKtHi  iti  their  .shu|M>,  exlcnl,  aiid 
boiindarir.s  by  Hiiomalies  of  (Icvflopiiient  of  the  heart,  Iiimj{,  m  itchrHl 
coliinin,  and  .sterniini. 


▲CQUIEKD  AVOMAUIS  OF  UZI,  8HAPI,  AKD  POUTIOH. 

Transiulatiotis,  inflammatory  etfu.sions,  extra va.saljons  of  IiIinhI;  infil- 
trations, inflanmuitory  or  neoplastic,  whether  of  the  mediastinal  .spHcc 
itself  of  the  nei)(hlK>rin^  viseeni  and  sennis  <'avities;  and  aneurisms  will 
alter  the  size,  shap(>,  and  jMxsition  of  the  mediastina.  In  eases  of  cxtfii- 
sive  pleural  effusion  the  heart  anil  mediastinum  may  l)e  <lisl(Kut(Hl  con- 
siderably to  one  si«le;  or  the  mediastimim  may  Ik*  draj^gtHi  out  of  its 
normal  position  by  imhiration  and  retraction  of  the  lung. 

OntOULATOKT  DnTUBBANOU. 

H3rper6mia. — Active  Oongettioii. — Active  con^stion  occurs  in  the  first 
stages  of  acute  inflammation. 

Pauiv*  OongMtion. — Passive  congestion  is  foun«l  in  general  venous 
stasis,  and  in  liK-al  conditions  which  lead  to  obstruction  in  the  veias 
leaving  the  mediastitium,  such  as  enlargiti  glands,  and  tumors.  Hemor- 
rhage into  the  metliastinum  may  arise  fn)m  traumatism,  the  er«)sion  of 
vessels,  or  the  rupture  of  an  aortic  aneuri.sm. 


mrLAMlIATIONS. 
Mediastinitis. — Inflammation  of  the  mediastinum— 


-^fimtl; 


is  not  uncommon,  and  is  to  Ik?  attributed  to  trauma,  the  exi.  iision  of 
disease  from  neighlK)ring  parts,  and  to  hematogenic  infection. 

Traumatic  Mediutinitii. — The  traumatic  form  is  due  to  external 
injuries,  such  as  stal>  wounds  or  gun.shot  wounds.  Occasionally,  too, 
foreign  ImkUcs  within  the  u'sopluigus  may  \w  the  cause. 

Mediutinitis  by  Eztention. — Mediastinitis  arising  per  rxlcii-iiinifm  is 
much  the  most  common  form.  It  may  Im-  st-coiidary  to  pleurisy,  periear- 
•litis,  or  pi>ritonitis ;  it  may  extend  from  the  neck  along  the  vessels,  from 
the  retn)pliaryngeal  glands,  the  larynx,  tnichea,  or  esophagus;  from  the 
thynnis,  lungs,  or  bronchial  glands;  or  from  the  vertebne.  .Vcconling 
to  the  type,  we  may  rtH-ognize  .limplc,  .supjmrdilve,  ttiid  .ipcci'Jir  mrdias- 
tinhh:  these  may,  again,  be  iirutr  or  chronic. 

Heitutogenic  or  Metutatic  Mediastinitis.-  Hematogenic  or  ni<  iM-laiie 
mediastinitis  has  Ikh-u  met  with  in  connc<-tion  with  typhoid  U-my.  erv- 
sijH'ljLs,  acute  rhemnatism,  pneumonia,  and  variola. 

Simple  me<liastinitis  usually  is  a  complicatiim  of  acute  pli  iiii>y  or 
pericanlitis.  It  is  almost  certain,  too,  that  there  is  an  iiiHaiiiinatory 
hyperpla.sia  of  the  mediastinal  glands  in  cases  of  bronchitis,  piiriiiionia, 


SYPHILIS 


335 


and  many  of  the  infpcticiiis  fevers.  No  doubt  matt  of  these  cases  heal 
without  leaving  any  tintowarti  results,  hut  octasionallv  the  proctss  ends 
in  sti|i|>uration.  or  the  jjlunds  iH-ciime  ehronically  enlarged  and  indu- 
rat<il  Subsequently,  should  contraition  of  the  inflamed  structures 
mriir.  w.  may  f,n-t  traction  or  pressun-  up«in  important  structures,  such 
as  the  vess«ls,  trachea,  bn>nchi.  or  oesophagus.  One  tnrm  of  diver''culiim 
of  the  (esophagus  is  due  to  the  traction  of  a  contracting  jjlaml  which 
has  iK-come  adhiTcnt  to  this  orjjan.  Metlia-stinal  abscesses  mav  extend 
ami  rupture  externally,  but  have  lieen  known  to  discharge  'into  the 
tm<h(a,  o'sophagus.  pleural  cavity,  ijericanlial  sac.  left  ventricle,  and 
aitrtii.  .\  common  ^hiucI  of  me«liastuml  inflammation  is  the  formation 
of  i>aii(ls  of  adhesion  iH-tw.-en  the  external  surfac-e  of  the  pericardium 
Hiiil  the  pleura,  or  In'tween  Ou-  pericardium  and  the  chest  wall  ( meiluuthio- 
prrnvrfhhn).  In  the  latter  event  .systolic  retraction  of  the  thoracic  wall 
111  III.-  neigh iKirluKxl  of  the  apex  of  the  heart  may  be  pnxluced,  a  fact 
that  IS  of  some  diagnastic  import  in  connection  with  pericarditis.  In 
sonnMnst-s  adhesions  may  Ik- .so  widespread  that  the  mediastinal  space  is 
practicuJiy  obliterated. 

.\|)art  from  the  adhesion  and  induration  of  the  tissues  just  referred  to 
whuh  are  to  be  n-gardcl  raiher  as  relics  of  an  inflammation  past  and 
pine  than  as  evidences  of  a  pn-sently  active  pnx-ess,  there  is  a  form  of 
(•hn>iiic  iiHMliastmul  inflammation  which  is  of  a  steadily  progres.sive 
(•hanictcr.  In  this  case  the  pr«x-ess  begins  either  as  a  perihepatitis,  which 
txltii.ls  to  the  nicdiastmum  by  the  lymphatics,  involving  in  its  course  the 
ri);lit  pleimi.  or  as  a  pericarditis.  The  meiliastinal  .space  is  obliterated 
and  the  various  serous  sacs  are  eventually  more  or  less  completely  involve*! 
(nuiltiple  progressive  hyaloserositis.'  chronic  multi.serositis,  polyorrho- 
menitis,  ( '..ncato's  disease).  The  adhesions  produced  are  very  numerous 
an,l  ,|.iise  and  the  newly-formwl  fibrous  tissue  may  undeivo  hyaline 
•lep-iuration.  so  that  a  peculiar  substance,  of  pearlv  white  color  and 
tartiiajrinous  appearance,  is  proilucwl.  This  material  mav  form  thick 
»h«.ts  „n  the  surface  of  the  different  viscera,  liver,  luiigs,  or  heart 
iAurkirijuDH).  ^ 

Tuberculo8is.-Tul)erculosis  of  the  mediastinum  ari.ses  by  extension 
rroin  the  vcrtei)ral  column  or  from  the  Ivmph-nodes.     It  is  frequcntiv 

Mippiirativc  in  tyjie.  11 

Syphilis. -Syphilis  of  the  mwliastinum  appears  to  he  as  rare  as 
tiilHT, UI..S.S  IS  common.  The  few  reconled  cases  appear  to  have  been 
>»"<^.i.darv  to  giiniinata  of  the  sternum  or  ribs.  In  one  then-  was  enlanre- 
iiMiit  of  til,.  iiKHliastinal  glands  as  well. 

-No  .oMsi.hTation  of  inflammation  of  the  mwliastinal  structures  would 
•]'  (..mpl.t,-  without  a  more  detailed  reference  to  the  important  role 
"i'.v,,  ,v  the  nuHliastinal  lymph-tKnles.  Repeated  observations  have 
|)n.v.Hi  Ihv.wuI  question  that  the  tracheobronchial  Ivmph-iuHles.  l)oth  in 

""'  : "'<"  '"««T  animals,  not  ii,fre«|ueiitlv  contain  living  Iwcteria, 

p«'i  i„  ,1,,.  absence  of  local  disturbanc-e  or  disease  elsewhere.  The 
pr.,.n,,.  „f  pncumococci,  staphylococci,  or  tubercle  bacilli  has  been 
'  Nitliulls,  StuUies  from  the  Royal  Victoria  Hospital,  1:  1902:  No.  3. 


THE  MEDIASTINUM 


ilt^  i 


determined  in  these  rawM.     Pisxini,  for  instance,  found  the  Imcilli  of 
tuberculoiiis  in  the  perihronehial  raMles  of  non-tuherculoat  aihihs,  iiviii|; 
from  aeeitlent,  suicide,  or  acute  infectious  dLst^ase,  in  42  p<>r  (fiii.  of 
cases.    This  \ynnf^  the  fact,  the  ptrtewy  for  evil  of  the  niciliustinal 
lymph  apparatas  must  In*  athnitted.     Moreove^r,  in  prol>al>ly  evcrv  (ust- 
of  broiK-hitls  and  piH'urnonia  the  trache«thr(>iH-hiai  and  iNTilirotuliia! 
lymph-nodes  are  involvwl,  its  are  the  anterior  mniiastinal  niKles  in  uciiie 
peritonitis.     A  simple  inflammatory  hyperplasia  may  result,  eitli<-r  luntr 
or  chronic,  which  may  lead  to  cnlar}^>ment  ami  often,  finally,  indiiriuion 
of  the  .structun>s;  or,  a|;ain,  a  suppurative  prtK-ess  may  Ih"  initiiilcd. 
Amouf;  the  c<munonest  fonns  of  disease  of  the  mediastinal  lympli-inNles 
is  tulM>r(iilosis,  whi<-'  may  Ik>  of  the  acute  miliary  «)r  the  <'as«'atinj;  w^-. 
It  was  for  a  lon^  time  thouf(ht  that  this  affection  was  siH-ondary  (o  pul- 
monary tulM*rculosis.     ( 'onsidend>le  eviden«'  has  now  accuinultilttj  to 
show  that  this  view  is  incorn-ct,  however.     Weij{ert  has  denionstratrd 
that  the  dissemination  of  tulN>rcle  Imcilli  in  the  luu);  follows  tlit>  siune 
path  as  the  absorption  of  <-iHd  dust  or  other  pigments,  and  the  work  of 
Aufrecht  proves  that  it  is  next  to  impossible  for  foreign  particles  to  reucli 
the  alviHili  of  the  lung  by  inhalation,  save  in  the  |N>ssible  case  of  forced 
inspiration.     The  observations  of  )lil>lK>rt,  Haiimgarten,  and  others,  re- 
femtl  to  alK)ve,  strongly  support  the  view  that  tuln-rcle  l>acilli  do  not 
wach  the  lungs  din-ctly,  i>ut,  entering  by  way  of  the  nasoplninnj^al 
muc«>sa,  pass  into  the  cer^-ical  chain  of  lymph-n(Hles  and  thence  into  the 
tracheobronchial  and  p<-ribronchial  group.     The  e.xact  method  by  which 
the  lungs  eventually  Infome  infecte<l  is  less  certain,  but  it  is  pn)l)tiltl«' 
that  it  is  either  by  retn»grade  metastasis  in  some  cases,  or,  in  otliers, 
by  the  rupture  of  a  ea.seous  focus  into  one  of  the  pulmonary  arteries. 
The  presence,  tiien,  of  infected  lymph-no<les  o|K*ns  up  several  ijossibijities. 
Inflanunation  may  spread  througfiout  the  mtHliastinum  and  evcntiiaih 
involve  important  structures.     Enlarged  masses  of  nodes  niii\   press 
upon  the  traelua,  bronciii,  (rsophagus,  or  large  vessels.     Ciciitricial 
contraction  of  the  chronically  inflamed  gnnips  may  lead  to  truction  upon 
the  .same  strueturi's.     In   this  way  diverticula  if  the  hollow  viscera 
are   not   uncommonly   pnxluced.     Ca-stHms   or  suppurating  Uv.\  ina,v 
di.scharge  into  the  me<liastinal  space  or  into  the  trachea,  bn)n('lii,  arteries. 
or  veins.     Further,  al>.sce.s.ses  have  l)een  known  to  ruptun'  cxicmallv, 
or  into  various  cavities  and  viscera.    The  results  are  often,  tlicrefore, 
far-reaching. 

Pansites. — Simple  and  ec''in<MVccus  cysts  of  the  metliastiinim  have 
been  describetl. 


li  r 


PR00RE8SIVK  MXTAM0RPH08U. 

Tomon. — Tumors  of  tl""  me<liastinum  may  be  primary  and  .sec- 
on«lary.  The  sec<ind)iry  ^  n-ths  nrigioiite  in  the  bronchi.  !ii!ii;s.  or 
<e.sopliagus  and  involve  the  region  by  direct  extension,  or,  !if;itiii,  are 
metastatic.  The  primary  neo|>lasms  liegin  in  the  lymph-n<Mics,  connec- 
tive tissue,  thymus,  or  in  the  thyroid  or  an  accessory  thyroid. 


J 


TU.yoHS 


Xi7 


l^ii'  primary  li(>niKn  ((n>wth.>*  n>|M>rt<>il  art-  Upom*.  IbnaM, 

iTBpbraw,  ehondnma,  atui  ttntoaa.  In  mmw  vhh(>h,  hnwever,  it  is 
imixw  il)l«'  to  (Iftc'niiiiie  whether  such  tutiuirK  have  (it-veltipmi  priinarilv 
in  the  iiic4liH.stiiiiiin  or  not. 

Arm.  ij{  the  nn»st  itiinmoii  of  the  iM'iiigii  tumors  are  the  ttntrauM 
(.lmn..i«l  ey.Hti).  of  whieh  ('hri.Htiaii'  ha-s  made  the  most  re«-ent  stmlv 
Thiv  are  usually  iH-niKn. hut  (KiusiouHJIv show  evidences  of  maliirnaiiev 
ITiev  ..rijcinate.  aeetmiin^  to  Manhamr.  K»wter.  aiHi  I'iriders.  fn.ni  the 
thyiiMis  ^laiMl.     Waldeyer  •ies.riJH's  «me  whieh  eontainwl  thvroi.1  tL«wue 
Dirmoid  eysts  an-  usually  soft,  fluctuating.  iK-easionallv  pulsatintf,  ami 
»rp  situatwl  imder  one  clavicle  or  i>u  lM)th  sitJes  of  the'  sternum.    The 
pulsation,  which   nay  Ik-  due  to  their  own  vas<ularitv  or  to  transmitted 
imimlM-  fn>m  the  w.rta.  has  le<l  to  their  iM-ing  mistaken  for  aortic  aneii- 
asm.    The  c«)ntents  of  the  «yst  are  similar  to  those  «)f  dermoi.ls  eLwwhere 
Thes»'  cysts  ar«'  dangi-nms,  inasmuch  as  thev  mav  rutur«>  into  .stime  im- 
portunt  structure,  such  as  the  pericanlium.  pleura.'left  lung,  the  bronchus 
»r  aorta.    In  alM>ut  20  p«r  c..nt.  of  <a.ses  they  have  l)een  diagnosticated' 
l).v  the  |)re.sence  of  hair  m  the  sputum. 

Tumors  of  the  meihastinum  mav  arise  from  thvroid  tissue     Occa- 
simially.  the  thyroid  glan<l  is  situatwl  much  lower  .lown  than  usual 
IvitiK  iH-iund  the  steriumi    In-twiH-n  the  trachea  and  cpsophagus      \c- 
wss;,ry  thyroids  may  also  at  times  U-  found  in  the  superior  me«liastinum 
y  uhrinann  lius  nnimlwl  01  tumors  of  thyn.id  origin  in  the  mediastinum 
..J  Ixiiipi  an<l  Hi  malignant.     .Such  tumors  mav  a.s.sume  the  tvpe  of 
an  a(l(-ri.Mna,  caninoma.  or  sarcoma.    Thev  maV  attain  a  largi;  size 
Diltncli  mentions  a  substernal  "endothoracic  struma      the  size  of  a 
man's  head,  which  had  compre.sswl  the  right  lung. 

.\lto)r<tl)er,  the  most  c-ommon  primary  newgrowthsof  the  me<Iiastinum 
are  tlu.se  originating  in  the  lymph-iKKles.  Thcs..  are  bv  far  the  most 
frer|iuiiilv  i.;alignant  and  .sarcomatous  in  tvi)e,  but  benign  lymphonu 
has  iHi-ii  (iescril)e<l.  — •     *    f    «» 

Benign  lymphomas  are  to  be  distinguishe*!  from  malignant  Ivmphomas 
orlym|.l,.,.sarcomas,on  the  one  hand,  by  their  l(K-alize«l  non-'infiltratinif 
chardctcr  and  from  leukemia  and  p.s«.udoleukeniia,  on  the  other,  bv  the 
ahsence  „f  the  jH-culiar  UUhhI  chang»-s  and  of  enlai^ment  of  the  spleen 
'dTui  liver.  ' 

Tlu-  most  common  primarj-  tumor  ..f  the  me<liastiniim  is  the  tueoma 

:■';'/  "'",)'  ?'""T  '!'*■  ^"'*™  "^  lymphmnm.ma,Jil,rw,„rcoma,  round  or 
'fimlle^rll,;!,  and  (dwd»r.  bdotheUoma  is  also  met  with  The.se 
);r..wtl.s  originate  either  in  the  media.stiiml  Ivmph-nodes  or  in  the  areolar 

"nnectiy,-  tissue;  it  is  not  always  p<miblc  to' determine  which. 
Ainpliosarcomas  of  the  mediastinum  are  soft,   vellowish-white  in 

anil  7  !  """:*■''""'  '■^■■''^'■^-  '^Vv  usually  infiltrate  .somewhat 
,  r   •     '     "f «f  "'a'b'are  of  slow  growth.     The  newgrowth  In-gins  in 

M  mp  '-'""l^-s.  burst-,  timnigh  the  fibrou.s  invciitur,.  of  these  structures. 
nentuallv  invading  all  the  ti.s.sues  of  the  me<lia.stinum  and  fusing  them 

^      '  1  itrraoid  Cysts,  Jour,  of  Med.  Kfscgn-h,  ii  (N.  .s.) :  KkG :  541. 


rnr  mediastinum 


cut  iimli)(naiit  nrw^mth  of  ilic 
,i(<v.pv      i      'nost  hIwuvs  vKiHid- 


\. 


I" 


1 1      il '       foniis  (U'rivcd  fniin 

•  i'  the  ca-M's  n-iMM-tiif  liv  the 

'■[■  woukl  niiw  lie  |>liutil  ill  iIk' 

nriiii  an-  carciniiriiatiiii^  or  snr- 


itilii  u  tnoiT  or  lew  h(»»n(^i;«i  •  ina.<4.<*.  The  n'sultiiif;  tiim.»p  i>  .iri.n  „f 
enonnoiLs  Mze  aiirl  extent,  ami  may  involve  the  heart,  \»nf,ri,  Imtiuhi, 
fi>MiphHt(n.H,  the  .stemiim,  und  vertebral  eoliitnn.  It  ha.s  Utm  knoun  tn 
reaen  even  the  ineniiip<'>  l»v  v  •  «)f  the  inter\'erteliral  foraniiim.  In- 
like  other  fonn.s  of  .san-onia,  Hu-  nutliastinal  lynipiioMan-oma  ^'ivcs  rix' 
to  nieta-stafw-H  hy  pn'rcrem-e  iii  (In- 1  'estinal  tract,  lesM  often  in  (lie  \n\mi- 
ehyniMtouM  or)(an.H,  .such  a.H  the  liv<  i.  |)leen,an<l  kidneys.  On  (lie  wliolr. 
however,  nie<iia.>itinal  .sarcoii-n  h  •,'-  to  spn-ad  l>y  liN-al  liitTiision,  ami 
iliHtant  meta-stajtes  an-  not  <-)iiini(it! 

IIi.<ttologieally,  we  fimi  .■.>  >:^  edition  of  xinall,  rounilHi-lls,  lidtl 
together  l>y  a  varialtle  ai><ii.i>i  .  '  li!  >ii.><  reticulinn,  and,  if  sniiiH,  pri'- 
.Hentinj;  evidence  of  a  <-a|>;.il  .  .  liilii  uieieatiHJ  and  .H|»indl«'-sh«|Mtl  nils 
are  not  often  seen. 

Ae«)rdiiij{  to  Han>,'  the  ini.i  (m 
media-stinuni  is  the  eardno/  m  I  '<'- 
ary  in  character,  the  few  <'■  ;»ti<ii, 
thyroid  tisoue  alaive  refc  ir  ^  d  ^ 
older  patholof^'Sts  a.s  canino  hm 
catejfory  of  eiMlotheliomas. 

The  secondary  tumors  of  liic  medi.i>.i 
comatoiis,  and  arc  confined  to  ilie  iyiupli-niNles.  In  the  <-usi'  nf  cHni- 
noma,  th»-  printary  growth  is  usually  to  Ik-  foimd  in  the  hrcasl  or  liin^', 
le.s<<  often  in  gall-l>la<ider,  kidney,  pancreas,  or  stomach. 

Secoialary  sarcimia  i.s  nol  very  fr(H|uent,  hut  ha.s  U-cn  dIimtvciI  in 
casi'.s  of  .sarcoma  of  the  upjxT  extremity. 

The  .symptoms  resulting  from  the  pn-sen(r  of  nusiiiistiiial  tiiniors 
of  all  kinds  de|M-nd  largely  on  their  sixe  aiul  |K>sition,  ami,  in  p-iicnil. 
a'e  those  of  pn'.s.sure  and  irritation,  together  with,  in  some  iiistiincfs, 
the  ortlinary  features  of  malignancy.  At  first,  there  is  usually  a  'siii>- 
jective  .seasation  of  fulness  and  pre.ssun-,  generally  referreil  lo  llic  neck, 
with  .some  palpitation  of  the  heart,  hut  with  at  first  no  pain.  Later. 
actual  dy.spntea  .set.s  in,  due  to  pre.ssur*'  u(m)U  one  or  mon-  of  the  iiiifxir- 
tant  structures  within  the  thora.x,  trach.  a,  hroiu-hi,  the  veins  of  the  litttrt, 
nerve  or  lungs,  ami  the  rwurrent  laryngeal  nerves.  Irritation  of  ilir  vajjiis 
possibly  accounts  for  the  cough,  vomiting,  palpitation,  rc>;iir;.'iiati(iii  of 
fiKMl,  and  the  ginlle  .stMi.satioii  complained  of  in  some  cii.ses.  I  n iialioii  iil 
the  .sympathetic  leads  to  dilatation  of  the  |)Upil  on  the  atliiiiil  side; 
destruction  of  the  nerve  to  contraction  of  the  pupil.  I'n^Min  mi  ilir 
aorta  will  prixluce  a  difference  in  the  volume  of  the  radial  nr  canitiil 
pulse  <if  the  two.siiles.  Irritation  of  the  phn-nic  nerve,  which  i^  rare,  \mi- 
duces  .severe  pain  and  .singultus.  Compression  «)f  tin- o'siipliai/iis  ai«l 
the  thoracic  veins  is  common.  Where  there  is  much  obstruction  to  the 
venous  return,  cyanosis  of  the  head,  chest,  and  ami,  dilataiinn  nf  tin- 
.superficial  veins,  and,  later,  hn-al  (»'<lenia,  an-  met  with.  1'iiN:iinhi  nm\ 
be  detc^'t'"''  and  Ic;!;!  to  the  s!i-pi<i->ii  of  an  Hnruri-m. 

'  .Vfffctioiis  of  till-  MtHiiiLstiiiuiii.  I'liiludclphia.  IS-SH. 


SECTION  rii. 
THK    AMMEXTARY   SYSTEM. 


(  HAPTER    XVI. 

THK  r)KlKSTIVK  KINCrK.XS  AND  THKIlt  I>ISTn{BAX(K.S 
DIVILOPMIMIAL  AMD  AMATOMIOAL  OOHIIOnATIOlfl. 

Hkk.rk  wr  c«„  Ih.  pn-pHr..!  fo,  uii  a.lef,UHtf  .■.....-..ption  of  the  gnmt 

ihv.rsiJv  .,f  .lisfuse  pnKrsscs  tliitt  ,kvut  in  tho  alitnentar^    tract    w 
iiHist  Ij..  .■..nwrsant  with  (vrtain  feutun-s  „f  the  clev.Jopmeiu  .„„!  kiw- 
-nnurul  stnuture  of  this  system.     F,.rthem,..r...  it  is  „„^^,a^^   to  have 
a  «„rk.nK  k.mwU.lK,.  "f  its  r,.,r.„„^  futK-tiorus,  inasmuch  as  it  is  fm.n 
th..  ,.hys,oi.,KKal  sHie    Jone  that  «.    ean  attack  n.anv  ,.f  the  pn.l.lems 
lliHt  ••..nfmnt  us  as  a  msult  ..f  ,li...r,len^|  .i.tivitv."    We  can  in  this 
WHy,a.Hl  ,„  this  way  only.  lHr.„n.  ......petent  t..  re^.l^ni^.  and  to  apprt- 

■  mtr  not  only  the  grosser  .struetural  eviden.vs  of  n,ori.i,litv.  I,„t  miJ!,  the 
•  .rMHl  a.Hl  ex..  rnal  manifestations  of  ttl)nonnal  function  to  which 
'Ifv  ^.ive  rise.  A  very  <-urs„ry  .xaminatioii,  inclml,  wouki  In-  all  that  is 
iiHrssarv  to  «.nv,nce  us  of  the  wide  ranp-  and  imp«,rtan.e  of  this  part 
of  our  „.l,j,rt.  for  its  ,-.,.u|,H-xitv  is  .-vidt-nt  at  one-  ^ 

11...  alimentary  tn.. .  is  deriv.sl  from  the  invujrinatio,.  of  the  endo- 
'■"..Hl  l^..v,.r  of  the  embryo.  .sup,.,rt..l  by  the  v'sc^-ral  ,..r.ion  of  th^ 

-m,     ,.„,  ,    „,.„  as  its  a.-,..ssory  structun".  the  lun^.s.  liver   a^ 

■  -■'        1 1..-  latter  forms  the  nms<.„lar  and  .ser„„s  eoati;,,..  toLth" 

«"    tl..    iMesen.ery  and  ^m-at  .mientum.     We  .    |  no.    ■    ke  up  t     e 

-'p.r,l,n„  the  ,hn.nokvieal  s..,ue„„.  of  events,  fo,    ,l.at  w,ml(T^ 

::'"'", """'"I-;-  P..r,-se.  1.U,  will  .mfin. rselves  to  indSin. 

' ""  ^'il'.!-'. ..      I  he  ..uHKinution  of  the  two  tissue  lav-rs  i„st  menrioned 

^.rXh,  :      „""  ''f-'  f^T"."'  '"   •^•"••r^"""-  -^i^tenee  a  simple 

traiaht  .„       nrallin^  the  .on.h.ion  nf  rhimrs  fo-.M^j  i„  ..-rtai..      ;   i, 

■'>  -^in,,  Mmphibians.  I,u,  ...r.nina.i...  i,li„dlv  „,  ,,»h  em!  ;Mth....t 
^"  nu.l ,  ..„n„.m„.at,o„.     The  .entiai  p.rtion. .  n-  „m|-g„t.  ..s  it  is   !£.> 

L ;;""■'  ""\""' >;•"'-«•  ''^ "Wide pa.sa,e.*;hi<.h uiti,  il::;;: 

mi>  r,  uracteU    to  form  the  omphalomesenteric  or  ritellin,    rW 


M)     THE  DIUESTIVE  FUNCTIONS  AND  THEIR  DISTVRBAXCHS 

From  the  posterior  part,  or  hind-gut,  a  diverticulum  grows  out,  forminj; 
a  thick-walled  stem,  the  allantoic  stalk.  These  two  structures  evt'iitiially 
liecome  approximated,  and,  together  with  the  umbilical  arteries  and  vein, 
form  the  umbilical  cord.  As  development  pror>e<ls,  the  j)rimirive 
gut  increases  in  length,  but  the  body  cavity  enlarges  disproportionately, 
so  that  the  tissues  uniting  the  dorsal  and  ventral  aspects  of  the  ^tit  to 
the  body  wall  become  elongated  to  fonn  ultimately  two  ligaments,  eaeii 
compased  of  two  .serous  layers  united  by  connective  tissue.  These 
are  the  dorsal  and  the  ventral  mesenteries.     During  the  fourtli  week  of 


Iifi.  81 


If* 


9 

'M^^^B 

1  p?' 'Jpf'll; 

OiaffTamtnatii*  wliema  iif  the  alimentary  ranal  nf  a  human  embryo,  twenty-fifElit  ■l;iv>  nld:  Pi. 
pituitary  fi>!«<a;  Ta,  lonitue;  l,z,  larynx;  T,  trai'hea;  O,  (E!H>|.hacU!>;  /,.  Iuiik:  .v.  -ic.iuaih;  /', 
pancreai*:  ///).  hepatic  'ucl;  Lr,  liver;  \'0,  vitelline  duol;  .1/,  allantoi:*;  //t,',  Itin.I  iriit;  A',  kid- 
ney;   HI).  Wiilffian  ilurt. 

firfal  life  tiie  various  parts  of  the  alimentary  tract  begin  to  lie  ililferenti- 
atitl.  The  dorsal  aspect  of  the  tul>e  towanl  the  head  gradiiiillv  Unljys 
backwanl  to  form  tiie  primitive  stomach.  The  liver  iH'gins  as  ii  diverti- 
ciiluni,  whic-h  ari.ses  on  the  ventral  aspect  of  the  archeiitoroii  just  Ih-Iow 
a  point  corre.s|)on<ling  to  tlr  future  duoilenum.  StMiM-tiiiie  later,  a 
similar  pouching  of  the  ilorsal  side  of  the  same  portion  gives  rise  to  the 
pancreas.  The  accompanying  diagram  .shows  very  clearly  tin  position 
of  things  at  tliis  stage. 

The  mouth  Ls  at  first  indicatwl  by  a  pit  (stonKHla-iini)  on  ilie  under 
surface  of  the  primitive  head,  which  gradually  deepens  until  it  meets 


DEVELOPMENTAL  AND  ANATOMICAL  CONSIDERATIONS     341 

the  liliiitl  end  of  the  foregiit.  At  first,  a  thin  membrane,  compased  of 
wtoilfrin  and  endoderm,  the  pharyngeal  membrane,  separates  the  two, 
but  this  finally  ruptures  and  communication  is  thus  establishe<l.  The 
anus  is  formed  in  a  somewhat  similar  way.  The  tissues  in  a  small  area 
on  the  ventral  aspect  of  the  Inxly,  in  fnmt  of  the  neurenteric  canal, 
l)ec()ine  thinne<l  and  again  form  a  depression  (procto«lfeum)  which 
j;ra<iiiai!y  approximates  to  the  hind  gut  until  it  is  separated  from  it  by 
ail  anal  membrane,  which,  in  time,  also  disappears. 

TIh-  intestine  thus  constituted  .soon  loses  its  primitive  simplicitv.  It 
\)efimws  somewhat  folde<l,  and  we  can  early  distinguish  four  divisions: 
Th(«  first  iKvomes  the  duodenum;  the  .second,  the  small  intestine;  the 
thirti,  the  colon;  and  the  fourth,  the  sigmoid  ami  rectum.  There  is  at 
first  no  ascending  colon,  f<ir  the  cecum  Ls  situated  high  up  umler  the 
livtr.  It  gij<lually  descends,  however,  and  this  piirtion  of  the  gut 
el<)ii>;al(s  t<i  form  the  a.scending  portion.  Finally,  the  small  intestine 
littinncs  extremely  long  and  convoluted. 

The  stomach,  which  at  first  is  vertical,  its  long  diameter  lieing  parallel 
to  the  vertebral  column,  a  condition  that  occasionallv  persists  into  adult 
life,  alters  its  position  considerably  by  rotation  in  two  axes.  The  long 
axis  Ik-. oiiies  obli(|ue  an«l,  later,  almast  transverse,  owing  to  rotation  on 
the  (iorsoventral  axis.  The  pylorus,  thus,  comes  to  Ik-  on  the  right  side 
ami  lies  somewhat  higher  than  Jie  cardia.  During  the  same  perio<l 
the  stoiiiacli  also  n>tates  on  its  longitudinal  axis,  the  left  asp«H-t  In'coming 
iiiit.rior  and  the  right  posterior.  Thus,  tlie  greater  curvature  assumes 
the  lower  iM)sitioii,  and  the  lesser  the  upp-t.  This  torsion,  also,  to  some 
extent  atfiHts  the  lower  part  of  the  (esophagus. 

.\  oroliwtion  of  the  facts  just  mentionwl  will  suggest  an  explanation 
for  iiiaiiv  of  the  anomalies  of  development  that  are  met  with  in  later 
life;  for  example,  atresia  oris,  imperforate  anus,  tracheo-<Fsophageal 
fistula,  <)iiiplialonies:'nteric  fistula,  preperitoneal  cvst,  enterocvstoma. 
alHTRinl  paiumis  and  liver, certain  regional  hy|M)plttsias, and  the  like. 

•Apart  fn)in  the  embryological  considerations  that  we  have  just  dis- 
•iisse,!,  ihere  are  certain  other  |)oiiits  which  have  an  important  iH-ariiig 
"11  the  etiology  of  disease  of  the  alimentarv  tract  and  its  accessories,  to 
which  a  brief  n>ference  should  In-  made.  These  have  to  do,  on  the 
one  hand,  with  the  anatomical  structure  and  peculiarities  of  the  tract 
"■-elf,  and,  on  the  other,  with  the  relationships  which  the  tra<t  l)ears  to 
other s\ sttins and  to  the  Inxly  at  large. 

The  first  iinjjortant  fact  is  that  the  mucous  membrane  of  the  alimentjiry 
"^^teiii  IS  liiuMJ  with  cells  that  are  of  different  tvpes  in  various  part.s. 

has,  m  the  mouth  an.l  oesophagus  we  have  stratifie«l  Wjuamous  epi- 
llieliiiiii:  in  the  stomach  we  have  i-olumnar  cells  of  certain  specialized 
'yiKs;  111  (|„.  intestine,  columnar  cells,  of  a  diflferent  character  still, 
arraiip,!  m  a  characteristic  and  i-omplicatwl  wav.  The  s<|uamoiis 
••ells  have  little  to  do  with  absorption  or  with  secretion,  ami  from  their 
"aliiiv  an  adaptitl  rather  to  a  protective  function.  Therefore,  thev  are 
imt  litil.  hk.ly  to  get  out  of  gear  ami  are  relatively  insusceptible  to  irrita- 
lier  forms  of  trauma.    The  more  highly  specialize*!  and  deli- 


tioii  ami 


.tt^. 


:M2     THK  DiaKSTlVK  FUXCTIONS  AND  THEIR  DISTUUHASdS 

cate  tflls  of  the  .stomach  and  iiit(>8tiiie  are  much  more  easily  (Icraiigcd 
and  are  liable  to  di.sonier  from  a  jjreat  variety  of  .soum's.  Aiiv 
derangement.  to«i,  of  these  .structures  will  Ik-  likely  to  Ik-  utteiuidl  hV 
far-reaching  results. 

Another  point  is,  that  there  are  .several  places  at  which  the  cpitlicliiim 
is  transitional,  for  example,  at  the  lip,  the  |>a.s.sage  of  the  cr.sophagiis  into 
the  stomach,  the  pyloric  ring,  and  the  anus.  These  are  points  of  (ianjrcr, 
l)ecause  the  lining  cells  at  the.se  points  are  more  or  le.ss  unstaldc.  ("oti- 
.sequently,  we  find  that  they  are  the  favorite  .seats  of  carcinoma.  Xfjun, 
at  certain  points,  the  lumen  of  the  alimentary  tul)e  is  narr«)wc<l,  for 
instanc>e,  at  the  level  of  the  cricjid  cartilage,  the  pylorus,  and  tlic  anus. 
Mechanical  irritation  and  stasis  are,  therefore,  more  likely  to  (K( iir  at 
.such  platrs  and  .set  up  inflammation  and  newgrowth.  A  similar  n-sult 
is  apt  to  (Kfur  at  points  where  there  is  an  abrupt  turn  in  the  dimtion  of 
the  tul)e,  at  the  cardia  of  the  stomach,  the  (huxienum,  the  ihwccal  valve, 
the  hepatic  and  splenic  fle.xures  of  the  ct)lon. 

The  extreme  mobility  of  the  gastro-intestinal  tract  is  also  an  clcnicnt  of 
danger,  in  that  dilatation  and  obstruction  of  the  lumen,  displaccnit-nts, 
kinks,  twists,  and  invaginations  are  wmparatively  easily  brought  alKHit, 
any  of  which  may  Ik-  most  of  .serious  moment. 

Moreover,  the  alimentary  tulx',  lieing  in  direct  communication  w  itii  (lie 
external  air,  is  a  bretnling  place  for  Iwcteria,  .some  hannlcss  or  |Mts.sihlv 
even  l)eneficial;  others  potentially  dangerous  and  at  times  workiiij; 
havoc,  not  only  on  the  alimentary  tract  itself,  but  in  the  giMicra!  iMHJily 
.system. 

The  digestive  tract,  finally,  is  brought  into  touch  with  the  Ixxly, 
as  a  whole,  through  the  medium  of  the  1)Io<k1  an<l  lymph-circiilatorv 
.systems  and  the  nervous  .system.  Toxic  substances  and  iiif»Hfive  a>,'ents 
may  he  carrieil  to  the  tract  or  away  from  it,  congestion  may  cKciir  and 
lead  to  lowered  vitality,  catarrh,  and  impaired  function.  I  )is()nl<rs  of  tlie 
nervous  mechanism  may  lead  to  impaired  motility  anil  .swri-tion.  The 
absorption  of  toxic  matters,  in  turn,  may  affwt  the  nervt-  trunks  and 
centres.     These  relationships  wiil  Ik-  dealt  with  in  more  dctuil  later. 

The  fimctions  of  the  alimentary  .system,  stutwl  briefly,  arc:  (I)  to 
ingt-st  fiKMl.stulTs,  and,  by  mechanical  action,  to  render  tlicui  more 
easily  actinl  upon  by  the  various  digestive  ferments;  (2)  To  (onvert 
by  the  .secretory  activities  of  the  mucous  membranes  lining  the  digestive 
tul)e,  and  of  the  parenchymatous  cells  of  its  acce.s.sory  "{lamls.  siili-^tanci-s 
largely  in.soluble  into  thixse  that  are  largely  .soluble.  '^  -rt-by  |)ri|)arin)r 
them  for  incorporation  into  living  cells  and  vital  fluids;  (.{)  in  alwirl) 
and  assimilate  the  .substances  thus  transformed;  and  (4)  to  eliminate 
from  the  iMxly  tho.se  pnMlucts  that  an-  uniicces,sary  or  even  liarniful 
to  the  ec«)nomy.  We  may,  therefore,  con.sider  thi.s  subject  iiiider  the 
headings  of  mastication  and  pn>pulsion,  digestion,  aKsorptioii  and  assimi- 
lation, and  Anally,  excretion  and  elimination.  Or,  in  other  wonls,  it 
may  lie  di.scu.ssed  from  a  mechanical,  a  chemical,  and  a  vitalisiir  |Hiin(  of 

view.     While  this  method,  however,  c-onduces  »•)  precis*-  il irlit.  it 

mu.st  not  lie  imagined  that  the  subject  in  hand  is  .so  simple  a-,  at  first 


THE  MECHANICS  OF  DlGESTlUN 


:u;} 


sight,  it  nii);ht  appear.  Even  the  iiurmal  processes  connected  with  the 
fiimtii)n  of  alimentation  are  highly  complicated,  and  this  complexity 
and  confusion  l)ecome  still  more  confounded  when  we  come  to  deal  with 
(ILseaseil  conditions.  While  in  the  alimentary  system  we  have  particularly 
well  exemplified  the  peculiar  features  of  a  division  of  labor,  the  factors 
alxne  mentioned,  while  separate  and  distinct,  are  still  in  a  large  measure 
iniitiially  complementary.  A  disorder  of  one  function  is  liable  to  be 
followed  by  disor«ler  of  another,  and  may  even  lead  to  a  derangement  of 
the  general  .system.  Thus,  an  insufficiency  in  the  motor  power  of  the 
digestive  tul)e  leads  to  abnormal  fermentation  of  its  contents,  impaired 
digestion,  and  .systemic  intoxication.  Defects  in  its  .secretory  functions, 
again,  may  alter  its  motor  functions.  Not  infrec|uently  a  "vicious 
cirele"  is  thus  poKluced.  Or,  again,  a  local  condition  of  the  tract  will 
pnHliur  an  effect  for  good  or  evil  on  a  distant  portion  of  it  or  on  the 
economy  at  large.  A  correlation,  more  or  le.ss  intimate,  therefore,  exists 
Ijetween  its  various  functions  and  between  its  anatomical  divisions. 


THE  MEOHANIOS  OF  DIGESTION. 

The  purely  mechanical  fimctions  of  the  alimentary  tract  are  con- 
cerntHl  with  the  duties  of  ingestion,  mastication,  deglutition,  admixture, 
pmpulsion,  and  defecation. 

FchmI  is  taken  into  the  mouth  through  the  mutual  cooperation  of  the 
lips,  teeth,  cheeks,  and  tongue.  It  b  ground  up  by  the  teeth  and  jaws 
so  a.s  to  provide  a  greater  surface  for  the  action  of  the  <ligestive  ferments. 
It  is,  by  the  tongue  and  cheeks,  intermingled  with  saliva  and  mucus, 
and  rolled  into  a  Ixihis  convenient  for  swallowing.  The  process  of 
deglutition  is  somewhat  i-tricate,  for  during  the  act  the  larynx  must  be 
shut  off  by  liecoming  raised  up  under  the  liack  of  the  tongue  and 
by  the  e|)igl()ttis;  the  nasal  cavity,  by  the  soft  late  and  the  superior 
constrictors  of  the  pharynx.  This  part  of  the  mechanism  is  a  reflex 
one,  tiic  eeiitri|M'tal  impul.ses  originating  in  the  pharyngeal  mucous  mem- 
lirane.  iM-ing  coruTve*!  to  the  appropriate  centre  in  the  medulla,  and 
froni  till lue  reflectwl  to  the  muscles  c«)ncerned  by  means  of  the  tri- 
geniiniil  iind  vagus  nerves. 

When,  by  the  contraction  of  the  mu.sciilar  wall  <»f  the  (e.sophagus, 
thr  IkiIus  is  eonveye*!  to  the  stomach,  it  is  stored  up  in  the  fundal  portion. 
There,  after  a  brief  |)eri«Kl  of  rest,  it  is  intimately  mixtnl  with  the  gastric 
secretion,  owing  to  a  quiet,  rhythmical  churning  action  of  the  cardia, 
and  is  then  pas,se<l  on.  The  antrum  pyloricum  seems  to  have  the  p<wer 
"f  pickint;  <>"'  the  v..iter  rnd  the  finer  particles  of  food  from  the  rest 
Infore  |i(  iniitting  it  to  enter  the  intestine.  By  this  .selective  action  the 
more  iMiiiite  lH)wel  is  prote<-ted  .'nmi  possible  injury  by  the  lai^jer 
masses  n|  |-,„mI.  ( )niy  a  small  pn)po,'tion  of  the  total  nica!  can  lie  actetl 
"11  ni  till-  (huHlenum,  so  that  an  imp  >rtant  function  of  the  stomach  is 
to  act  iis  ,1  r»reptacle  for  footl.  It  is  known  that  the  action  of  the  pyloric 
sphnici.  1  IS  intermittent,  {)eriods  of  relaxation  alternating  with  periods 


:U4     THE  DIOESTIVE  b'UNCTlOSS  ASD  THEIR  DISTURB.iXCK.S 

of  poiitractioii,  thus  allowinj;  only  small  amounts  of  huxl  to  puss  «!  a 
time.  How  this  is  hniiight  aUiut  is  even  yc-t  not  well  nnderstcnxl,  ami 
has  leil  to  (-onsitierahle  theorizin)^.  The  most  we  can  say  p<xsitivclv  is 
that  the  act  npiK-ars  to  Ih>  reflex  an<i  <le|)eiMlent  on  the'  amount  and 
condition  of  the  fixnl  in  the  pyloric  antrum  ami  its  dejjrw  of  aciditv. 
Once  in  the  (hio«leniim,the  acidity  of  the  partially  digeste<l  f(Kxl  is(|iii(kiv 
neutralimi  by  the  alkaline  contents  of  that  portion  of  the  Ixjwel,  and  it 
is  thus  pnpare*!  for  the  action  of  the  pancreatic  secreticm,  the  siktiis 
entericus,  and  the  bile. 

The  semisolid  and  partially  dij^sted  food,  »t  chyme,  jis  it  is  now 
c-alled,  is  rapidly  pa.sse<l  on  thnm^h  the  small  intestine  by  |)eristal.sis. 
The  movr.nents  conn«H-te<l  with  |)eristalsis  appear  to  l)e  threefold.  'I'hcre 
is,  first,  a  simultaneous  contraction  of  the  circular  and  lonj^itudinal  fillers 
of  the  muscular  wall,  which  has  the  effect  of  thoroughly  mi.\in<r  the 
chyme  and  brinfjinf,'  every  part  of  it  in  contact  with  the  mucous  mem- 
brane; secondly,  waves  of  contraction,  affecting  the  circular  laver  of 
muscle,  which  tend  to  progres.-  forward  and,  as  a  crm.se(piencc, Cam 
along  with  them  the  intestinal  contents;  thinlly,  simultaneous  (-(.ntrae- 
tjons  and  relaxatioas  of  the  muscle,  producing"  a  rhythmical  segmenta- 
tion '  f  the  lK)wel  and  its  lumen. 

The  iletx-ecal  valve  is  the  liounilary  In'twwn  the  large  tiiid  small 
intestine.  It  is  slit-like  in  shape,  uimI  when  the  cecum  In-conies  dis- 
tende«l  with  fcMnl  pnxlucts,  or  is  the  site  of  mus<-ular  c«)ntra(tioM,  it  is 
doseil,  thus  preventing  the  return  of  the  contained  material  into  the 
-small  lx)wel.  The  movements  of  the  larg<'  intestine  are  not  unlike  those 
of  the  small,  but  are  sh)wer  and  less  vigorous.  In  the  sacculated  portion, 
they  result  largely  in  the  transference  of  material  through  contrHctieii 
from  one  .sacculus  to  another,  which  dilates  to  rect>ive  it.  The  move- 
ments of  the  sigmoid  anil  rectum  are  comparatively  infre(|uent. 

Defecation,  or  tht  expulsion  of  the  unused  n-sidue  of  the  fo<Hi  from  the 
Inxly,  is,  or  at  least  may  Ik-,  a  purely  reflex  act.  The  sphincter  ani  is 
usually  kept  in  a  state  of  tonic  contraction  thmugh  the  action  of  a  centre 
in  the  lumlmr  ccjni.  The  accumulation  of  fwes  in  the  large  Ixiwel  leads 
to  increased  peristaltic  action,  an<l,  therefore,  increasetl  pn'ssure  a^'ainst 
the  sphincter.  The  limiUir  centre  is  then  inhibited,  and  tlir()iij;li  the 
combined  action  of  the  intestinal  an<l  alxhrniinal  muscles  and  the  levator 
ani,  the  contents  of  the  IkjwcI  are  ejectwl.  It  should  Ih-  remarked. 
however,  that  in  human  beings,  at  all  events,  the  act  of  defecation  is 
largely  controlled  by  the  will.  The  glottis  is  closed,  the  (li:ii)liragm 
is  fixe<l,  and  with  the  chest  thus  .splinteil,  as  it  were,  the  alMJnminal 
mu.scles  can  contract  effe<-tively,  and  drive  the  contents  of  the  luri;.'  Iniwel 
forwanl.  The  lumlmr  centre  also  ap|>ears  to  Ik>  to  some  extent  under 
the  control  of  the  volition.  The  power  of  the  will  to  hasten  or  to  delay 
«lef«-c-ation  is  too  well  known  to  refpiirc  comment. 


DEGLUTITION 


345 


DII0BDIR8  or  TBI  DIOUTIVK  MIOHANIBM. 

S«rious  resulu  may  follow  the  imperfect  perfommnce  of  any  of  the 
motor  functions  of  the  alimentary  canal,  results  that  are  often  far- 
reaching  in  tlicir  character. 

1 1 )  BCMtication.-  Insufficient  mastication  may,  for  example,  result 
frr)i:i  deficient  or  painful  teeth,  inflammation  or  injury  to  the  maxillie 
or  tcmpororaaxillary  joints,  spasm  of  the  mascles  of  the  j  ,,-,  or  paresis 
of  the  miLscles  concerned  with  the  movement  of  the  food  within  the 
mouth.  Moreover,  painful  affections  of  the  mouth,  tonsils,  or  parotid 
glands  will  render  patients  averse  to  taking  a  sufficient  amount  of  food. 
If  such  conditions  Ik-  of  some  standing,  malnutrition  of  the  body,  as  a 
wliolc  will  inevitably  result.  WTien  fcHxl  is  imperfec-tiv  chewed  or 
insalivated,  the  bunlen  of  the  stomach  is  greatly  increa.se«l,  and  digestion 
may  Ik-  greatly  delayed.  In  aggravated  cases  even  gastriti-s  mav  be 
iiuluccd. 

Deglutition.— Deglutition  may  \w  rendered  difficult  or  impossible  from 
ilefcct  in  the  palate,  and  through  paralysis  of  the  tongue,  cheeks,  or 
wsopliagus.  Thus,  the  motor  nuclei  in  the  medulla  may  l)e  destroyed, 
as  in  bulbar  paralysis  and  tumors  of  the  nieilulla,  or  there  may  \ye  a 
peripheral  neuritis,  such  as  is  not  infrtxpiently  met  with  in  <liphtheria. 
Similar  n-sults  may  follow  diminishetl  excitability  of  the  trntre  or  of  the 
sensorv  iier\es.  Spasm  of  the  necessary  muscles* again,  such  as  we  meet 
with  in  tetanus,  strvchnine  poisoning,  hysteria,  and  hydrophobia,  mav  pre- 
voitt  deglutition.  The  appnipriate  movements,  not  iH-ing  properlv  cor- 
ri'lated,  or  lieing  rendere<l  impassible  through  tlisease  or  physical  (Jefect, 
may  result  in  the  ftKxl  taking  an  abnonnal  course,  for  example,  into  the 
larvrix,  (nichea,  or  bronchus,  or,  again,  into  the  nasal  cavitv.  OKstruc- 
tioii  of  the  larynx  lea<ls  rapidly  to  suffocati<m,  if  the  wndition  \\e  not 
ppHiiptly  r«iiev«-d,  or,  should  theoffemlingsubstancr  InH-ome  lodged  in  the 
liMiK.  an  infective  pneumonia,  with  not  infre<|uentlv  gangn-ne,  is  almost 
(rrtaiii  to  result.  The  passage  of  fiKnl  into  the  nasal  cavitv  is  attend«-«l 
with  .lisconifort  rather  than  danger,  but  may  Ik-  so  disagreeable  that  the 
IHTsoii  so  affe<ted  refrains  from  eating.  A"large  pro|K)rtion  of  the  f«KKl 
may  I,,.  |„.st  in  this  way.  Pain  in  swallowing,  like  pain  in  chewing, 
mav  Iciid  the  patient  to  take  insufficient  nourishment  and  thus  induce 
marasmus. 

Ill  iIk  ( use  of  the  u\sophagus,  difficulties  in  the  matter  of  deglutition 
art-  usually  to  Ik-  referre«l  to  positive  obstruction.  This  mav  Ik-  .lue, 
""  tlu  ..„(■  hand,  to  inability  of  the  mu.scle  to  force  the  fcKxl  onward,  or, 
<m  tlic  oiJuT,  to  a  narrowing  of  the  lumen,  which  renders  the  onward 
passiijr,.  of  the  IhiIus  difficult  or  impos-sible.  Not  infre<|ueiitlv.  l)oth 
•I'liditii  MS  are  combined. 

Muscular  ingoffidoncy  ».f  the  «e.sophagus  is  alwavs  asstniated  with 
"lata  I  mil  of  ,ts  lumen.  Some  of  the  acute  cases  are,  l)evon.l  doubt, 
""If  to  ^1  prmiary  paralysis  of  the  musculature,  f(.r  the  condition  has  l)een 
priHlii,,,!  exprimentally  in  the  dog  by  cutting  both  vagi  in  the  neck. 


•,m     THE  DWESTIVE  FUXCTIONS  AND  THEIR  DIHTURBASCKH 

Aa  a  result,  thuii^h  the  eanlia  remaiiut  o|x>ii,  the  fiMNi  dnes  not  [>u.s.s  into 
the  stomaeh,  but  aeeumulates  in  the  n'sophngus,  tIec-onifMxses  tht-n-,  an<| 
eventiially  cauws  death.  Tlien'  are  some  eases,  also,  (»f  s<M-alle<l  "  i(li<H 
pathie"  dilatation  that  art>  apparently  eon^renital  and  <levelopnieiiliil. 

Hwroving  of  the  Inmen  of  the  lesop'  '^irus  arises  from  a  variciv  of 
eauaes.  Some  few  eases,  sueh  as  those  foun<l  in  hysteria  and  hyjMMlKMi. 
driasia,  appear  to  be  due  to  a  funetional  disonler  of  the  nature  of  u  spasm 
of  the  lower  end  of  the  orf^n.  The  majority,  however,  result  from  some 
<lemonstrable  physieal  eondition,  eieatricial  eontraetion,  the  pn-ssim- 
or  traetion  of  inflammatory  Imnds,  the  pressure  of  enlary^Ml  ftlaiKJ.s, 
tumors,  aneurismal  sacs,  or  divertieula.  When  the  stenosis  is  fjnuiiml 
in  its  onset,  the  walls  of  the  a-sophapus  above  the  strieture  hy|K>rtroph_v 
and  for  a  time  may  l)e  able  to  foree  the  ftxxl  onwani.  S<M)ner  or  later. 
however,  disability  l»eeomes  apparent,  only  the  smaller  particles  of  food 
being  able  to  pass,  and,  finally,  liquids  alone.  Hypertrophy  is  succct-ded 
by  dilatation  and  the  inability  may  then  l)eeome  eompiete.  IiiHani- 
mation,  and  even  ulceration,  of  the  crsophagus  may  1h'  induceil,  and 
death  result  from  infection  or  from  starvation. 

The  symptoms  are  those  of  okstruction  to  the  passage  of  food,  stasis 
and  decomposition  of  the  contents  of  the  sac,  and  regurgitation.  The 
regurgitation  is  quite  different  fnim  vomiting,  inasmu<-h  as  tlie  UtoA 
appears  to  return  of  itself;  there  is  no  nausea,  and  the  alMloniinal  nuiscles 
are  not  calle<l  into  play.  The  symptoms  <K-casionally  resemble  those 
of  rumination.  In  the  cases  where  then>  is  only  a  partial  anaidiiiical 
obstruction  or  an  intennittent  functional  stenosis,  symptoms  may  (K-etir 
irregularly,  and  the  condition  is  compatible  with  prolongjnl  periods  of 
perfect  health.  A  j)ersistent  close  stricture,  on  the  other  hand,  which 
cannot  be  relievetl,  results  in  death. 

Apart  from  muscular  weaknes.s  or  stenasis,  deglutition  may  Ik'  rendered 
impassible  through  a  solution  of  the  continuity  of  the  nesophagus.  Rup- 
ture of  this  organ  from  traumatism,  cancerous  inHltration,  or  |M'plic  self- 
digestion  anil  ulceration  has  ix-casionally  In-en  met  with. 

(3)  Gastric  Motility. — The  disturbances  of  the  motor  fuii(iii)iis  of 
the  stomach  take  the  form  of  overactivity  anil  insufficiency. 

OverMtiTlty  may  l»e  the  result  of  excrssive  irritability  of  flic  mrvoiis 
mechanism  of  the  .stomach,  l)ut  is  much  more  often  due  to  some  diflicnhv 
in  discharging  its  contents.  Any  obstruction  at  the  pyloric  orificf  niav 
bring  this  alxiut,  whether  it  Ik-  from  newgrowth,  the  pressure  of  tiihtrj;e<l 
glands,  the  traction  of  inflammatory  adhesions,  hyp<'rtropliy  of  the 
pyloric  ring,  or  spasm  of  the  mu.sculatim*  of  the  pylorus.  In  such  <!ist"s 
the  efforts  of  the  stomach  to  empty  itself  Inx-ome  very  fonil)lc.  .ind  the 
increased  peristalsis  may,  in  thin  subjects,  l>ecome  visible  on  tlir  surface 
of  the  alxlominal  wall.  ShouKl  the  stoma<-h,  in  spite  of  its  more  iioucrfiil 
contractions,  Ix'  unable  to  force  its  contents  onward  within  tlir  usual 
time,  its  muscle  gradually  weakens  an<i  dilatation  sujx'rveiies  iiihim  the 
motor  inadequacy. 

Motor  inanffieiency,  or  atony  of  the  stomach,  is  a  not  infre<|ii('iit  ( ondi- 
tion,  and  almast  invariablv  lx>comes  as.s(x-iated  with  dilttation.     It  inav 


(lASTRlC  MOTlI.irV 


347 


lie  aciiU'  or  <-lin>iiic-.  The  chroiiif  fomi  i.s  usually  the  result  «>f  s!»me  form 
of  okstriK'tion  ti)  the  outflow  of  the  pistric  eonteiits  through  the  pylorus, 
or  to  lialiitual  overeatinj;  or  ovenirinkin);.  The  causes  at  work  are  either 
operative  over  a  prolon|{e«l  pericNi  of  time  and  are  jrnuiual  in  their  efTecta, 
or  are  freijuently  repeated. 

The  acute  form  may  supervene  upon  the  chronic,  Imt  is  more  often 
spontaneous.  Here  pyloric  obstruction  is  rare,  the  fault  in  most  ca.ses 
lieiiij;  in  the  duiNienum.  Compression  of  the  (luodenum  by  the  root  of 
the  mesentery,  or  by  the  traction  of  adhesions,  or  kinks  leadii^  to  oblitera- 
tion of  its  lumen,  are  the  usual  lesions  found.  Not  a  few  ca.ses,  how 
many  we  cannot  veiy  well  say,  appear  to  lie  the  result  of  a  primary 
paralysis  of  the  gastric  mascle,  either  due  *n  some  toxic  effec-t  upon  the 
nerve  terminals,  or  to  disease  of  the  vagi,  or,  again,  to  inhibition  of  the 
(■e rel)ral  centres.  Conditions  predisposing  to  acute  gastric  dilatation  are 
8m'sth«'sia,  pi^olonged  ami  wasting  disease,  indiscretions  in  diet,  deformity 
of  tlie  spine,  injuries  to  the  heail,  Imck,  and  alxlomen.* 

The  results  of  motor  insufficiency  depend  largely  on  the  cau.se  of  the 
condition  and  its  extent.  In  the  milder  grades,  lieyond  some  slight  delay 
in  the  discharge  of  the  gastric  contents,  the  con.se(|uence.s  are  but  slight. 
Should,  however,  fo<id  particles  remain  c-ontiniiously  in  the  stomach, 
(Itfoniposition  st'ts  in,  with  the  production  of  abnormal  acids  and  ga.ses, 
ami  leads  to  .serious  disturl>ance  of  the  .secretory  power  of  the  mucasa,' 
and  to  dilatation  of  the  organ,  (iastritis  is,'  also,  a  not  infre(]uent 
result.  The  presence  of  an  exce.ssive  amount  of  food,  the  retention  of 
fluid,  which  is  normally  .secreted  by  the  stomach  in  considerable  quantiiy, 
the  dcjreneration  of  the  mu.sc-le  fillers,  all  contribute  to  the  production 
of  dilatation.  In  ca.ses  of  functional  obstruction,  such  a.s  may  be  due 
to  spasm,  the  dilatation  is  not  neces.sarily  a.s.sociate<l  with  inability  of 
the  stomach  to  discharge  its  contents.  Examples  of  this  are  found  in 
(winccfioii  with  chronic  ga.stritis,  peptic  ulcer,  and  carcinoma,  and  in 
hvp<Ta(idity  and  hypersecretion.'  Possibly,  here,  the  wndition  is  an 
intemiittciit  one,  giving  the  ga.stric  mu-scu'latiire  time  to  rei-over.  It 
^houl<l  not  Ih-  forgotten,  either,  in  this  wmnection,  that,  like  other  organs, 
the  stomacii  has  a  certain  amount  of  mser\e  force,  so  that  for  a  time  a 
slijrhtl.v  dilat(Hl  stomach  may  be  able  to  empty  itself  within  a  rea.sonable 
IK-ridd,  and,  so,  continuous  retention  of  foo«l  diH's  not  cKfur. 

Wlicrc  obstruction  to  the  onward  flow  of  the  stomach  contents  is 
(i)m|)hi.'  or  nearly  .so,  death  will  eventually  take  plac-e  from  inanition, 
unless  tlie  condition  lie  relieve*!  by  operation.  In  the  le.ss  extreme 
instaM( . ,,  in  which  there  is  stagnation  of  f<Mxl  and  the  pnxlucLs  of  .secre- 
tion and  dijfestion,  conditions  an-  favorable  for  the  growth  of  micro- 
|>r(;ani>iM~.  so  that  we  have  abnonnal  fermentations  g«)ing  on  with  all 
I lat  niiplus.  Not  only  is  the  nonnal  process  of  secretion  impaired  bv 
the  rei.iiii,,,,  „f  products  that  .should  lie  removed,  but  the  abnormal  pn^ 
'ii"iion  nt  fatty  acids,  ga.ses,  and  other  chemical  substances,  leads  to 

^  Niohuil-.  Acute  Dilatatian  of  the  Stomach,  International  Clinics,  4 :  1908 :  80. 
•Kii'i^l..  Mittheil.au8d.Grenj!geb.,4:ai7.  '  Kausch,  Ihiil.,  7. 


H^4^gfMH4li|. 


34S     THK  DIGKSTIVE  fUSCTlOXS  AM)  THEIR  DISTUHttASCt.s 

irritation  of  the  tmic«Ma,  ililntHtion,  min,  «-nictiition.s,  and  voiiiitin^r. 
When  the  ilecompoHed  niuteriulM,  witii  the  enornioii-s  uccuniiiiiitiiui  of 
JMU-teria  that  aeeompanieM  them,  Is  in  j-oiirsi'  «if  time  (>a.s.se«l  nn  imo  (Ik- 
intestine,  further  irritation  and  further  dec«)in|>osition  ar«>  initiulnl. 

In  the  acute  ea-ses  a  lethal  tenninntion  eonie.s  on  nion-  or  less  rji|iiillv 
in  eases  that  are  not  reeogniwHl  and  treatnl  judicioUHly,  ap|>an>nil\  fniiii 
the  eoinbine«l  effeets  of  inanition,  shiN-k,  an<i  collapse. 

Some  rurioiu  ner\'oiis  effects  are  priNiuced  h\  Kastri<-  dilatation,  siH-h 
as  tetany,  epileptiform  convulsions,  tetanoid  niuscniar  <-onlraiti<iih, 
general  depression,  ami  collapse.  Whether  these  are  the  n-stilt  of  svstcmir 
intoxication  owing  to  the  alisorption  of  |M>isonous  siii>stunccH  frmn  tin- 
alimentary  tract,  <ir  to  more  mechanioil  causes,  su«'h  as  the  disitiisidn 
of  the  gastric  mascle,  or  the  loss  of  fluids  fn>m  the  ImmIv,  is  iiy  no  nitaiw 
definitely  estaliHshcHl.  The  striking  olise  vations  of  Wrstraeteii,  Nnmlrr- 
linden,  Halstead,  lioeb,  and  the  MacCallunLs,'  however,  sn>;;;t>t  an 
explanation  for  a  hitherto  oKs<'ure  condition,  for  they  have  |irov«i 
conclu-sively  that  the  important  factor  in  the  etiology'  «if  tctnnv  aiiil 
various  convulsive  phenomena  is  a  deficiency  of  calcium  salts  in  the 
system,  in  some  ca.ses,  at  least,  dep«>ndent  on  parathyroid  insnfficifiK  v. 

VomitiBC  is  a  common  feature  in  liilatation  of  the  stomach.  In  ilie 
slowly  progre.ssive  chronic  ciwes  vomiting  cK-curs  at  comparativcK  nnv 
intervals,  an  enonnous  ipiantity  of  offensive  material,  <-<insistitii:  iif  iin- 
digesteil  fiMxl,  fluid,  fermenting  and  dei-om|Mising  matter,  Ih-Iii);  liri>iij;lit 
up,  the  acc-umulation  of  .sevend  days.  The  vomiting  in  the  mwu-  forms 
is  essentially  <lifferent,  In-ing  mon»  of  the  nuturi'  of  a  rcgnrgilation,  the 
material  ctiming  up  with  little  effort  and  at  brief  inter\als.  FikkI 
has  no  time  to  accumulate,  as  it  is  immediately  rej«-<-t»Hl,  and  tin-  vmnitiis 
coasists  chiefly  of  watery  .secretion  from  the  stomach,  with  grc«iii>h  or 
hlacki.sh,  curtly  flakes,  hile,  and  often  a  diaslutic  ferment.  The  uiiioum 
brought  up  is  quite  enormoas,  as  the  vomiting  is  jn-rsistent  aixl  micon- 
tmllable. 

The  act  of  vomiting  is  a  .somewhat  complicated  one,  and  is  i,'iivtrii(>i! 
by  a  .special  "vomiting  centre"  in  tin-  medulla,  situated  not  far  fn.iii  the 
respiratory  c-entre.  This  centre  may  Ik-  stimulated  dircitiv  l.v  tuxic 
sulxstanc-es  circulating  in  the  bl(N)d,aiid  by  a  varietyof  intra(rani;ii  loiu'i- 
tions.  It  may,  also,  be  affecfe«l  r«>fle.\iy  by  .stimuli  n-acliiii;:  it  fmiii 
other  orgaas,  such  as  the  no.se,  stomach,  |H>ritoneum,  and  iitcrns.  \  .unit- 
ing begins  with  a  deep  in.spiration.  The  glottis  is  cI().s«hI,  the  ili.i|)lira).'in 
is  depre.s.sed  and  fixed,  an<l  the  alMlominal  respiratory  iniiscli  >  ^irr  con- 
tracte«l.  The  .stomach,  in  .some  cases  at  least,  und'  .pH-s  aiiii|>i  ri-ialtic 
movements,  and  a  small  amount  of  its  contents  is  aspiraiid  ii.i.)  the 
•psophagus.  Finally,  the  aUlominal  muscles  contract  vi^rofnlv  ami 
the  contents  of  the  stomach  and  le.sophagus  an>  forcibly  exptll((l  tliniii;;h 
the  mouth.    The  act  of  vomiting,  however,  includes  inon'  than  thi>.  for 

it  has  a  profound  sy.stcmic  effe<t.     Sulivation  and  sweating  ar i n 

occurrences  at  its  inceptii/.  ,  the  bloo<l  pn'.ssun-  falls,  aiul  tlir  jiiil>e  is 

'  W.  G.  MacCalluin,  Johns  Hopkins  Ho»p.  Bull.,  9:l<J0.S:!i!. 


l\TF.STL\A  L  PURIST  A  LSIS 


349 


»l(.wc«l,  owing  to  va){UH  .stimulation.  I^ter,  the  IiIikmI  pre.ssure  ami  tlie 
nW  of  ihe  pul.<w  are  inarlcerlly  increased. 

\oniitiii>r  is  always  an  imiication  of  dUonlereri  function,  whether  of 
the  stomach  it.wlf  or  of  ,s<»ine  remote  or^an  with  which  it  is  connected  bv 
neni-  [wtlis.  It  is  cs.s<-ntially  a  nerv(»us  phenomenon,  the  stimulus  of 
which  is  either  |ieripheral  or  central.  Organic  dLse&se  Ls  not  neces-sarilr 
itnxnt,  and  many  casj-s  are  purely  functional.  The  power  of  un- 
p'cHsi  lit  sights  rir  smells,  for  example,  is  well  known.  The  influence 
of  the  rnimi  is,  therefon-,  ap[>an-nt. 

Akin  t<.  vomiting  is  balehing,  by  which  is  meant  the  expulsion  of 
(ras  tlinmgh  the  mouth.  This  gas  is  either  air  that  has  been  swallowed 
or  the  |inNhict  of  fermentative  processes  going  on  in  the  stomach.  Very 
oftfii  the  gas  brings  with  it  small  <|uantities  of  liquid,  containing  fatty 
acitU  or  hydrcK'hioric  aci<l,  which  gives  rise  to  unpleasant  burning  sensa- 
liidH  ill  th«  mouth  and  gullet.  This  is  known  as  pyrogU  or  "heart-bum." 
.Xlipaniiliy.  there  is  a  preliminary  relaxation  of  the  canliac  sphincter  of 
the  stomacli,  which  p«'rmits  gas  to  l)e  forced  through  in  consequence 
of  coiiiinvssive  action  of  the  diaphragm,  abdominal  muscles,  or,  possibly, 
of  the  stomach  wall  itself.  The  eructation  of  gas  in  certain  hysterical 
ptr-oiis  may  attain  extraonlinarj-  proportions,  the  belching  being  almast 
(•\|)lo-;ivf  in  character  and  ret  irring  at  fre<|uent  intervals.  ITie  condition 
a[)|H;irs  to  l)e  due  in  these  cases  to  the  habit  of  "air-swallowing."  Re- 
Ht\»>  from  the  stotnach  and  peritoneum  play  an  important  role  in  the 
causitioii. 

HiccouKhing  is  somewhat  similar,  but  is  due  to  a  clonic  spasm  of  the 
miiM  I.N  in  ijiicstion.  As  in  the  case  of  Mching.  it  may  be  initiated  by 
rtH.\f>  from  the  stomach  or  alxlominal  cavity.  The  remarkable 
Iwriviiii;  hicfoiigh.  sometimes  met  with  in  hystericarconditions,  Is  perhaps 
iiiiftiMciitr.il  caus«'s.  " 

4  Intestinal  PeristalsiB.— I  )uring  perio«k  of  complete  fast  the  entire 
pi-tn>-iMt.-itinal  tract  is  at  rest.  With  the  initiation  of  the  digestive 
fiiiKiii.ii.  iiowever,  movements  are  instituted  having  for  their  object  the 
ihor..iii:li  inixiiig  of  the  fo«Kl  and  its  subjection  to  the  action  of  the  various 
.hii-tii.  tVrm.'iits  in  turn.  The  jieristaltic  movements  of  the  bowels  are 
noniially  iiiiol,trusive,  although  tht-  individual  is  often  conscious  of  their 
prev:,,, .  i„  thin  persons  they  may  l)e  seen  and  felt  in  consequence  of 
traiiMiiitt.wl  undulations  of  the  unterior  alMlominal  wall.  Tsuallv  no 
sound  i-  prixliutil. 

I  n.|.  r  iii.iiomial  conditions  these  paristaltie  moTemento  mav  be 
Sreatly  increaied,  lK»th  in  force  and  frequency.  This  is  especially  well 
vrii  111  fh..v  (UMs  where  there  Ls  some  oKstriiction  in  the  lumen  of  the 
ljo«.l  I,.  U-  overcome.  As  illastrations  of  this,  mav  lie  cited  kinks  in 
the  !»>\,1.  volvulus.  <icatri<ial  contracture  of  the  llimen,  new-growths 
in  III.  !„,u..l.  luTiiias  aiul  other  causes  of  external  pressure.  When  the 
"O-T!.  ,.„  ,01ms  on  siuidenly.  violent  cramp-like  movements  of  the 
-iw.i  ;,  .,,v,.  the  Milt  of  the  tn)uble  are  induce.!.  Should  the  condition 
i»- ii-t  ■  l,..v„i.  houcver.  these  cea.s«>  in  time,  giving  place  to  an  atonic 
ana  ,,i,.r,,i  condition  of  the  bowel,  which  leads  cjuicklv  to  toxemia, 


aV)     Tin:  MdKSTIVK  FUSCTinSS  ASH  THEIR  DISTURBAM  IS 


nilla|M4«',  uimI  iltnitli.  In  c-u.<w>m  wluTt-  tlu'  olislnictioii  iiiint'H  mi  mon' 
gratliially,  tin-  iiH'n>a<w>4i  work  of  die  ImiwcI,  in  Htteniptinj;  to  Utnv  iis 
(■ontenLs  |Ni.<*(  the  (xiint  of  nurn)win)(,  nituhs  in  iiyprrtntphv  of  its 
inu.s«-ular  wall,  though  in  tin-  later  .<«taK«^  a  tvrtain  amount  of  irilaialion 
LH  prcMMit  an  well. 

Nlon-  ctunnion,  aiHl,  fortunately,  less  serious,  are  those  ease's  of  in- 
rreaMHl  peristaltic  action  that  «time  on  in  the  ahsentv  of  olwiriictinn. 
To  understaiHl  tlu-se  we  must  In-ur  in  mind  that  the  motor  activitiw  of 
the  Iwwel,  like  the  s«-«>relory  functions,  are  initiate*!  hy  and  an-  iarp-lv 
under  the  eontnil  of  the  nervous  system.  Peristalsis  is  fonuuonlr  rp- 
flex,  the  stinniliis  U-inj;  the  pn>s«MHT  of  solid  and  li(|uid  matter  within 
the  lumen.  Insome  instances,  however. the  stimulusappears  toliecfiitnil, 
as  in  tlHwe  cast's  due  to  emotion,  excitement,  fear,  worry,  antl  tin-  likr. 
The  influentv  of  the  miiHl  over  the  activities  <if  the  stomach  and  Inmels 
is  a  well-n-t-onnizetl  fact.  Kxcessive peristalsis,  then,  may,  cimcciviihlv, 
Ih'  ilue  to  an  increase  in  the  nonnal  stimulus  within  the  JMnvcl,  to  an 
incri'iuu-*!  irritability  of  the  ImiwcI  wall,  whether  nervous  or  inuMnUr, 
or  to  impulses  priK-eciling  fn»m  the  (•erebrum. 

Csually  the  condition  is  accompanied  hy  diurhoa,  though  not  iii\  iirialiiv 
so.  In  elderly  persons  and  hysterical  subjects  it  is  not  unctHniiimi  lii 
have  gurgling  soinids  [hurlxtryfjini)  priMluctnl  within  the  intestines,  which 
may  Ik-  autlible  at  a  j-onsitlerable  distance,  without  diarriiiea.  This 
is  more  aj)t  to  o<rur  when  the  Uiwels  cimtain  gas  but  a  relntivciv  siimll 
amount  of  solid  mutter.  The  nonnal  stimulus  to  the  contnuHoii  of  the 
iH>wels  conies  fnmi  the  ciwrser,  indigestible  constituents  of  the  food. 
Should  these  Ih'  in  excess,  increusetl  p<'ristalsis  and  diarrhcea  will  ri'siih. 
Mjcm*  often  chemical  irritants  are  at  work,  either  iiitnxj'iced  vitli  ihr 
fcMMl  or  the  result  of  faulty  digestion  and  of  abnonnal  f<Tni<rilation. 
The  organic  acids  and  the  various  gases  rt>sulting  fn)m  de<i>in|)ositi(iM 
are  the  chief  «)tTemlers.  .\n  interference  with  the  absorption  of  water  liy 
the  lH)wel.  in  some  instances,  will  cause  diarrhieu. 

Any  condition  that  leads  to  increase<l  irritability  of  the  inicstiiu'. 
either  of  its  mucosa,  muscle,  or  nerves,  favors  the  prcxluction  of  (iiarrho-a. 
for  here  normal  stinnili  may  pn)duc«'  excessive  response.  In  niaiiv  forms 
of  acute  enteritis  such  an  increas«'d  irritability  is  pn'senf.  tlioiich  we 
have  to  n-ckon  with  the  stimulating  eff«H-ts  of  the  pnNliicIs  of  alwioniial 
fermentation  as  well.  It  is  singidar.  however,  that  a  coii^iihwlplr 
degHH'  of  inflammation  of  the  lM>wel  may  Ih-  present  in  some  casis  h  jihoiit 
diarrhiea.  when  we  might  n'a.soiml>ly  have  expected  it.  Ty[)hni(l  fever, 
for  example,  is,  in  this  country  at  least,  nmre  often  as.s<Hiati il  with 
constipation  than  with  diarrhira.  The  same  thing  is  true  alM>  lif  many 
chronic  inflaininutions  of  the  Iniwel,  even  when  associated  with  iih.  ration. 
Such  conditions  an'  often  remarkably  sluggish. 

We  have  .se«>n  that,  normally,  the  movements  of  the  ga.strit-inteMiiial 
tract  arc  more  or  less  inHuen<  itl  by  the  central  nervous  sy>!.  m  I'his 
o|>eralcs  pn>bably  through  the  agency  of  the  vagus  and  ~|  Iniehnie 
nerves  In  hysterical  and  neurasthenic-  subjects  companitiM  !\  >licht 
Stimuli  itff  .■jufficient  to  bring  on  ovcrtjction  of  the  lx)wel>.    i^-n  ihe 


IXrk.fTIXAL  hERISTA  LSIS 


351 


fnir  of  a  (iiarrhu-a  may  l»p  rnou^h  in  certain  '-isreptihle  inriiviiiuals. 
In  iHiMiiw  of  a  iMTvoiiH  lvp<\  wfirry,  uiixirty.  U  r.  or  .tiirpriw,  in  fact, 
anv  Muklcii  emotion,  will  liriiig  on  a  watery  evuniatitm  of  the  lioweh.' 
IimLt  such  ein-nniHtanees  the  -iliijhte.st  inili.<MTetion  in  diet,  also,  may 
\tt  tnoii){h  to  precipitate  an  attack,  though  at  other  titm-s  it  might  lie 
iii-nfficient  to  prtMluce  this  result.  ()rKani<-  tilseast*  of  the  central 
m-rvims  xystetn  may,  iMi-ationally.  priNliice  <liHrrh(Pa,  as,  for  example, 
hicoiiiolor  ataxia,  during  an  intestinal  crisis. 

'I'lif  act  of  defecation  is  to  a  considenilih'  extent  (le{H-nilent  on  peri- 
staisi'  of  the  ImiwcIs.  'llie  descendiii|;  cohm  a<-ts  &s  a  storehouse  for  the 
iiniiMsl  resiilue  fmm  the  ingesta.  the  rectum  lieiiig  onJiitarily  a  olowd 
tiiU'.  owing  to  the  artion  of  the  so-callnl  thini  sphincter  .sitiiated  at  it<i 
tipper  eiul.  With  the  entry  of  feces  into  the  rectum  the  stimulus  comen. 
ami  leails  to  h  desire  for  evacuation.  .Vs  has  been  statt-d  previously,  the 
act  of  defecation  i.s  more  or  less  uroler  the  's>ntrol  of  the  will,  hut  not 
fiitinlv  so.  'ITie  act  may  Ik*  jlelayi-d  for  a  time,  hut  eventually  the  call 
liei-onics  imperative.  In  cases  of  diarrhira  the  contraction  of  the 
t-xterna!  sphincter  canmit  for  l()ng  Ik-  voluntarily  maintained,  and  evacua- 
tion takes  pla«e.  either  as  a  gentle  cM>King,  or  with  explosive  force,  af*-onl- 
i»>r  t"  the  forte  of  the  expulsive  movements  and  the  retaining  power  of 
the  cxn-rriul  spliin<-ter.  In  s<»me  inflammatory  affections  of  the  Ijowel, 
Midi  :i>  dysentery,  the  acts  of  defecation  are  git>atly  increa.sed  in  number 
and  ar.'  accs.nipanied  by  painful  seasations  or  ten'e»miu.  Hemorrhoids, 
fi'>ims  of  the  anus,  and  fLstiila-  also  render  the  act  exceedineiv 
painful.  ^ ' 

Involuntary  evacuation  (»f  the  lM)wels,  or  ineontinanea  of  facet,  is,  also, 
not  iiifns|uently  met  with.  It  may  result,  for  e.xampl«-,  from  organic 
ili-»aM-  of  the  brain  or  cord,  during  delirium  and  coma,  in  sleep  and 
intoxication,  and  fnmi  stning  mental  impre.s.sions,  as  fright  or  fear.  It 
U  |)r( -iiriitsl  in  these  ca.s«'s  that  the  cerebral  control  is  inhibited. 

|)ifi(  itnt  action  of  the  IniweN  is  a  common  ctmiplaint,  lieing,  inleod, 
with  many  an  almost  habitual  condition.  The  tenn  eonttipation  iinplie.s 
v>in.  what  more  than  a  mere  infrefpiency  of  evacuation,  connoting,  a.s 
It  ill-"',  an  aiierulion  in  the  character  of"  the  fe<-es.  Owing  to  the  fact 
that  fh.-  fixMl  remains  too  long  within  the  intestine,  the  fluid  parts  are, 
to  a  lari:.-  extent,  absorln-d.  or,  it  may  W\  the  fluiils  in  the  fo«Kl  mav 
haw  l» .  n  d.fi('ietit  from  the  iM-ginning.  ('on.se<jiiently,  the  ft-ces  liecom'e 
fimi.r  in  ( onsisteiMy,  and,  in  wme  cases,  even  dry!  hard,  and  stony. 
Ihe  latt.  rnsiijt  is  in  great  part  an  effect  of  pri'ssiire,  "and  the  fecal  masse.s 
"ft.  II  ir.  nioulde.!  to  the  shape  of  the  intestinal  cavitv.  Wliat  consti- 
lilt.'-  lii.  .i.ndition  of  constipation  is  .somewhat  hani  to  define.  Some 
[H-iN.,!,-  liave  an  evacuation  of  the  Iniwels  regularly  once  or  twice  daily, 
I  >tattsl  time.  ( )thers  may  g<>  without  a  movement  for  two  or 
V  Still  others,  women  esfx-cially,  may  go  a  week  or  ten  dav.s, 
"i::.'r.  Many  |MTsoas  affected  in  this  way  with  sluggishne.s.s'of 
1-  pn-M-rxe  the  manners  and  appt>aran(v  of  perfect  health. 
not  iHTha|xs  suffer  from  the  alxlominal  fulness,  the  .sallow, 
!aple.\ion,  the  furred  tongue,  the  loss  of  appetite.  «nd  the  head- 


"ftfli  a! 

ihni'  ,!, 

th.-  U.v 
Th.v  ',, 
tanh-.  ■■ 


.V)2     Tilt:  DWKSTIVK  FUSCTIOSH  AXIi  TIIKIR  UlSiURH.XStKS 


will*  ehat  an-  m)  oft»Mi  th«»  Hrc^mpiiniinriiU  «»f  thU  ctMHlitiun,  Imt  jn 
tli«>  nion*  iimrkttl  ch-m-h  i(  woiilit  Iw  iiiwafe  ti>  aiwiiini'  that  no  harm  wa.s 
Iteiiift  iloiM>,  i-vcii  Khtri  thi'iv  an*  ih*  nhvioiM  external  evUh'ti^rs  nf  ihr 
ili.'Mtnler.  A  wrtain  a'iii»iint  of  .slow  |i<>L<«>niiiK  '»'»y  Ik*  ff»\\^  mi  \\»\\ 
will  make  il.<M>lf  iiutnifi-Mt  in  (he  eiNl,  or  may  .h«>  Map  the  vitnl  eiiei  .  *ui 
the  iiiiiiviiiiial  will  fall  a  pn\v  to  iliscait*  of  other  kiiHls. 

Infn>«|tient  evuciiation  of  the  liowei.x  may  renult  fnmi  jjn'ws  olisinii  lion 
to  the  |Ni.H.Ha^>  of  f«H-«',s  through  the  lumen,  or  from  <imi>h's  uiiaNs.Hiaif<j 
with  MH'\\  olwtriK  tion. 

(iross  (iiiiHi>s  of  okstnietion  ar«'  foiiml  either  in  the  inieilinal  lulir 
it-telf  or  in  strueturef)  external  itnt  adjacent  to  it.  That,  in  tlu*  (irtf 
class  of  cases,  the  passa^'  may  Ih'  Itlm-keti  hy  feeal  niasseo.  jpillsforw"!. 
Itones,  or  other  fon4gn  siiUstances  that  have  Uhmi  swalloweti,  or 
bo  completely  ohiiterateti  at  a  \^\^'\\  point  hy  volvulus.  The  •  i  i 
may  l)e  iiarrowe«l  as  a  n-sult  of  clin>nic  inflammation,  cicatri«"  '  . ,. 
traction,  intits-susception,  tumors,  or  hemorrlioi«ls. 

In  the  s«'<'oihI  class,  the  oltstniction  is  caatitl  cither  hy  pn'  „ 

tra<-tion   exert*-*!    fn>m   without.      The   luinen   may,   for  exai  Ik- 

encnNtcheil  U|M>n  or  obliteratnl  hy  hernial  .sa«'s,  fiontus  ailhcsinns,  a 
retnivertinl  uterus,  or  other  misplacetl  or)(an.s,  or  tumors.  The  tnuijon 
of  adhesions,  the  dilatation  and  des^-ent  of  the  stomach,  ami  the  pn)lui>M' 
of  (rrtain  portions  of  the  Ik»wcI  owinj;  t«»  the  weight  of  tumors  in  tlic  wall, 
may  result  in  kinking  ami  oltstruction. 

Much  more  common  an*  those  cast's  of  constipation  that  an-  iiimssoci- 
ate«l  with  nuvhanicnl  olxstruction.  As  we  have  .seen,  the  finictioii  of 
peristalsis  is  commonly  reflt'x,  the  stimulus  iH'inp  the  pn-sencc  of  foiNt 
in  the  IkiwcI  of  sufficient  hulk,  and  especially  the  pnvsence  of  tin  liidiKcst- 
ihle  n'sidue.  .\n  insufficient  .stimulus,  affections  of  the  iniis»ular  wall 
of  the  IkiwcI  interfering  with  its  <oiitractility,  and  denin);eiii(iiis  of 
the  nenons  apparat.is,  have  all  to  Ik-  reckoned  with  in  a  disi-iission  of 
the  etiology'  of  <-onstipation. 

Unsuitable  diet  plays  an  important  role  in  many  cases.  FcmmI  that 
is  too  concentrated  and  easily  assimilable,  such  as  milk,  eggs,  itm'  meat. 
will  often  pnxluce  constipation.  A  deficiency  in  the  watery  con^iiiiifiils 
or  of  the  organic  acids  will  have  the  same  effect. 

Deficient  muscular  jxiwer  is  a  [xiteiit  cans*-  of  constipation.  We  sw 
this  ill  elderly  persons  and  tlios«'  of  a  setlentary  dis|M>.sitioii,  nnil,  also, 
during  the  convalescence  from  acute  diwase.  The  mu.s«le  in  llie.sf 
ca.ses  seems  to  undergo  a  wrtain  amount  of  degeneration  or  atroph; 
which  coiLsiderably  les-sens  its  effwliveiie-ss.  It  .should  Ik"  iMiiiitcil  out 
in  this  connection  that  mu.sciilar  contraction  of  the  intcstilM^  often 
exhibits  tt  definite  periodicity,  the  call  for  evacuation  and  tin-  n  ^iiltin^; 
peristalsis  (Kfurring  ut  alHiut  the  .same  hour  each  «lay.  Negic*  i  of  the* 
calls  is  one  of  the  imxst  potent  causes  of  constipation.  The  -tiimiliis 
iHtsimes  incn-asingly  ineffective,  anil,  owing  to  the  accuiiiiiliium  of 
fwes,  the  lower  {Mirtiim  of  the  large  IkiwcI  Inn-omes  dilattsl,  it-  iinw-ie 
thiiiiK><l,  and  its  jMiwer  of  ccuitraction  corresp<mdingly  (liihinished. 
Ultimately,  the  power  to  evacuate  by  natural  means  Is  entire!  v  l.^t,  and 


DimRDERS  or  SiiRBTloy 


s^ 


etn  oiiK  hr  rxcittti  bv  the  iwe  of  oath* rtirs.  It  hiu  been  f  -und  by 
rxperimrnt  that  a  rerttttn  ttmount  ot  material  within  the  bow»-  m  ncces- 
Min-  to  iralm  c  i(M  contraction,  but  if  the  lH>wel  lie  ^rpatly  diatrmiMi  the 
contractility  It  h'mcnetl  and  finally  aboiixlwd.  IV  power  to  miract 
will,  however,  return  if  tin-  dilatation  \w  rrli»-vi><l.  The  {■onstipatioii  that 
Mx-onipanic!!  peritonitis  appear!*  to  lie  due  to  a  combination  »»f  caiwe- 
(•li)iidim'!w  aiMl  de^>tH>rution  of  the  mns<'le  fiU-rs,  inflammatory-  oedema, 
ttiMJ  inhibition  of  the  ncrvoat  inipul.<*e!«.  A  .somewhat  siioiUir  ak^ujciation 
of  morlkid  comlitioas  is  met  witli  in  ent    'tis  and  colitis. 

llcfcn-nce  should  l»e  mwle  here,  also,  ...  a  form  of  <'oastifiation  titougbt 
hv  many  authorities  to  l»e  d«H-  to  a  coiMiiti«m  of  hv^M-rtoniLsof  the  intestinal 
niiwle.  'ITiu-s,  |iersonH  enjoyirijj  robust  healin  niay  Ih-  the  ..bjet-ts 
«)fi'oiisti|iation.  'Has  may,  in  jwrt.  lie  due  to  the  fact  that  the  usMunlativf 
fumli«)n.s  of  the  Uiwel  an*  p«rticularly  active,  but,  .erhaps  il.so,  to  an 
im Tea.-Ksl  t«me  of  the  whole  intestitml  tract.  Hela.xation  < -f  r!ie  Ik:  -el 
b*  rrii(ler«l  nuire  tlilfkiJt.  and  the  wave-like,  propulsive  is,  .vemen*.s 
characlrristie  of  perlstnl.si.s  an*  not  .so  ea.si!y  .set  up.  .S)metiincs  this 
hv|MTfoiias  Is  .so  exces-sive  us  to  leail  to  actual  .spa.sm  «f  certain  (K>rtioiis 
of  the  tract.  'i'iM>  condition  is  often  a.si)<N-iate<l  with  rulic,  and  the  pro- 
piiisioM  of  the  feces  for  the  time  lieing  is  n-ndered  ,n'iM.s.sil>lc.  Tliia 
form  is  met  with  in  chmnii-  lead  poisoning. 

The  (ii^)nlers  of  the  ner\ou.s  mechanism  of  the  Uiw.l  and  /I  ,  ii  ni., 
tioii  to  iH-ri-italsls  arc  .is  yet  very  imperfe»-tly  understtwd.  The  uiinglia 
atMl  |»iexu.se«*  of  ner\fs  in  the' intestinal  wall  jpivcrn  peristal 'i  and 
clianp's  in  tlw-se  .structures  have  Xiei-w  de.s<ri»K?<l  in  conntn lion  vi ith  l« wl 
poisoiiiii);  and  constipation,'  but  .similar  ap|M>arances  have  l»een  ob.s»-r\-e<l 
in  other  affections, 

("oiLstipntion  is  o<ta.siuiia!ly  met  with  in  Iwth  functional  and  orjp»nic 
ilis«'iise  of  the  central  nervous  .system,  as,  for  cxampl<  in  hv.steria, 
iitiira>tli(iiia,  melaiu li»!ia,  and  meningitis.  Why  thi.s  .should  lie  we 
do  tiot  know.  IVrhap  s«m»e  centrifugal  impulse  is  interfered  with 
«(n<li  is  ns|uir(sl  to  bring  aUmt  normal  ix'ristalsis.  Or.  iigain,  an 
iiiliiditory  nie<'hanism  is  fNis.sibly  set  in  action. 

<  onstipution  may,  in  .some  cases,  Ih«  unattended  by  obvious  signs 
of  (iisonirr,  i>ut  the  condition  imdoidititlly  interferes  with  the  proper 
"•oniiiK  t  of  dige.stion.  Abnormal  fennentation  of  the  intestinal  contents 
tak<s  place,  leading  to  flntidcncy.  Poisonous  substances  an'  pnxluce<l 
which  initv  enter  the  ciriulation  and  produce  far-reachir»g  results. 
Inflanimalion  and  even  ulceration  of  the  bowel  mav  occur,  or,  again, 
the  wcijiht  of  the  retained  material  may  lead  to  pro*lap.se  of  the  l)owcl 
ami  traction  on  important  stnicturcs. 


DISORD «:;«  OF  8I0RETI0K. 


^^).-i^||,tr     when  re<luce«(    'o  i..eir  simplest  <-on.stituents,  con.si>f  of 
P^<'t<lll^  ( arl)oliydrates,  fat.s,  water,  atid  i-crtain  mineral  salt.s.      I'h. 

'  Juripi «.  IJerl.  klin.  Woch.,  23:  1882;  Z-";  Maier,  Virch.  .\rehiv,  90:lssa:455. 


354     THE  DIOBSTIVB  FUNCTIONS  AND  THEIR  DlSTURBANCf:s 


digestive  fluids  concerned  in  the  transformation  of  food  are  the  salivs, 
gastric  juice,  bile,  pancreatic  secretion,  and  the  succus  entericus.  'llip 
food  materials  and  the  different  ferments  act  and  react  upon  one  another 
variously  in  different  parts  of  the  alimentary  tract,  so  that  it  is  convniient 
to  discass  the  process  of  digestion  as  it  takes  place  in  the  mouth,  stomach, 
and  intestines. 

Ih^  Salira. — In  the  mouth  the  digestive  fluid  is  the  ?aiivu.  'ITiis 
consists  of  the  excretions  of  the  various  salivar}'  glands  dischurf^iii);  into 
the  buccal  cavity,  and  contains  mucin  and  a  digestive  ferment— ptvalin. 
The  chief  function  of  the  saliva  is,  apparently,  to  facilitate  deglutition,  for 
the  ptyalin,  the  only  chemically  active  substance,  is  absent  in  cfrti.in  of 
the  lower  groups  of  animals,  notably  the  curnivora.  In  the  course  of 
mastication  the  food  is  ground  into  small  particles,  thus  facilitatiii); 
the  action  of  the  saliva.  The  watery  constituents  of  the  scciftioii  render 
the  food  of  softer  consistence,  and  the  mucin  provides  it  with  a  slipper^' 
coating,  so  that  swallowing  of  the  bolus  Ls  greatly  facilitatctl.  The  saliva, 
further,  dissolves  certain  mineral  su'^stances  that  are  soluble  in  weak 
alkaline  solutions,  fe(>bly  emulsiflr^  fats,  but  exerts  no  action  upon 
proteids,  excepr  that  of  maceratioi..  The  active  tH>nstituent  of  the  saliva 
IS  the  ptyalin,  which  is  a  diastatic  enzyme  acting  on  the  starches.  In  the 
chemical  traasformation  that  easues,  the  ptyalin  initiates  livdrolysLs 
of  the  complex  starch  molecule,  so  that  it  is  nnluctnl  to  siiM|)hr  mn- 
stituents.  The  first  action  of  the  ptyalin  is  to  render  the  viscid  starch 
more  fluid,  and  then  to  convert  it  into  a  variable  mi'itun-  of  dextrin, 
maltose,  and  isomaltose.  The  conversion  of  the  starch  into  a  thin, 
watery  fluid  takes  plac-e  ver}'  rapidly,  only  a  few  seconds  beirifj  rc(|iiircd 
to  briiig  about  the  result.  Thorough  mastication  of  the  fcKxl  and  its 
admixture  with  the  saliva  are  very  important,  for  the  amount  of  salivan. 
digestion  is  quite  considerable,  and  renders  the  fcKxl  to  that  extent  more 
suitable  for  the  action  of  the  gastric  juice.  In  fact,  the  conversion  of 
the  starches  into  dextrin  and  sugars  <H)ntinues  for  some  time  after  the 
fcHxl  enters  the  stomach  even  when  there  is  consi(lenil)lc  ;iciditv  of  the 
gastric  contents. 

A  diminution  of  the  amount  of  sulivu,  tVcn,  materiu'.ly  interferes  whh 
the  rapidity  of  the  tligcstive  pnx-ess,  and,  moreover,  interferes  with 
mastication,  deglutition,  and  .s|N-uking.  It  wcurs  in  many  fchrih'  condi- 
tions, notably  in  typhoid  fever  and  pneumonia,  as  Mosler  lias  |H)intc(l 
out,  and  in  all  conditions  in  which  there  is  an  incn<a.s(><l  cliriiiiialion  of 
water  from  the  .system,  as,  for  example,  diaU'tes,  cholera,  and  chronic 
interstitial  nephritis.  .Some  few  cases  are  definitely  nervous  in  orijiiii, 
e.  g.,  those  «lue  to  certain  paralyses  of  the  facial  nerve  involvini;  i  hi  chorda 
tympani.  An  is  well  known,  in  many  ci.iotional  states,  such  :is  lear  and 
"nervousness,"  the  mouth  iK-comes  for  the  time  lH'ing<|uiie  div  Mfoi- 
tomia).  Dryness  of  the  mouth  fn-ipUMitly  leads  to  the  rctcniimi  within 
the  buccal  cavity  of  small  particles  of  Unnl  which  (leconi|M>sf  jml  had  to 
a  great  multiplicatior.  of  Imcteria.  In  this  way  irritation  and  im  iitually 
inflammation  are  not  infrecjuently  proiluced.  Not  only  do  tin  liaiteria 
produce  their  local  effects  in  the  mouth,  but  they  may  be  iiilnxliufd  into 


PTYALISM 


355 


tilt- stomach  iii.NiU'li  niitnlx>rs  that  thlsdrKaii  is  uiuhle  to  rope  with  them, 
iiMil  scrimis  disturlMince  may  Ik-  set  up.  The  tcmRue.  h'ps,  and  gums  are 
(Irv,  <-(>ttted  with  (l(>(-nm(N>siiig  secretion,  cies(|iiamate(i  cells,  and  decaying 
fcKMl  (Kiirde»),  uDii  may  tlien  In-come  Kssim-d  and  inflamed. 

Alt  •  MTcascd  How  of  saliva  (ptyaliim)  may  lie  priMliiced  experimentally 
!>y  irritation  of  the  chorda  tym|>ani  nerve  or  hy  cutting  the  salivary 
iicncs.  The  ner\-ous  element  is  of  considenihle  im|)ortance,  for  we  find 
ii  iriitalile  increas«>  in  the  sjiliva  in  cases  of  hiilliar  paralysis,  in  which 
tlii-rt'  is  a  degenemtion  of  the  ganglion  c«'lls  of  the  me<lulla.  This  has 
Imtm  consideretl  hy  some  authorities  jis  U-ing  analogous  to  the  paralvtic 
swrctioii  that  msults  when  the  salivary  nerv«'s  an*  cut.  Krehl'  is'in- 
(•iintHJ  to  think,  lnjwever,  that  this  is  not  the  c«>rrtH't  explanatior,  hut  that 
till-  plu'iiomenon  is  an  irrit^itive  one  «hie  to  the  degi-neration  of  the  cells 
in  tiic  medulla.  Very  susceptible  |)eople  will  also  manifest  salivation 
at  ihf  sight  or  thought  of  foo»l,  or  even  when  they  think  they  have  taken 
(uloiml.  ( )ther  cast-s  are  undouhte<ily  «'flex,  as,  for  example,  those 
iisscKiiitj-d  with  ulcer  of  the  stomach,  pregnancy,  and  trifacial  neuralgia. 

I'tviilisiii  is  also  met  with  in  all  fonns  of  stomatitis  and  in  m»rcurial 
|x)is()niiig.  In  thcst?  cases  not  only  diH's  there  swin  to  l)e  a  reflex 
stiiiiiilatiou  of  the  salivary  and  mucous  glands,  hut  there  are  hical  changes 
in  llu-  iniicous  nu>ml>rane,  in  the  form  of  degenemtion  of  cells,  hyperemia, 
anil  iiiHununatory  exudation. 

I'lvalism  must  l>e  cari'fully  distinguished  fnini  the  apparent  increaje 
ill  the  salivary  secretion  which  is  present  in  some  f(»nns  of  paralysis  of 
tlic  iiiiisclcs  of  th  mouth,  in  which  the  patient  is  unable  to  swallow  and 
llif  saliva  simply  dribbles  out. 

Ill  i-AM's  of  ptyalism  the  character  of  the  stiTetion  may  Ik-  altered. 
Tiuis,  in  the  reflex  varieties,  the  secretion,  while  it  is  increased  in  amount, 
IS  (Icficiciif  ill  solids.  In  others,  the  amount  of  ptyalin  may  l>e  reduced. 
Odiisioiially,  as  has  Ihh'U  iiote«l  in  dialtetes,  fevers,' and  certain  dvspeptic 
(oiiditions.  the  reaction  is  acid  instead  of  alkaline.  This  is  due  to  the 
a(ii\ity  of  microorganisms,  when-by  lactic  acid  is  pnNliiced.  Th 
aliiralioii  in  the  characters  j)f  the  saliva  (Mrasionally  leads  to  curious 
rivsiilts,  such  as  the  fonnation  of  calculi  in  the  <lucts  of  the  salivarv 
(.'iaiiils.  Probably,  infection  and  inflammation  are  here  the  primary 
laiiscs,  anil  lead  to  abnormal  chemical  reactions. 

rill'  swallowing  i>f  large  amounts  (»f  secretion  may  l)e  injurious, 
rsixriallv  when  alkaline,  by  diluting  the  gastric  juice  and  neutralizing 
Its  iicidiiy.  \yhere  multitucies  of  s-ptic  micro<)rganisms  have  l)een 
swallottcl.  serious  changes  in  the  stomach  mav  <K-cur.  as  Hunter  has 
lxmii.,1  ,„it,  in  the  fomi  of  catarrh  and  atn)phy  of  the  glands. 

The  Gastric  Juice.—  Tlie  primary  function  of  the  stomach  api)ears  to 
!«•  I'l  Muc  as  a  storelumse  for  the  flxnl  ingested.     This  is  proved  bv  the 
fiwt  tl.ai  the  stomach  has  iKt-n  removetl  in  dogs  and  digi-stion  g<K«s  on 
rovided  that  f(MMl  issupplie<l  in  small  |>iirticl«'s  and  fre<|uentlv. 
the  bowel  distends  at  the  site  fomu-rly  occ-upied  by  the 


l»Tf.- 

Afiir 


•lly. 
a  tunc 


I 


'  I'rinciples  of  Clinical  Pulhologj-,  1<)07:248:  Lippincott. 


<^'' 


Hi.:;; 


356     THE  DKIESTIVE  FUNCTIONS  AND  THEIR  DISTURBANCES 

stomach,  to  arrommodate  increased  quantities  of  food.  This  view  h 
corroborated  by  the  results  in  the  few  cases  where  the  stomach  has  \wn 
successfully  removed  in  man.  An  important,  thoujfh  secondary,  duty  of 
the  stomach  is  to  thoroughly  mix  the  food  with  the  gastric  juice  an<l  I'ms 
it  on  to  the  intestines  in  quantities  which  they  can  comfortably  deal  with. 
Thus,  the  delicate  mucosa  of  the  bowel  is  protected  from  contact  with, 
and  possible  injup-  from,  coarse  mas.ses  of  food.  Only  a  small  propor- 
tion of  the  food  ingested  is  absorbed  in  the  stomach.  Most  of  it,  himI 
nearly  all  the  water,  is  passed  on  into  the  duodenum. 

The  ferments  of  the  gastric  secretion  are  pepsin  and  rennin.  Some 
authorities  believe,  also,  in  the  existence  of  a  fat-splitting  fenmnit,  hut 
others  dispute  this.  Pepsin  acts  only  in  an  acid  medium,  and  this  is 
supplied  by  the  production  of  hydrochloric  acid. 

It  is  extremely  difficult  to  study  the  phenomena  of  digestion  in  the 
human  subject,  ina.smuch  as  it  is  rarely  possible  to  obtain  pure  jfastric 
juice  unmixed  with  food.  Pawlow's  work  on  dogs'  has,  however, 
thrown  a  flood  of  light  on  the  problem,  an<l  many  of  his  coiKliisjons 
have  been  substantiated  by  later  observations  on  human  beings,  who  wen- 
the  subjects  of  gastric  and  cFsophageal  fistulw.  The  normal  .stimiiiiis 
to  the  secretion  of  gastric  fluid  in  the  dog  is  the  appetite,  but  it  is  prohahle 
that  this  element  has  a  much  .slighter  influence  in  man.  Here,  the  chief 
factor  is  the  direct  stimulation  of  the  gastric  mucous  membraiie  hv  tiie 
presenc-e  of  food  in  the  stomach.  As  the  French  proverb  ha.s  it, "  I,'a|)|)e. 
tite  vient  en  mangeant."  Pawlow  found  that  beef  extracts  aiul  small 
c|uantitie!i  of  alcohol  produced  the  same  effec-t,  but  that  alkalies  iiihihiteil 
the  secretion.  The  stimulation  of  the  special  nerves  of  taste  and  sinell 
also  !<eems  to  play  an  important  role  in  this  connection.  The  mere 
act  of  chewing  probably  produces  no  effect.  Nevertheless,  theri'  is  a 
close  correlation  lietwet'ii  the  appetite  and  the  gastric  secretion.  I'nder 
ordinary  circumstances,  the  majority  of  people  can  digest  the  fcxni  thev 
have  a  fancy  for.  The  hungry  man  Ls  rarely  a  dyspeptic.  Shak(s|H  are, 
then,  hau  an  insight  into  a  (leep  physiological  truth  when  he  makes 
Macbeth  exdaim,  ".\ow  g(KMl  digestion  wait  on  appetite,  and  health, 
on  lK)th."  The  influence  of  the  central  nervous  system  is  Iutc  ajrain 
apparent.  The  l>enum!>ing  of  the  sensorium  in  fevers  Icssiiis  the 
demand  for  fotnl,  in  .spite  of  the  fact  that  the  tissues  are  In-inj:  raimilv 
biinuHl  up  and  the  cells  have  every  need  for  increa.sed  nonii>hment. 
The  emotions  also  play  an  imfmrtant  role.  Anger  lessens  the  flow  of 
gastric  juice.  Worry,  anxiety,  hysterical  and  neurasthenic  coiKlitioiis 
often  cause  a  loss  of  app(>tite  {anorexia  nervosa). 

When  the  foo»l  is  swallowed,  after  the  preliminary  masti<atitpii  ami 
iiLsalivation,  there  is  a  perceptible  interval  before  the  gastric  jnii  t  lH>;iiis 
to  Im'  secri'te*!.  During  this  |M>riod,  which  averages  fn)ni  iwintv  to 
thirty  minutes,  de|)ending  (i(M)n  the  nature  of  the  menl,  the  tliiii(iii<,'hnes.s 
of  the  insjdivation,  and  the  vigor  of  the  secretion  of  the  hydnHlniir  acid. 


'  I'liwhm ,  I  he  vVork  of  the  DiitcHtive  (ilamls.    Kiig.  edit.,  C.  (irifliii  A  I 


I. nil!  Ion. 


THE  GASTRIC  JUICE 


3.'>7 


the  conversion  of  tlie  starches  into  ilextrins  uml  sugars  proceeds  rapidiv, 
for  ptyalin  Ls  even  more  effective  in  a  neutral  solution  than  in  an  alkaline 
one.  With  the  appearance  of  hydrochloric  acid,  however,  the  alkalinity 
gradually  gives  way  to  acidity  and  ptyalin  digestion  stops. 

The  further  steps  in  the  process  of  digestion  nmy  be  briefly  stated  to 
be  as  follows:  The  hydnK-hloric  acid  provides  a  suitable  medium  for 
the  operation  of  the  peptic  fer.aent,  which  it  thus  assists  in  hydrolyzing 
the  proteins.  It  also  conyertiicane  sugar  into  dextrase  and  levulose.  It 
inhibits  the  growth  of  microorganisms  and  thus  prevents  or  lessens  the 
acetic  and  lactic  fermentation  of  the  carbohydrates. 

Hennin  exerts  its  special  action  on  milk,  coagulating  it  and  thus  pro- 
moting  its  digestion  by  causing  it  to  be  retained  for  a  longer  time  in  the 
stomach. 

The  {lepsin  acts  on  proteins,  and,  a.ssLsted  by  the  hydrochloric  acid, 
converts  them  into  acid  albumin  and  eventually  into  albumases.  Accord- 
inji  to  Neiimeister,  there  are  two  sets  of  albumoses,  proto-albumose 
and  lu'fero-albiimose  (primary  albimiases),  which  are  grailually  con- 
verted into  deiitero-albuinoses  (secoralary  albumases).  Finally,  .some 
of  the  deutero-albumoses  are  transformed  into  peptones. 

Harnmersten  has  noted  the  presence  in  the  gastric  mucous  membrane 
of  an  oxidizing  ferment  (oxidase)  which  converts  milk  sugar  into  lactic 
acid. 

At  the  height  of  the  digestive  process  the  hydrochloric  acid  is  present 
in  vanoiis  conditioas.  Some  of  it  is  free  and  uncombine«l;  some  has 
united  with  the  inorganic  ba.ses  or  l>asic  salts  of  the  foo«l,  and  has  broken 
up  salts  of  the  weaker  acids;  some,  again,  has  combined  with  organic 
basic  .oinpounds,  of  which  the  proteids  are  the  most  important.  Toward 
the  close  of  gastric  digestion,  the  stomach  contains  a  variable  mixture 
of  starches,  dextrin,  sugars,  peptones,  and  unconverted  albumases. 

llie  length  of  time  that  the  food  remains  in  the  stomach  varies  con- 
si(Jeriil)ly  in  different  cases.  The  character  of  the  food,  the  state  of 
healtli,  and  the  type  of  animal  have  much  to  do  with  it.  Under  ordinary 
circuinstanees,  the  stomach  in  the  herbivora  is  never  empty.  In  t'le 
carnivora  the  food  may  pass  on  within  one  or  two  hours.  In'man  with 
his  mixed  diet,  gastric  digestion  takes  from  four  to  six  hours  '  fatty 
materials  lx>ing  retained  longest  in  the  stomach,  and  carbohydrates 
the  shortest.  Under  pathological  conditions,  however,  food  m&v  he 
retame,!  very  much  longer  than  this.  In  chronic  dilatation  of  the  stomach 
roni  pv  ,,nc  <arcinoma,  for  example,  the  stomach  may  lie  found  to  «)n- 
tjiin  f.M M I  that  was  taken  days  before.  In  such  cases  the  power  of  gastric 
«lipst„m  IS  much  impair«l,  and  the  retain«l  peptones  ami  albumoses 
cauM'  (linct  irritation  of  the  mucous  membrane. 

Ihc  sul,j,vt  of  flisonler  of  the  gastric  secretion  is  an  extremely  difficult 
one  lo  .leal  with,  (jur  knowledge  of  the  normal  phenomena'of  dijres- 
l'«»'  IS  ^tlll  in,jH.rfect.  for  it  is  gathered  from  ol)seryatioiis  carried  out  on 
wFniM.  Mtal  animals  and  but  rarely  on  human  l)eings,  in  all  cases 
'n<lcr .  oiMlitions  which  pre«!nt  wide  fleviations  from  the  normal.  Our 
weas,  th,  rcfore,  are  based  on  insufficient  data  and,  not  infrequently 


358     THE  DIGESTIVE  FUNCTIONS  AND  THEIR  DISTURB ANCKS 

oil  inferenct'  rather  timn  fact.  This  l)einj;  the  case,  it  is  not  siir|)risinjr 
that  our  <li.>M-u.s.sion  of  the  various  disturbances  of  secretion  will  Im'  (|iiit(' 
inadequate. 

Disonlers  of  gastric  digestion  involve  the  (|uantity  or  the  <|Uiilitv  of 
the  gastric  juice,  or  lioth.  Thus,  the  total  amount  of  the  secrt>tioii  iimv 
be  /<•«*  than  normal  or  it  may  even  \re  absent  altoj^ther.  Or,  ujtaiii,  it 
may  be  increiued.  The  qualitative  changes  have  to  do  with  the  pni- 
portions  of  hydrochloric  acid  and  the  ferments.  As  a  rule,  the  zynioj,'pns 
of  pepsin  and  rennin  continue  to  be  produced,  even  if  the  secretion  of 
the  acid  has  partially  or  completely  ceased.  But  in  advanced  oi^raiiic 
disease  of  the  stomach  both  acids  and  ferments  may  l>e  lacking. 

As  we  have  seen,  the  secretion  of  the  gastric  fluid  is  chiefly  rcHcx, 
the  stimuli,  which  are  rather  complex  in  nature,  Ix'ing  the  prest'iut-  of 
foG<l  in  the  stomach,  the  excitation  of  the  nerves  of  taste  and  smi'li,  uimI 
the  appetite.  Conceivably,  then,  a  defect  in  the  ne<-es.sary  stimuli  would 
result  in  a  diminished  secretion.  Thus,  organic  or  functional  dis- 
orders of  the  s{)ecial  nerves  cf  taste  and  .smell,  a  beinimbing  of  the 
cerebral  centres,  certain  emotions,  like  anger,  insufficient  or  unconpMiial 
food,  would  all  play  a  part.  In  this  categorj-  may  Ik-  place<l  most  of  the 
acute  infective  diseases  a.ssociated  with  high  temperature,  in  Hhich 
anorexia  is  a  well-marked  feature;  delirium  and  coma;  tunH)r.s  at  the 
base  of  the  brain;  hysteria,  neurasthenia,  and  melancholia.  Dcticient 
.secretion  (hyposecretion)  and  altsent  .secretion  (achylia  gastricai  are 
known  to  occ-ur  in  neurotic  iiKiividiuls.  The  .same  thing  has  Itecti 
observe*!  in  certain  ca.ses  of  talx's  dorsalis.  IIen>,  po.ssibly,  llic  cause 
is  to  \yc  refem-*!  to  interruption  of  the  reflex  arc. 

In  a  second  .set  of  ca.scs,  organic  changes,  involving  more  or  less  de- 
struction of  tlie  secn-tory  glands,  may  be  denionstrate<l.  Thus,  extensive 
carcinoma  of  the  stomach,  amyloid  disi-a.se,  atrophy  of  tlie  iiiiKosa, 
whether  senile  or  that  fonn  resulting  from  chn)nic  inflammation,  may  !»• 
cite<l  as  examples  in  point. 

In  still  another  series  of  ca.st's  there  is  some  .serious  systemic  disease. 
Thus,  pmfound  anemias  result  in  diminished  gastric 'secrclion.  Or 
there  may  Ix-  an  exivssive  output  of  fluid  from  the  liody,  us  in  dialietes 
and  chronic  interstitial  nephritis.  Or,  again,  a  deficiency  of  <ldorides 
is  the  cause  at  work. 

When  the  amoimt  of  liydnH-hloric  acid  in  the  gastric  juice  is  liiriiinislied 
or  aksent,  we  sjieak  of  lubaeidity  (liypochlorhydria)  aii<i  anacidity 
(aehlorhydria)  r«>sptvtively.  The  totid  "quantity  of  aciil  priMluinl  a|)- 
pears  to  In-ar  some  relation  to  the  (juantity  anil  churactcr  of  the  fiMxl 
inge.st(Hl.  Ilijw  much  acid  should  Ik-  foinid  nomiully  ap|KNir^  to  l«  still 
umler  discu.ssion,  for  different  authorities  give  ditfcniit  M.ninienls 
in  this  regard.  .\cconl'iig  to  Krt-hl,'  the  .secn-tion  prolwldy  .miiiiiues 
until  the  free  auu  combintni  liydrcKhloric  acid  in  the  gastrii  contents 
amounts  to  aliout  0.2  to  O.a  jht  cent.     Hickel- gives  consi4lcnilil\  hi^'lier 

'  The  I'riiiciplefi  of  Cliiiicul  I'athology,  VMM :  'i'A,  Lippiiioiti. 
'  Kungr.  f.  in.  Me<iiiein,  lUOti. 


THE  OASTRIC  JUICE 


sw 


Hl^urcs.  He  found,  in  individuals  the  subjects  uf  uesophaf^l  and  gastric 
fistula',  that  the  pure  gastric  juice  containctl  from  0.35  to  0.5  per  cent. 
It  U  important  to  remenilicr  in  this  connection  that  our  ordinary  clinical 
analyses  of  the  stomach  contents  arc  made  on  mixtures  of  food  and 
gastric  juice.  Consequently  we  are  apt  to  underestimate  the  extent  of 
acid  production.  An  estimation  of  the  free  hydrochloric  acid  is  of  little 
or  no  practical  value.  We  can  only  obtain  accurate  information  by 
detemiiiiing  the  total  quantity  of  acid,  both  free  and  combined.  To 
do  this,  we  have  to  find  out  the  total  quantity  of  chlorides  in  the  gastric 
contents  and  subtract  from  this  the  (|uantity  of  chlorides  contained  in 
the  food.  When  the  hydrochloric  acid  in  the  gastric  contents  is  found 
to  1)6  diminished,  we  have  to  exercise  some  care  in  the  interpretation  of 
our  results,  for  the  condition  may  be  accttunted  for  in  two  ways,  either 
there  is  a  diminished  secretion  of  the  acid,  or  else  it  is  neutralized  in  some 
abnormal  way  after  its  secretion. 

In  cases  where  the  gastric  secretion  is  inhibited,  either  partially  or 
completely,  the  amount  of  hydrochloric  acid  will,  of  course,  be  propor- 
tionately diminished.  The  ferments  will  naturally  be  diminbhed  in 
(|iiantity  as  well.  But  instances  are  not  infrequent  where  the  secretion 
of  tiie  acid  alone  is  defective. 

Free  hydrochloric  acid  may  be  absent  in  a  variety  of  conditions. 
For  e.\ample,  certain  acute  functional  and  organic  disturbances  of  the 
stomach,  notably,  the  acute  infectious  diseases,  may  be  mentioned. 
Perhaps  more  often,  anacidity  Is  found  in  chronic  conditions  affecting 
tlie  integrity  of  the  mucous  membrane,  such  as  atrophy,  carcinoma, 
and  amyloid  disease.  Curiously  enough,  disea.ses  in  parts  external 
to  tin-  stomach  may  prtxiuce  the  same  result.  Pernicious  anemia,  ab- 
dominal carcinoma,  advanced  tuberculosis,  and  cachexia  are  cases  in 
point.  The  exact  condition  of  things  has  been  more  carefully  studied 
in  coniuition  with  gastric  carcinoma  than  in  other  diseases.  Where 
a  lar>;c  uim>unt  of  the  .secreting  surface  is  involved  in  the  newgrowth, 
(•.s|M<i;illy  where  there  is  marked  ulceration,- it  would  not  be  surprising 
to  tiiKJ  a  total  defect  or  a  diminution  in  the  amount  of  acid  sec-reted. 
In  SDUU'  instances,  however,  it  is  un<juestionablp  that  hydnx-hloric  acid 
is  secreted,  though  it  is  not  found  in  the  free  state,  for  the  total  amount 
"f  the  comljined  chlorides  may  equal  or  exeee<l  the  normal.  Apparently, 
the  carcinoma  produces  substances  that  have  the  power  of  neutralizing 
the  acid  produced.  These  are  presumably  of  the  nature  of  enzymes, 
inasnnicli  as  they  are  destroyed  by  heat.'  Moore  has  laid  down  that 
in  all  ( arcinomatoas  states  there  is  a  reduction  of  acid;  this  needs  con- 
Hrnialion. 

A  (lificicncy  in  the  amount  of  hydrochloric  acid  secreted  will  of 
n(H(>  iiy  inliihit  to  a  corresponding  extent  the  activity  of  the  pepsin, 
ami  Ml  (It  lay  gastric  digestion.  Provided,  however,  that  the  motility 
|>f  till  -Kiniach  [te  not  impaired,  the  nutrition  of  the  individual  thus 
atfei  i.il  iiei-d  not  Ix-  seriously  disturbed.     With  a  suitable  dietary,  the 


m 


>  Emerson,  Arch.  f.  kUn.  Med.,  72:  426. 


P^," 


Ilih 


360     THE  DIOESTl    E  FUSCTIONS  AND  THEIR  DISTURBANCES 

intestine  may  U'  able  ti)  eonipcrwatc  the  iiieffieion*)'  "f  the  stoiuii.li 
It  Is,  further,  worthy  of  note  tliat  cttrcinonia-s  of  the"  stoinacli  an  jiW,. 
to  pitKluee  ferments  eornjietent  to  clifjcst  pmteicls  more  (iui«klv  ,  vcn 
than  the  normal  gastric  Huitl. 

One  of  the  most  important  n-sults  of  jhrninislu"*!  gastric  aciditv  is 
the  multiplication  of  bacteria  within  the  stomach.     It  is  well  estahlisli«i 
that  the  stomach,  under  nonnal  conditions,  contains  numerous  ini< ro- 
organisms  derived  from  the  ingested  food  and  external  air.     Pmvidwl 
that  gastric  motility  is  unimpaired  and  the  foo«l  is  passed  regularly  alon.' 
into  the  intestines,  no  great  multiplication  of  these  organisms  can"  (K-cur 
Should,  however,  stagnation  of  the  stomach  contents  be  present,  mon- 
or  less  growth  takes  place  and  fermentative  processes  are  set  up.     Tims 
for  example,  sugar  is  converted  into  alcohol  and  carbon  dioxide:  ukohol 
mto  acetic  acid;  dextro.se,  into  lactic  acid,  butyric  acid,  hvdrog,M  and 
carbon  dioxide.     Ga.ses  are  set  fre«',  such  as  carlwn  «hoxide,  livthown 
and  methane,  which,  together  with  the  air  that  has  l)een  swallowed,  pnl 
uuce  flatulency  and  disteasion  of  the  stomach.    These  fernieiUativp 
procrases,  however,  are  kept  within  Ixjunds  by  the  pn-sence  of  the  hydro- 
chloric acid,  which  has  decidedly  antiseptic  pniprties.    A  0.2  perVcnt 
degree  of  acidity  in  a  culture  medium  will,  in  time,  destroy  manv  bacteria 
though  some,  and  especially  spores,  are  not  greatly  affected.  "  It  should 
be  remembered,  however,  that  the  conditions  in  the  stomach  are  by  no 
means  so  favorable  for  this  inhibitory  action.    Some  of  the  hydroc  Idoric 
acid  secreted  is  neiitralize<l   by  alkalies,  or  enters  into  conibiiiatjon 
with  the  proteids,  wh    h  combinations  are  much  less  effective  than  fnt- 
acid.     Moreover,  ma       jiortions  of  the  f<MHl  do  not  come  in  contact 
with  the  gastr  a  all,  for  they  may  Ui  passed  rapidiv  aion^'  into 

the  intestine  m  in  the  centric  of  large  ma.s.ses.  Consc'iiientlv.  the 
antiseptic  powers  of  the  gastric  juice  are  .somewhat  limited,  and  inany 
active  microorgaiiLsms  gain  entrance  to  the  l>owel. 

In  cases  of  subacidity  and  anacidity  an  opportunity  is  afforded  for 
the  enormous  increase  of  Iwcteria,  l)oth  in  numbers  and  variety,  with  a 
concomitant  increase  in  the  amount  of  fennentation.  Under  these 
circumstances,  processes,  similar  to  thase  just  referred  to,  arc  s.t  in 
operation,  but  there  is  a  special  tendency  to  the  formation  of  lactic, 
butyric,  and  other  volatile  organic  acids.'  lactic  acid  fermentation  is 

a  chief  and  characteristic  feature  of  anacidity  with  stagnati f  the 

stomach  contents.  In  fact,  the  lactic  acid  may  l)e  so  abundant  as  to 
restrain  the  development  of  other  bacteria  that  ordinarilv  would  |.i,MliHr 
their  own  peculiar  form  of  fermentation.  In  such  cases,  the  ()piilri-|{(«is 
bacillas  is  usually  present  in  the  stomach  in  enonnous  numlKPs  ,ind  is 
the  cau.se  of  the  lactic  aciti  priKluction.  In  mark*-*!  cases  of  aiKic  idity 
putrefaction  of  the  proteins  may  occur  a.s  well.  In  some  few  inManccs 
fermentation  <K-curs  in  the  stoma<-h  in  the  alxsence  of  sul«uidliv  and 
impaired  muscular  |)ower.  Po.s.sibly,  here  we  have  to  do  with  th. mjres- 
tion  of  excessive  amounts  of  fermentable  material  together  with  ;i;.'tnts 
that  are  competent  to  produce  fermentation. 
It  should  be  pointed  out  that,  in  the  present  state  of  our  kmn  lolge. 


TUB  GASTRIC  JUICK 


mi 


tlicn-  U  n<>  pathugiiuinoiiic  r('lati(>iishi|>  lietwrcn  any  (>n«  kind  uf  liactfrial 
(lc<oiri|>«iHition  un<l  any  {mrtinilar  clinical  state.  ( )iir  Kndin^  have  to 
Im'  iiitfrprcted  in  such  cases  in  the  mast  f^eneral  way.  The  chief  factors 
arv,  tin-  chanwter  of  the  t<Kxl,  impaired  f^stric  motility,  the  amount 
(if  hy(lnH'hlon<:  acul  secretwl,  and  the  multiplication  of  bacteria.  On 
till  correlation  of  these  depend  the  result. 

.\l)iK>nnal  fermentation  in  the  stomach  is  injurious  in  a  variety  of 
ways.  'ITie  mucous  membrane  may  be  irritated  and  inflamed,  leading; 
to  anorexia,  pain,  regurptation,  and  vomiting,  and,  possibly,  spasm 
of  tlie  pyloruw.  (Jiises  accumulate  and  produce  distension,  flatulency, 
and  lieiching.  Toxic  suKstances  are  formed,  which  may  be  absortMnl 
and  Iciul  U>  systemic  disonler.  The  condition  is  not  without  its  effect 
on  the  IkhppI  as  well,  for  diminished  acidity  in  the  stomach  usually 
Iwiils  to  ineTea-sed  putrefaction  in  the  intestine. 

riieorctii«lly  speaking,  we  are  able  to  make  a  distinction  l»etween 
im'n'u.se<l  uctdity  of  the  gastric  .sit-retion  (hjparehtorhydtlA)  and  hypcr- 
Mcretiaii.  In  tlie  former  there  is  a  relative  increase  in  the  amount  of 
acid  pr«>«luce<l;  in  the  latter  there  is  an  absolute  increase  proportionate 
to  tlic  increase  of  tlw  gastric  secretion  as  a  whole.  In  view  of  the  gaps 
in  our  knowledg«>.  iMiwever,  as  to  the  normal  behavior  of  the  stomach 
in  (iij.'esting  varying  quantities  and  kinds  of  fiKxl,  it  is  hardly  possible 
to  make  this  dLstinction  in  practice.  .Vs  a  result  of  his  experiments, 
alK)Vf  n'fcrreil  to,  Hickel,  indeed,  concludes  that  what  is  usually  designated 
l)y  .liiiiciiuis  us  "  hyjH-racidity"  is  in  n'ality  hyjiersecretion.  The 
effcit  of  iiyixrsecrction  is  to  rais*-  the  pen-entage  of  hydrochloric  a«-id 
in  the  mixliirc  of  gastric  juice  and  fixxi  ordinarily  submitted  to  examina- 
tion, and  tlic  residt  may,  therefore,  Ih>  wrongly  interpretal.  The  total 
amount  of  a<id  in  the  stomach  contents  in  .so-calle<l  "hyperacidity," 
as  a  matter  of  fact,  does  not  exceed  that  present  in  normal  gastric 
jiiicc.  I'lider  the  circumstances,  we  cannot,  perhaps,  «lo  better  than 
use  tlic  (crins  hyjX'racidity  and  hypersw-retion  in  the  ordinary  sease  in 
wliicli  tin  y  are  einpl<)yc<l  by  certain  diniciaas.  IIyperaci<lity  may,  then, 
Ik-  taken  to  mean  an  increased  secretion  of  the  hydnx^hloric  acid  with 
tht-  <;a>tric  jui«'c,  occurring  during  digestion.  Hypersecretion  is  an 
txccssivc  siHTctioii  of  the  gastric  fluid,  usually  hyperacid,  occurring 
not  (inly  during  <ligestion  but  in  the  intervals  also.  Both  conditions 
art'  ti>  !)<■  n>gurded  as  symptoms  rather  that  actual  disease  entities. 

Til.'  diagnosis  of  hyperacidity  depends  on  the  detection  in  the  stomach 
coiitriiis  of  an  increased  amount  of  hydrochloric  acid.  The  chief  causes 
of  till'  ( cindition  are  dietetic  errors,  overwork,  Horry,  the  various  neuroses, 
ami  tlic  ai)use  of  tol>acco.  The  condition  is  '>;ind  also  in  cases  of  ulcer 
|f  till  -lonuuh.  Disease  elsewhen'  in  the  Ixidy,  such  as  chlorosis,  chole- 
litliMM-.  and  renal  calculus,  may  be  at  work  in  some  ciises. 

Hy|i(rs«"crction  may  l)e  a  transient  condition,  may  re<ur  perimlically, 
or,  a;.'iin,  may  be  contiimous.  Traasient  and  periodical  hypersecretion 
IS  iiK  I  witli  in  certain  nervous  affections,  such  as  locomotor  ataxia, 
liyitiiii,  and  neurasthenia,  or  it  may  occur  more  or  less  independently 
(j^oWn  .,//«.,«(  of  Rossbach).     It  is  apparently  due  to  irritability  of  the 


362    THE  DtOESTlVE  FUNCTIONS  AND  THEIR  DISTURBASCKS 

gastric  inucoiis  membrane,  of  its  aecivtory  nervos,  or,  in  sonif  <  jiscs 
to  .itinitilation  of  the  cerebral  ecntrra. 

Continiwua  hypenMxretioii  (Heichmann'ii  dUeaw)  is  fouml  iJurticiiliirlv 
III  young  neurotic  imliviiliiwL'*.    Dietetic  errors,  eniotioas,  and  inoin'r 
insufficiency  are  tlic  chief  causes.    The  coniiition  Ls  met  with  also  in 
association  with  certain  forms  of  chn>iiic  gastritis.    An  important  fiutor 
in  the  causation  is  dilatation  of  tlie  stomach,  with  its  concomitant  mii.s«iilar 
insufficiency,  whether  this  he  due  to  a  primary  pacesM  of  the  sioiimch 
wall  or  to  the  many  forms  of  obstruction  to  the  evacuation  of  the  jfiistrir 
contents.     In  the  chronic  forms  the  hypersecretion  is  prolwbiy  to  lie 
attributed  to  the  stimulation  of  the  mucous  membrane  by  the  ntHJiied 
food.    In  the  acute  forms  of  gastric  dilatation  a  iflatively  enonnoiis 
amount  of  fluid  may  Ik-  s«-<nt«-«l.     As  much  as  several  «nmrts  have  lietn 
removed  in  some  instuiKis  w  ith  lli<  stomach  tube.     Here,  as  in  the  larlicr 
stages  vomiting  Ls  persisu  ir  .iiul  !>•>  fcxxl  can  Iw  retained,  it  Ls  iniiMKsJhk. 
that  the  stimulus  can  Ik-  slujsimted  f.Kid.     I  nfortunatelv,  verv  few  com- 
plefc  studies  of  the  gastri<-  s«h  retioii  have  U-vn  made  in  thew  cases  so 
that  we  are  sonu-what  in  the  dark.     llydriKhloric  acid  has  Uh-ii  fouml 
present  in  some  <a.s(>s,  liit  not  invariji'  "v.     it  would  s«-eni  misi.iial.lf 
however  to  think  that  li.e  gastric  fluiii  ,,.  acute  dilatation  is  tart  a  true 
secretion.     Other  factors  may  enter  into  the  «|ue3tion.     Owing  to  the 
stretching  of  (lie  stomach  wall,  thi-  vessels  are  elongated  and  thin-walled 
awl  lack  tone;  furtherimm',  there  is  the  depn-ciatiiig  effe<t  of  the  (oxins 
present  within  the  stomach.     Consetpiently,  it  would  not  Ik>  snrprisinj; 
if  the  hl«iodve.ss»'ls  should  Ux-ome  more  ptTiiu-abK-  and  allow  a  (oii- 
sklerable  (|iiantity  of  Huid  to  exude  and  enter  the  cavitv.      ()v)imw 
obstruction,   too,   pmmotes   the   condition    by  |)n-ventiiig "  the   noniial 
discharge  of  the  stomach  stH-Prtions  into  the  liowel.     in  some  <as»s.  als.) 
Ill  which  obstruction  of  the  duodenum  Wow  the  bile  jwpilla  lia>  U^n 
demonstrate*!,  the  ga.stric  fluid  has  c-ontaiiie«l  bile  and  a  diastatic  ft  rih.iit. 
We  pass  on  now  to  the  consideration  of  the  subje<t  of  intestinal  (IIli-s- 
tion. 

The  IntMtiiial  and  ReUtetl  Secretions. -The  stronglv  .  '.i ,  imne, 

when  it  leaves  the  stomach,  jwsses  into  the  duodenum,  w!..  re  ii  iiarts 
with  un  alkaline  medium,  coin|)<xsed  of  pancr»*atic  secn>tion,  hi!.',  ami 
succus  eiitericus  The  hy<lnxhloric  acid  is  neutralized  and  the  ( livine 
IS  thas  prejwnHl  for  the  action  of  the  pancreatic  fennents,  win.  Ii  Can 
act  only  in  the  presence  of  alkalies. 

The  old  view  that  an  acid  reaction  of  the  chyme  persists  for  a  coii-idcra- 
able  distanc*-  down  the  intestine,  and  that  the  acid  is  onlv  ;:r,i.liiiillv 
neutralized,  is  almost  certainly  ernjiK-ous.  Mere  traces  of  liv.li,.,  hloric 
acid  an'  enough  to  destroy  th«'  activity  of  the  pancreatic  fenniiii^.  whi.  Ii 
are  only  pouretl  out  in  the  dii(»denii"in.  C'onseciuently,  it  is  iiii|m  ,il,|e 
to  uiMlerstand  how  paian-atic  digestion  txmid  b«'  carried  on  iiml.  r  >iicli 
circumstaiic«-s.  As  a  matter  of  fact,  only  small  amounts  of  f,.,.,l  pass 
through  the  pylorus  at  any  one  time,  and  they  come  in  coiitii. ;  with 
a  much  greater  bulk  of  alkaline  setwtion  in  the  duoilemiiii.  -■  ihat 
the  acid  is  immediately  neutralized.    The  chief  digestive  agent,  in  the 


ivf' ::fcS 


THE  BILE 


3)'i3 


intcstiim  are  the  pancreatic  !MH.'n-tioti  aiui  the  .siiiriiM  entericuH.  SiMiie 
authorities  «Ie!)cril»e  aha,  another,  malta.se,  which  c-«nvcrt.s  inaltime  into 
drxtntM". 

Th«  Snceai  Intcriens. — Litth*  is  known  alxxit  the  siicciw  cntericu.i.  It 
roiitaiiis,  however,  a  fennent  which  convert!*  cane  .suj{ar  ami  maltose 
into  ilextn)se  anil  levuluse,  lierH-e  calieti  invertin. 

Tht  PtnerMtie  l«cr«tiOB.— By  far  the  most  important  part  is  played 
bv  the  paiK-reatic  sec-retion.  This  contaias  three  ferments:  amylopsin, 
which  converts  the  (■arbohyd rates;  trypsin,  which  p<'ptonizes  proteins; 
ami  .steapsin,  which  hydrolyzes  fats.  Amylopsin  in  every  way  resembles 
ptyaiin  in  its  action  except  that  it  is  more  powerful. 

Steapsin  is  the  only  ferment  in  the  IkxIv  that  has  a  spe<-ific  chemiral 
action  on  fat.  It  is  true  that  some  oliservers  have  <lescril)ed  a  fat-.splittinf( 
ferment  in  tlie  gastric  .si-i-retion,  but  their  conclusions  are  by  no  nieaas 
as  yet  >c»'nerally  accepte<l.  Steapsin  acts  by  breakiuK  "'own  neutral  fats 
into  fatty  aci«ls  and  glycerin.  It  has  l)een  usually  held  that  only  a  small 
portion  of  the  fat  undergoes  this  «ie.-omposition,  and  that  the  fatty  acids 
prodnccd  combine  with  the  alkalies  of  the  intestinal  contents  to  form 
soaps,  which  soaps  emukify  the  unconverted  fat.  The  chemically 
unahcr«-d  fat  is  then  absorbed  by  the  columnar  c«'lls  of  the  intestinal 
villi.  There  is  considerable  evidence  for  thinking,  however,  in  view  of 
later  ex|M>rimental  work,  that  this  view  is  incorrect,  and  that  practically 
all  of  llic  fat  (84  p««r  cent.)  is  hydrolyze<l  into  fatty  acids  and  glycerin 
and  in  this  soluble  form  al>sorl)ed.  "    • 

Thi-  iicti«)t>  of  trypsin  is  similar  to  that  of  pejxsin,  but  is  more  rapid 
and  more  <s>niplete.  The  proteins  are  first  convcrtinl  into  alkali- 
allmuiin,  and  this  into  deutero-albumoses.  Whether  primary  albumases 
are  forme*!  is  <|ucstionable.  If  they  are.  they  appear  to  be  very  unstable 
and  undergo  rapid  conversion.  The  deutero-albumoses  an-  transformed 
into  [H-ptone  and  the  latter,  for  the  most  |)art,  into  nmido-acids  and 
organic  nitrogenous  liases.  Only  aUiut  half  of  the  p«'ptone  present 
is  (iinvtrlisl,  the  more  stable  moiety  remaining  l)eing  known  as  anti- 
Ix'ptorK'.  Those  suKstanc-es  that  are  partially  pi-ptonized  in  the  stomach 
will,  of  course,  only  recpiire  to  undergo  the  later  stagi's  of  tryptic  digestion. 

The  Bile.  The  bile  has  no  zymotic  action  on  ftMxIstuffs.'but  is  valuable 
as  an  iidjiivant  to  the  pancreatic  .secretion,  in  that  it  remlers  more  .soluble 
-iihstaiiccs  which  would  otherwise  be  quite  insoluble  in  water,  h  can, 
f'tr  ivani|)lc,  tlissolve  to  .some  extent  lecithin  and  cholesterin,  and  thus 
iu<K  ill  iluir  elimination  from  the  bo<ly.  It  also  aids  in  the  solution  of 
the  >o;i|.,  and  free  fatty  acids.  Its  atiti.septic  properties,  refemnl  to  by 
some,  arr  dctidetl,  though  not  powerful. 

riif  |.iir|K),se  .,f  the  milk-coaguluting  fennent.  .sai<i  bv  certain  anfliori- 
tiHs  t,,  |„.  present,  is  not  clear,  any  milk  in  the  food  U-ing  acted  upon 
In- tile  :,  iiiiin  in  the  stomach. 

llie  iir.cts  of  a  deficient  .secretion  of  the  pancreatic  ferments  cannot 
!)<■  >tat.  I  prctisely.  One  would  expect,  and  it  undoublctily  is  a  fact, 
that  uihli-c -ted  proteid  matter  and  unconverted  fats  are  to  be  found  in 
the  st.icU  in  increased  amounts  in  certain  cases  of  pancreatic  disease. 


iltW 


Mi 


■s-iBii 


IV 


SIM     TIIK  DIGKSTIVE  FUX(TIO\S  AND  TIIEIK  lilHTUKH.XNfUS 

Yet  clinical  atudiest  on  piitiriitM  liaviii);  rxtcii'tivr  i\<  ^rncntliiin  of  ih,. 

Cncrnu,  ami  the  experimental  rxtiqiation  of  th«-  jnuk  n>H.s  in  .ii« 
ve  xiven  oontndictury  r<>HulLs  in  the  expeririKW  of  ditferent  ol>s.ners 
Some  kuive  found  that  the  alMor|.<i.>n  of  protciroi  and  fntt  in  ih«>  IniwH 
were  conxiilerahly  diniini.sln-d,  whil«-  others  di<i  iM.t.     In  the  s«in(.  wav 
aome  have  notcti  a  (liminLshed  .  Ie8v«<p>  of  fats  in  the  Im)w.I,  while  i.ilirri 
did  not.     It  Is  probahif  that  these  di.s*rc|»Bnci«>s  in  the  r.>sults  of  <  liriKal 
studies  ate  to  be  expbiinetl  in  thin  *hv.     Unless  tlu>  jmnen-as  w.r.. 
extensively  damaf(rd  and  its  secretion  l.sseneil  almost  to  the  vanishin); 
point,  not  much  altenition  in  th«'  nornml  prtKrsses    >f  digestion  newi 
result.     For  it  w  clear  that  the  {Mtncreulic  secretion  is  iK>nnallv  si-cn-twl 
in  an  amount  much  greater  thiin  is  aKsolutcly  necessary  to  djp-^il  aiiv 
meal  that  is  onlinarily  tHkcn.    'V\w  cori»eni.s  df  the  'small  ini.siiw 
atapoint  justalmvetheilecx-ccul  valve  have  In-cn  shown  t.)l><«'xe«tiliiijr|v 
rich  in  amylolytic  ami  prole«ilytic  fennent-i,  and  it  is  ahofji-llier  prolml.lf 
that  these  are  not  aUsorlted  lint  dt-strovfsl  in  the  lar^c  Ixiwci.    An 
extreme  amount  of  degenenition  would  Im-  retpiisite,  then,  to  puNliKr 
noUble  changes  in  the  eoiLstitulion  of  the  fec-es.     In  a  similar  wav,  ilif 
pancreas  must  be  exfeasively  disea-s*-)!  l»efon>  diulnl.s  will  n-siili.    In 
any  case,  a  compensatory  mechanism  Is  not  unlikely  to  U-  at  work  in 
some  cases,  for  the  intestine  is  coniiietent  to  some  extent  to  ahsorl) 
unaltered  proteins  anil  fats  and  wouhl  Ik-  still  more  likelv  able  to  alisorb 
those  partially  converttnl.     IIydnNhh>ric  acid,  t«H),  .an  invert  snpirs. 
(Jiven  sufficient  time,  a  very  fair  amount  of  intestinal  dip-stion  nmv 
take  place,  even  if  the  pancreati*-  secretion  were  redn««d  lo  a  iniiiirnuni. 
The  experiments  on  dogs  are,  moreover,  scarcely  c<»mpanii>le  to  the 
ajnditions  prevailing  in  man,  for  the  extiqwtiot'i  of  the  pancreas  is 
attended  with  much  shock,  and  we  have  no  infonnation  how  the  seerp- 
tion  of  bile  is  influencwl  by  this  operation.     The  fact,  however,  that 
the  administration  of  pig's  panc«'as  to  the  animals  deprivisl  of  tlioir 
jwncreas  increased  the  al»s»)rption  of  foo<l  goes  to  prove  that  a  <l((i«  icnt 
pancreatic  secretion  may  inhibit  absorption. 

The  conditions  which  might  \te  cxfKxted  to  st-rionsly  int»rf(rc  with 
the  action  of  the  secretion  ar»>  those  which  ext.Misivdy  damafje  (lie  ^t^lp- 
tural  integrity  of  the  pancrea.s.  Such  arc  atrophy,  fibrosis.  <  Immir 
in/iammation,  and  carcinoma.  Obstruction  to  the  duct,  niikss  .iiic  to 
the  presence  of  a  new-growth  in  the  heail  of  the  pancreas  or  a  caldilus, 
is  not  likely  to  be  often  a  cause.  Opie'  has  shown  that  in  alxmt  two- 
thirds  of  all  cases  there  is  a  patent  duct  of  Santorini  in  man.  li  would 
l)e  extremely  unlikely  for  both  the  <luct  of  Wirsung  and  that  of  Sanlorini 
to  be  obstruci.-d  at  »me  time,  though  it  is  not  impo,s.sihle.  1  lir  iriosi 
likely  site  for  obstruction  is  at  the  papilla  of  \'ater,  and  hen'  the  roininon 
bile  duct  would  be  occlude*!  as  well. 

In  one  other  way  the  pancreas  can  suffer  severe  injurv,  iiinl  this  is 
from  the  entry  of  bile  into  the  duet  of  Wirsiuig.  This  oct  iirs  n\u-\  (.fitn 
where  there  Is  a  biliary  calculus  impacttxl  at  the  bile  papilh..  ol  such 

'  Uiaeaaes  of  the  Pancreas,  I  ippinuott  k  Co.,  1903. 


ll 


^:.M. 


THE  BILE 


305 


a  sm  and  shape  m  to  prpvent  the  diarharKf  of  bile  into  the  intestine, 
while  permitting  a  rr|{iir)(itation  into  the  pancreatic  duct.  Acute 
heiniirr)ia|{ic  pancreatitM  may  result'  or,  in  less  extreme  esses,  chronic 
jMin('n<utiti.s.  The  same  result  can  lie  produced  experimentally  by  in- 
jniiri^  bile,  hydrochloric  acid,  or  certain  other  substances  into  the  duct. 

'ilic  inudifictttions  in  the  comiMsition  of  the  bile  that  occur  as  the 
rtNiilt  of  disease  art*  by  no  means  well  understood.  Nor  is  their  practical 
si);iiili<-ancc,  if  any,  at  all  times  evident.  Only  in  the  case  of  the  forma- 
lion  >r  gallstones  have  we  anything  like  an  adequate  conception  of  the 
pnH  .'^s«>s  that  take  place  and  the  important  results  that  may  eventuate 
fnmi  them. 

'i'lic  nuidu*  operandi  in  cholelithiasis  has  lieen  sufficiently  coasidered 
clscwhen'  in  this  work  (vol.  i,  p.  874),  so  that  we  need  not  occupy  simh-c 
liy  discussing  the  subject  agam  here.  Suffice  it  to  say,  that  the  chief 
factors  at  work  are:  (1)  An  infi>ctious  catarrh  of  the  biliary  passages; 
(2)  sta^Miution  of  the  bile;  (3)  the  secretion  of  cholesteryl  oleate  and  cal- 
cium suits  by  the  inflamed  mucous  membrane;  (4)  the  splitting  up  of 
choh-steryl  oleate,  under  the  influence  of  alkalies,  into  cholesterin  and 
oleie  aciil,  with  the  precipitation  of  the  former  and  the  formation  of 
inon'  or  less  soluble  soaps;  (5)  the  ciimbination  of  the  calcium  salts 
with  l>ile  pigment  to  form  bilirubin  calcium. 

The  stagnation  of  the  bile  and  the  injury  to  the  walls  of  the  bile  pa-s- 
saps,  that  so  commonly  result  (nnn  the  pres«>nce  of  calculi,  lead  often 
til  secondary  infei-tion  and  other  widespread  results.  'ITiese  will  lie 
licult  with  later,  and  we  shall  simjily  content  ourselves  here  with  con- 
sidering; tin-  effects  of  a  cleficiency  of  the  supply  of  bile  in  the  intestine 
u|KMi  the  prtK-esst-s  of  digestion. 

Hile  iii'iy  Ik»  pri'venttnl  from  entering  the  l>owel  by  obstruction  of  the 
coinmiiii  or  lie{)atic  ducts  by  calculi,  the  pressure  of  enlarge<l  glands  or 
infliiiniiialory  adhesions,  i>y  catarrhal  inflammations  of  the  passages, 
iiihI  liy  new-growths. 

Tlic  results  that  follow  de|N>nd  u|Hm  the  position  of  the  obstruction. 
If  at  ill'-  l)ile  papilla,  the  outflow  of  the  pancreatic  juice  may  Ik-  more  or 
less  iiiierfere<l  with  as  well  as  that  of  the  bile.  If  higher  up,  the  supply 
of  liile  alone  is  cut  off.  Complete  absence  of  the  bile  fnnn  the  intestine 
is  <  vidcncisl  clinically  by  jaiuulicc,  more  or  less  malaise  and  constitutional 
||i^lllrllall(■e.  and  a  |M>(uliar  coloration  of  the  stiH)ls.  The  discharges 
arc  pull-  ..'ray  or  "chiy-colimil,"  owing  to  un  excess  of  fat  and  an  abs«'nce 
i>f  tile  liile  pigments.  It  has  U-en  found,  as  a  ri'sult  of  expi'rimentation 
on  iloK,.-  .,|„|  ol,>ervations  on  man  (Fr.  MUller),  that  the  process  of 
iiilcsniiai  iligestion  is  considerably  interfered  with.  The  absorption 
of  (arlM.liydrales  is  practically  normal,  that  of  proteins  only  slightly, 
if  at  all.  .liriiinished,  but  about  VA)  to  SO  per  cent,  of  the  fat  ingested  escapes 
aliM.r|)ii(,ii.     'I'liis  fffiH-t  is.  in  part,  explained  by  the  fact  that,  to  lie 


'I'i'    I'liiis  llcipkiiis  UoHpitjil  Hulleliii,  12;  I'JOl :  IS2. 


\"lIi!     Ikilragu   z.   Hiologie,    Stuttgart,    18«2;   Koliiniiiiii.   PHub'.t'k   Archiv 


MKaocorr  rbowtion  tbt  chart 

(ANSI  ond  ISO  TEST  CHART  No   2) 


/APPLIED    IIVHGE      In 

1653    East    Main    StrMt 

Rochester,    New    York  14609       uSA 

(7'6)    482  -  0300  -  Phone 

(716)   2B8  ■   5989  -  fo» 


3()u     THE  DiatSTIVE  FUNCTIONS  AND  THEIR  DISTURBANCES 

absorlieti  the  fats  must  Iw  first  hydrolyzed  and  rendered  soluble,  and 
the  chelates  are  excellent  solvents  for  fatty  acids.  Should  the  bile  he 
deficient,  the  solution  is  rendered  correspondingly  diiScult.  Hewlett,' 
also,  has  shown  that  bile  has  the  power  of  accelerating  the  fat-spiittinj; 
action  of  the  pancreatic  secretion  eightfold  or  more.  I^ack  of  bile, 
therefore,  will  gri'atly  <liminish  the  activity  of  the  pancreatic  juice  in 
respect  to  fats. 

While  the  bile  has  no  great  antiseptic  properties,  so  that  an  absence  of 
bile  in  the  intestine  is  not  attended  by  any  notable  increase  in  its  ba(  tcrial 
flora,  yet  it  is  |)ossib!e  that  in  the  condition  of  biliary  obstruction  tin- 
processes  of  fermentation  may  l)e  more  or  less  abnormal.  On  this 
point,  however,  we  have  little  accurate  information. 

The  practical  application  of  these  facts  is  that  in  c;ises  of  this  kind, 
the  diet  should  consist  mainly  of  proteins  and  carl)ohydrates.  \\\ 
keeping  out  the  fats,  we  not  only  avoid  giving  a  food  that  cainiot  he 
digeste<l  and  absorl)e<l,  but  lessen  the  possibility  of  abnormal  decomposi- 
tions and  consefjuent  irritation. 


;:■  m 


DISORDERS  OF  ABSORPTION  AND  ASSIMILATION. 

By  the  term  absorption,  as  we  shall  use  it  in  the  present  discussion, 
we  mean  the  prcK-ess  by  which  the  various  nutritive  substances  contained 
within  the  alimentary  tract  are  taken  up  into  the  circulation.  The  sul)- 
stances  to  be  absorbixl  are  the  reiluction  prcxlucts  derived  from  the 
primitive  constituents  of  the  fotxl,  proteins,  carlnJiydrates,  and  fats, 
as  a  result  of  the  action  of  the  various  ferments.  These  are,  in  the  main, 
peptones,  albumoses,  dextrin,  various  sugars,  glycerin,  and  fatty  acids. 
To  a  slight  extent  proteins  and  fats  ire  ab-sorbed  as  they  an;  without 
preliminary  hydrolization.  Water  and  .salts  also  have  to  l)e  considere<l. 
In  our  discussion  of  this  subject  we  are  concerned  with  the  process  as 
it  occurs  in  the  stomach  and  lM)wel.  Ab.sorption  practically  does  not 
take  place  in  the  mouth  and  (esophagus.  These  structures,  for  one  thiiif;. 
are  covered  with  a  dense,  comparatively  imper".eal.  membrane  of 
squan-'uis  epithelial  cells,  which  is,  further,  during  mastication  and  dej;lii- 
tition,  protecte«l  by  a  coating  of  mucus.  It  is  true  that  tuider  certain 
circumstances  toxic  sui)stances  may  gain  an  entrance  through  the  hiiecal 
mucous  membrane,  but  the  mastication  of  fixxl  is  not  a  parallel  case, 
for  the  f(Kxi  remains  much  too  .short  a  time  in  the  mouth  for  ?mc1i  a  result 
to  follow  and  the  different  elements  of  the  food  are  scarcely  i  .  i  sohiMe 
state.  The  chief  function  of  the  stomach,  as  we  have  seen,  is  to  he  a 
receptacle  for  the  ingested  f(M)d.  Its  powers  of  digestion  arc  cciiipara- 
tively  limited  and  its  powers  of  al>sorption  are  also  limited.  The 
carbohydrates,  dextrin,  saccharos*-,  dextrose,  lactose,  and  inalin^e,  are 
absorbe<l  fairly  well,  the  better  the  more  concentrated  the  -nliiiioii. 
Peptones  are  absorlwHl  with  difficulty,  and  water  bartlly  at  all.  .Mi uliolir 
solutions  are  taken  up  with  fair  avidity  and  .seem  to  increase  tli<'  [lower 

'  Johna  UupkiiiH  Uuspitul  Bulletin,  January-,  1905. 


DISORDERS  OF  ABSORPTION  AND  ASSIMILATION  3(i7 

of  the  stomach  to  absorb  other  substances.  By  far  the  most  important 
ajient  in  the  absorption  of  foodstuffs  is  the  intestine,  for,  unlike  the 
s.'omiich,  it  is  provided  with  special  organs  for  the  purpose,  namely,  the 
villi  and  solitary  follicles.  Peptones,  sugars,  emulsified  fats,  glycerin, 
and  fatty  acids  are  ahsorlR-d  chiefly  in  the  small  and,  to  a  much  less 
extent,  in  the  large  bowel. 

To  gain  anything  like  an  adequate  apprehension  of  the  complicated 
pnK'esses  concern«l  in  absorption,  we  must  acquaint  ourselves  with  the 
|)liysical  and  chemical  conditions  present  during  digestion.  Let  us 
tiike  the  small  intestine  as  an  illustration. 

Here  the  organs  specially  differentiateil  for  the  purpose  of  absorption 
are  the  villi.  Each  villus  is  u  minute  elevation,  projecting  alwut  1  mm. 
alK»ve  the  general  level  of  the  mucosa.  It  is  -omposed  of  a  core  of 
delicate  are<jlar  and  iwlenoid  tissue,  covertnl  with  a  basement  membrane 
and  a  single  layer  of  columnar  cells  continuous  with  those  lining  the 
intestine  elsewhere.  In  the  centre  is  a  lacteal,  or  possibly  two  lacteals, 
connected  by  lateral  channels,  and  an  afferent  bloodvessel.  The  wall 
of  the  lacteals  is  composed  of  a  single  layer  of  endothelial  plates.  About 
the  lacteals  can  be  detecte<l  a  few  fibers  of  unstriped  muscle,  whose 
function  is,  by  their  contraction,  to  empty  the  lat  teals  of  their  contents. 
Surrounding  the  lacteals  is  a  freely  anastomosing  meshwork  of  venous 
capillaries,  lying  iK-tween  them  and  the  superficial  epithelium.  The 
total  lunnber  of  the  villi  is  very  great  and  has  Ijeen  estimateil  at  4,000,000. 
Tliey  are  so  closely  packed,  as  a  matter  of  fact,  that  the  mucosa  presents 
a  velvety  appearance.  During  digestion  the  blootl  capillaries  are  con- 
gested and  the  villi  assimie  an  erectile  condition. 

In  regard  to  the  process  of  absorption,  the  position  of  affairs  may  be 
briefly  summarized  in  this  way.  In  the  villi  the  bloodvessels  are,  of 
course,  filled  with  blood,  and  the  other  structures  are  bathed  in  lymph. 
The  lumen  of  the  intestine  contains  foodstuffs  largely  in  solution. 
Between  the  two  sets  of  fluids  there  is  only  a  basement  membrane  and 
a  sinj;le  layer  of  cells.  The  diffusion  of  the  fluids  must  take  place  through 
tins  barrier.  To  reach  the  circulation,  furthermore,  the  resulting  mixture 
must  pass  another  obstruction,  namely,  the  cells  forming  the  walls  of 
the  lacteals.  The  old  view  was  that  this  interchange  was  of  the  nature 
of  an  osmosis,  but  no  physiologist  of  repute  would  indorse  this  idea 
now.  One  of  the  fundamental  properties  of  primitive  cells,  the  amoeba 
for  ixaniple,  is  the  power  of  taking  up  from  the  surrounding  medium 
foodstuffs  and  other  materials,  assimilating  what  are  necessary  and 
iist'ful,  and  rejecting  those  that  are  not  required  or  positively  harmful. 
I  lure  is  no  reason  for  supfwsing  that  the  cells  of  the  animal  body,  even 
whin  differentiated  for  special  purposes,  lose  necessarily  these  early 
!><■<  Hilarities.  In  fact,  all  the  evidence  that  we  possess  points  untpiestion- 
al'Iy  the  other  way.  Applying  this  to  the  subject  in  hand,  we  lielieve 
that  iihsorption  cannot  l)e  explained  on  a  mere  phvsical  basis  of  osmosis, 
I'lit  are  forced  to  conclude  that  the  process  is  inseparablv  bound  up  with 
tlH'  Mi.il  properties  of  the  cells  concerned.  Absorption  and,  for  that 
raaticr,  secretion  are  selective  processes. 


Mih 


368     THE  DIGESTIVE  FUNCTIONS  AND  THEIR  DISTURBANCES 

The  investigation  of  the  subject  of  absorption  is  one  attended  byxrciit 
difficulties,  and  the  finer  details  of  the  process  are  still  to  a  large  exttiit 
matters  for  conjecture.  So  far  as  can  be  gathered  from  recent  work, 
what  takes  place  is  briefly  this:  The  various  substances  resulting  from 
protein  decomposition  are  taken  up  by  the  columnar  c-ells  covering  the 
villi,  pass  through  the  cells  into  the  suliepithelial  reticulum,  and  iiiul 
their  way  into  the  bloo<l  capillaries,  whence  they  eventually  reach  lln' 
portal  vein  and  the  liver.  The  farther  the  pn)cess  of  tlecomposition  lias 
been  carried,  the  easier  and  more  rapid  is  the  absorption.  It  is  likely, 
moreover,  that  these  pnulucts  of  protein  metamorphosis  luulergo  some 
further  modiflcation  in  the  tissue  spaces  liefore  they  enter  the  bliKMl.  In 
a  similar  manner,  the  greater  part  of  the  sugars  rea{'h  the  blood-vascular 
system,  though  possibly  some  small  pt)rtion  may  be  taken  up  by  the 
lymph.  'I'he  fate  of  the  fats  has  l»een  a  matter  of  great  di.scussioii.  It 
is  a  fact  that  globules  of  fat  can  l)e  demonstrated  by  ap  )ropriate  metlKwls 
within  the  columnar  cells.  On  the  older  theorj*,  the  cells  in  (juestioii 
took  up  the  fats,  which  are  in  a  finely  emulsifie<l  state,  bodily,  by  a  sort 
of  amieboid  action.  We  know  now,  however,  that  the  most  of  the  fats 
ingested  are  hydrolyzed  in  the  intestine  into  fatty  acids  and  },Iyceriii. 
These,  with  the  soaps,  are  soluble,  and  are  probably  taken  up  in  tin's 
form  by  the  columnar  cells  and  there  recombinetl  to  form  neutral  fats. 
For,  it  has  l)een  shown  experimentally,  that  if  we  feed  an  animal  with 
fatty  acids,  neutral  fats  can  l)e  demonstratetl  in  the  epithelium.  A))- 
parently,  then,  the  columnar  cells  can  .synthesize  the  products  of  fat 
decomposition,  an«l  even  supply  the  glycerin  for  the  purpo.se.  The  n*- 
combined  fats  are  then  taken  up  by  the  lymph-radicles  and  pass  into  the 
central  lacteals,  and  eventually  into  the  thoracic  duct  and  general 
circulation.  As  in  the  case  of  the  pn)teins,  the  fats  undergo  transforma- 
tion in  their  pa.ssage  from  the  epithelium  to  the  lacteals,  for  a  large  part 
of  the  fat  in  the  chyle  is  in  a  state  of  fine  division  or  molecular  disiiilegra- 
tion. 

The  carlM)hydrates,  chiefly  in  the  form  of  sugars,  are  takf  ii  up  by  the 
epithelium  and  pa.s.sed  into  the  jwrtal  bloinl.  To  .some  extent,  also, 
•iextrin  can  be  dealt  with  by  the  o(,luinnar  cells. 

The  water  is  taken  up  by  the  niuco.sa  of  the  small  intestine,  but  the 
amount  lost  in  this  way  is  replaced  by  water  excreted  by  the  cells,  for 
the  contents  of  the  bowel  at  the  ileocecal  valve  are  ju.st  alx)ut  as  fluid  as 
those  at  the  (huMli'innn.  The  chief  ab-sorption  of  water  takes  pin  in 
the  large  ImjwcI,  so  that  the  feces,  when  they  reach  the  recttnn,  arc  firm 
and  ct)niparatively  dry.  In  cases  of  constipation  almost  the  whole 
of  the  water  may  l)e  taken  up  and  the  stools  l)ecome  hard,  stony,  iiiid 
scybalous. 

The  fate  of  the  unused  ferments  is  .somewhat  doiditful.  Pr()li.il)iy, 
they  an"  not  rcsorlieil,  but  are  destroyed  in  the  colon. 

We  must  not  leave  this  part  of  the  subject  of  absorption  wiihuut  a 
brief  reference  to  the  role  playe<l  by  the  leukocytes  in  the  juimcv- 
I  Hiring  digestion  numerous  leukocytes  can  lie  seen  in  the  sul)e|iiiii(  li;" 
connective  ti  between  the  columnar  cells,  and  on  the  surface  t!  the 


DISORDERS  OF  ABSORPTION  AND  ASSIMILATION 


369 


mucous  membrane  of  the  intestine,  which  are  apparently  attracted  from 
the  vessels  and  tissue  spaces  by  positive  chemiotaxis.  This  fact  was 
long  ago  pointed  out  by  Heidenhain,  and  has  been  amply  demonstrated 
by  numerous  observers  since.  One  part,  at  least,  of  their  function  is 
connected  with  absorption,  for  fat  and  the  precursors  of  fat  c>>,n  be 
detected  in  their  substance  by  appropriate  methods.  A.  B.  Macallum' 
has  very  prettily  and  conclusively  shown  that  the  leukocytes  can  take 
up  foreign  substances,  notably  iron.  Experimenting  with  the  lake 
lizard  (necturus),  he  took  an  animal  ('at  had  fasted  for  thirty  months 
(to  insure  that  the  intestine  would  be  empty)  and  fed  it  on  albuminate 
and  peptonate  of  iron.  Killing  the  lizard  eight  hours  later,  he  found 
leukocytes  laden  with  iron  within  the  lumen  of  the  bowel  between  the 
columnar  celb  of  the  mucosa,  and  even  in  the  capillaries  of  the  liver 
anil  spleen,  showing  that,  through  the  agency  of  leukocytes,  iron  could 
enter  the  portal  system  and  general  circulation.  Presumably  the  same 
would  hold  good  for  other  substances,  bacteria  and  foodstuffs.  We 
must,  however,  interpret  this  attraction  of  the  leukocytes  to  the  mucous 
surface  of  the  bowel  with  some  caution,  for  the  same  thing  occurs  as  a 
result  of  the  exhibition  of  a  saline  purge,  such  as  magnesium  sulphate, 
where  the  process  at  work  is  quite  the  reverse  of  absorption.  Still, 
tills  probably  only  means  that  in  this  case,  also,  we  have  to  deal  with 
an  irritation  and  stimulation  of  the  secreting  cells,  which  determines  the 
attraction  of  the  leukocytes.  It  is  altogether  likely  that  the  leukocytes 
plav  an  important  part  in  the  function  of  absorption,  perhaps  not  so 
much  in  the  case  of  the  neutral  fats,  but  more  especially  in  regard  to 
proteins  r.nd  the  soluble  products  of  digestion. 

We  shall  Je  helped  to  a  better  understanding  of  the  disorders  that  may 
aite.ul  absorption  if  we  l)ear  in  mind  the  chief  factors  in  the  mechanism 
of  tills  function.  It  is  evident,  from  what  has  been  said  above,  that  the 
structures  mainly  concerned  are  the  columnar  cells  lining  the  mucosa  of 
the  <;astro-intestinal  tract,  the  bloodvessels,  and  the  lymphatic  system. 
Disorders  of  absorption  would  naturally,  then,  be  likely  to  attend  dis- 
turbance of  any  portion  of  this  mechanism.  But  there  is  another  way 
in  which  these  disorders  might  arise.  The  stomach  and  intestine  may 
contain  abnormal  substances  that  are  actually  deleterious  to  the  economy, 
or  secretions  that  are  quite  normal  may  l)e  resorbed  instead  of  passing 
away. 

We  must  admit  that  our  knowledge  of  the  pathology  of  absorption  is 
far  from  being  complete,  but  some  points  seem  fairly  clear.  The 
liitesiiMiil  mucosa  constitutes,  as  it  were,  a  first  line  of  defence.  So  long 
as  the  layer  of  columnar  cells  is  intact,  it  is  possible  for  secretory  and 
abs()r|)tive  processes  to  go  on  normally,  and  a  powerful  barrier  exists 
a^aill^t  microbic  invasion.  Should  a  solution  of  continuity  occur,  or 
shoii!!  tlie  vitality  of  the  lining  cells  be  damaged,  then  infection  and 
into\i  ition  are  likely  to  \ye  induced.  Yet  this  is  not  absolutely  necessary, 
for  ii  tias  been  shown  conclusivelv  that  under  certain  circum.5tances 


■r 


f 


in  I 


i* 


: 


I 


.'I 


'  Jour,  of  Phyg.,  16: 1894 :  268. 


370     THE  DIOESTIVE  FUSCTIOSS  ASD  THEIR  DISTURBANCES 

bacteria  may  |)enetrate  a  normal  miKtxsa.  Notably  is  thi^  the  case  wiili 
the  Iwcillus  of  tulierculasis.  Similarly,  sohilile  toxins  may  pass  in.  S( itne 
of  these  may  Ije  ingested  with  the  fo<Hl,  while  others  are  pHxIiucd  In 
situ  by  abnormal  decompositions  an<l  bacterial  fermentations.    Tlius, 

fttomaines,  like  nenrin,  mydalein,  niytilotoxin,  and  tyrotoxicon,  innv 
>o  present  in  putrefying  foo«l.  Specific  1  •'cteria,  such  as  the  typlmlll 
bacillus,  the  cholera  vibrio,  the  bacillus  of  tuberculosis,  and  the  iiclino- 
myces  Inivis,  may  lead  to  infections  of  alimentary  origin.  Or,  iij;aiii, 
chemical  substances,  like  the  metallic  salts,  aromatic  compounds,  inid 
the  fatty  acids,  may  cause  trouble.  In  the  >;ist  majority  of  cases,  how- 
ever, these  substances  are  distinctly  irritating  and  lead  to  injury  of  ilu- 
intestinal  nmcosa. 

Normally,  the  gastro-intcstinal  tract  contains  bacteria  in  considiTid)le 
numl)ers  and  some  variety.  The  excessive  growth  of  these  is  luld  in 
check  by  the  acid  in  the  stomach,  and  by  the  biliary  acids,  tlu-  fatty 
acids  resulting  fnun  the  decomposition  of  fats,  and  the  digestive  secretions, 
in  the  intestine.  Perhaps,  of  even  more  importance,  is  the  regular  and 
frctiuent  elimination  from  the  Ixxly  of  fecal  matter,  whereby  stasis  is 
prevented  and  little  time  is  allowed  for  development  to  occur.  In 
the  large  lM)wel,  where  the  refuse  products  are  retained  longest,  the 
greater  part  of  the  nutritive  material  has  been  absorbed  and  there  is  less 
for  the  bacteria  to  decompose.  Probably,  too,  those  microorganisms 
that  may  l)e  calleil  the  natural  inhabitants  of  the  alimentary  tract  ]H>rforin 
a  useful  function  in  antagonizing  the  effects  of  foreign  invaders. 

Di.sorders  may  be  brought  about  by  excessive  multipli.itioii  of  the 
normal  bacterial  inhabitants  of  the  tract  or  an  increase  in  their  viruhtice. 
Indigestible  f(MMl,  disturbances  of  secretion,  and  motility  are  coiiii)eteiit 
to  cau.se  the  former  condition,  while  strangulation  of  the  bowel  may 
cau.se  the  latter.'  I.,ocal  inflammntion  and  irritation  of  the  bowel  often 
then  result.  Pathogenic  bacteria  of  extraneous  origin,  when  iiii;esie(i, 
do  not  always  pro<luce  serious  results,  for  they  may  \w  rendered  inert 
by  the  various  agencies  already  referred  to.  But  if  they  gain  entrance 
to  the  body  in  large  numl)ers,  or  in  small  do.ses  frecjuently  repeated,  or 
if  their  virulence  Imj  high,  infection  usually  occurs.  Their  pathofrenic 
powers  will  l)e  aided  by  any  diminution  of  vigor  in  the  ordinary  !>a(torial 
flora,  or  by  diminished  resistance  on  the   part  of  the  mucosa.' 

I)isturl)ances  affecting  the  vitality  of  the  lining  coliuniiar  (ilK  of 
the  gastro-intcstinal  mucous  i.iembrane.  if  widespread,  .seriously  inter- 
fere with  ab-sorption.  Thus,  in  enteritis  of  a  moderate  grailc.  the 
absorption  of  fats  is  diminishe<l,  and  in  the  most  .severe  fortns  flic  al'-oi|)- 
tion  of  all  kinds  of  fmnlstuffs  is  difficult  or  impo.ssiblc.  Where  only  ^mall 
i.solated  Hatches  of  the  nuK-o.sa  are  involvi-d  this  result  does  not  fr''low. 
Thus,  in  most  ca.ses  of  tvphoid  fever  the  power  of  ab.sorptioM  i-  not 
notablv  diminished. 


'  Macaie^e.  .\rch.  K('m.  de  Mod.,  1  )c'C«'Mit)er,  1890. 
'  Tlio  reader  will  find  tlie  subj.'ct  of  intoxication  and  infection  orif!iii;i'i 
digestive  tract  dealt  with  in  vol.  i,  pp.  279  and  ?49. 


1  I  111' 


JAUSDICK 


371 


I'lissive  c-ongi'stion  of  the  intestines  will  delay  absorption  un<l  espe<'ially 
inltTfe«-s  with  the  absorption  of  fats.  Obstruction  of  the  lymphatics, 
siiih  as  (KTiirs  in  tul)erculosis  of  the  IkjwcLs  and  mesenteric  );lands, 
notiibly  hampers  the  absorption  of  the  fats. 

Incn-asetl  peristalsis,  as  in  diarrhoea,  if  affecting  the  small  bowel,  will 
s<rii)iisly  diminish  alxsorption  by  lessening  the  time  that  the  chyme  re- 
iiiiiiiis  in  contact  with  the  mucosa.  \Vhen  due  to  «lisordered  conditions 
rif  tlif  large  bowel,  the  absorption  of  water  is  lessened,  but  the  effect  on 
the  ijeneral  nutrition  is  not  so  great,  for  by  the  time  the  fowlstuffs  Imve 
na<  h(Hl  the  colon  the  greater  part  of  the  nutritive  material  has  already 
Ufii  extracted. 

.\  iiuml)er  of  serious  disturbances  may  arise  from  the  resorption  of  the 
.sf<ri'li()ns  normally  found  in  the  intestines.  A  certain  amount  of 
rMi>ri)tion  is,  indeed,  physiological.  For  example,  the  solidity  c'  the  fe<'es 
found  in  the  large  Ixjwel  indicates  that  a  considerable  amount  of  water 
i-  taken  sigain  into  the  circulation.  The  increase  In  the  viscosity  of  the 
liilf  < oiitaintnl  within  the  gall-bladder,  as  compcnHl  with  thiit  ^»u  '  in 
thi'  ducts,  j>oints  in  the  same  direction.  It  is  pnjbable,  too,  that  a  con- 
'liltTaldc  [)roportion  of  the  bile  salts  and  pigments  are  resorln'd  from 
tlif  intestine.  We  have,  in  fact,  to  recognize  a  reversibility  of  cellular 
actiiiii.  Acconling  to  the  direction  of  the  forces  exerte<l  upon  a  cell  or 
Mrii>  of  cells,  either  secretion  or  resorption  will  take  place.  I'lidcr 
oriiitiary  ••ircumstances  resorption  is  followed  by  no  noticeable  effects, 
imt  -liduld  a  given  secretion  J)e  resorl)eil  in  exc(>ss,  or  should  it  Ih'  taken 
iif)  liv  cells  other  than  those  that  pro<luce<l  it,  far-reaching  disorders  are 
(rrtaiii  to  follow.  The  most  impirtant  disonlers  that  we  have  to  coii- 
-iiler  here  are  those  connecte<l  with  the  bile  and  pancreatic  secret!'. n. 

iJilr  will  be  resorbed  into  the  circulation  if  from  any  cause  there  In* 
iili-triK  ti(jn  to  its  free  discharge  into  the  intestine.  Thi:  may  be  brought 
il.'iiit  hy  calculi  in  the  common  or  hepatic  ducts,  a  catarrh  of  the  fiiicr 
liilt  rliannels  (cholangitis),  tumors  of  the  common  bile  duct  or  the  head 
«i  till  [.aiicR-as,  enlarged  glands  or  abscesses  at  the  hilus  of  the  liver, 
mimI  tuinors  of  the  liver  it.self.  The  condition  is  evidenced  clinically  by 
jiundice,  slowed  p'llse,  mental  hel)etU(le,  itchin-ss  of  the  skin,  and 
It".  !i. i|  ( oagulability  of  the  blotnl.  According  to  the  degree  of  obstruc- 
tiiiM.  liic  digestive  processes  wivhin  the  bowel  are  interfered  with,  as 
ilf^rn'hiil  above,  and  the  stools  are  more  oi  less  devoid  of  their  normal 
Imiwi  ]iii;nient.  Bile  can  be  detectetl  in  the  urine.  The  immediate 
mti  ha  iial  effect  is  dilatation  of  the  bile  passages,  particularly  the  capil- 
lari.-.  ,\ith  compression  and,  possibly,  atrophy  of  the  parenchyinatJ)iis 
i^ll~ '  f  the  liver.  The  retaine<l  bile  passes  into  the  lymph-channels  a. id 
IH  system  and  eventually  reaches  the  general  circulation.  The 
I'l  of  the  bile  is  dependent  not  only  on  the  ('egree  of  the  mechanical 
11.  but  on  the  character  of  the  secretion  also.  A  thick,  vi-cid 
!«•  resorbed  even  when  the  obstruction  is  comparatively  slight, 
result,  for  example,  from  a  catarrh  of  the  finer  !>ik'  passages 
.  liepatic  cells.  The  icterus  found  in  phosphorus  and  toluyleii- 
lisoning,  snake-bite,  and  certain  infections  and  i'ltoxications 


the  vi  ■ 

.ih-tn 

hiltM.l 

or  «\v. , 
liianii: 


f       1 

If 


;}72     rWAi'  DIGESTIVE  FUSCTIOS       \NU  THEIR  DISTURBANCES 

is  of  this  type.  The  toxic  symptom-.  ;iw  referable  to  the  presence  of  the 
bile  sahs  in  the  I)Io(nI,  us  Iihs  re|H>ate<ily  been  deinonstratetl  experinit-iit- 
ully.  The  cholates,  even  in  small  quantities,  stimulate  the  vagi,  and 
lari^-r  amounts  act  upon  the  heart  itsi>lf  and  produce  eonvuisioiu.  'I'he 
resorption  of  bile  from  the  intestines  in  such  amounts  aa  to  pnHliice 
jaundice,  in  the  abseni-e  of  mechanical  obstruction  to  its  outpouriii);, 
is  hanlly  likely,  though  Quincke  has  considered  this  probable  in  the  cnsc 
of  icterus  neonatorum.  Jaundice  can  l)e  brought  about,  of  course,  in 
other  ways  liesides  obstruction,  but  this  phase  of  the  subject  dix's  not 
cjincern  us  here.  For  fuller  information  on  this  part  of  the  subjiit,  (lie 
reailer  is  refernnl  elst-whert!  in  this  work  (vol.  i,  p.  SSa  et  se(|.). 

Obstruction  to  the  fre<'  out[M>uring  of  the  pancreatic  secn-tion  iiiay  at 
times  be  foUowetl  by  serious  results.  Dilatation  of  the  ducts  and  the  line 
ramifications  of  the  duets  within  the  acini  are  the  immeijiate  se(|iit'l, 
but  a  chronic  interstitial  inflammation  with  fibrosis  is  evenn.ally  set  up. 
( )bstruction  of  a  lateral  branch  leads  to  cystic  dilatation,  provided  that 
the  cells  of  the  utfiM'tetl  lobule  are  capable  of  .secretion.  Some  of  these 
retention  cysts  attain  a  relatively  enonnous  size.  Shoidd  large  area-*  of 
the  .secreting  structure  Ik-  destnnofl  by  catarrhal  inflammutioii  and 
pressure,  the  internal  .swretion  of  the  pancreas  may  be  interfered  witli 
and  a  form  of  glyo^suria  result.  Obstruction  to  the  outflow  of  secretion 
may  1m>  prcxluced  by  new-gn»wths  and  fibrosis  in  the  head  of  the  pancreas, 
or  a  calculus  iinpacte<l  in  tlie  ampulla  of  Vater.  Should  the  <al(iilus 
be  v-f  a  certain  shape  and  si/,e,  and  so  plaee«l  as  to  allow  the  eiitrv  of  hile 
into  the  pancreatic  duet,  acute  hemorrhagic  pancreatitis  is  apt  to  l)c  set 
up.  This  is  ass(K'iafed  with  a  curious  condition,  known  as  fat  necrosis, 
in  which  ,.hitish  opaipie  areas  are  to  1h'  found  in  the  fatty  tissues  sur- 
rounding the  pancreas,  the  omentum,  the  appendices  epiploicie,  the 
mesentery,  and  jM-ritoneum.  This  has  InfU  shown  to  l)e  due  to  the 
action  t)f  the  fat-splittiry  ferment  of  the  panen-atic  juice  ujkhi  tlic  fat, 
wlierel)y  glycerin,  fatty  acids,  and  calcium  soaps  are  formed  in  the  tissues. 
The  diffusion  out  of  the  secretion  appears  to  l)e  due  to  pressure  within 
the  duets  or  to  actual  injury  to  the  cells.  The  condition  has  Iwcn  nut 
with  in  otlier  forms  of  inflammation  of  the  pancreas,  but  is  rare  in  cases 
of  suppuration  (see  vol.  i,  p.  5)03). 


1 1  {rP^HkII^^k 


THE  RELATIONSHIP  OF  DISEASES  OF  THE  ALIMENTART  TRACT 
TO  DISORDERS  OF  THE  GENERAL  STSTEM. 

As  we  have  ha<l  occasion  to  point  out  already,  the  aliineiitarv  inu  t  is 
brought  into  dose  connection  with  the  other  great  .systems  of  ih'  Iwnly 
through  the  blood  and  lyinph-eirculation  and  by  means  of  tlic  mrvous 
mechanism.  It  is  not  surprising,  therefore,  that  disorders  of  otiicr-'-icm!, 
or  of  tlie  ImkIv  as  a  whole,  will  often  have  a  profound  effect  ii>".ii  die 
digestive  organs,  and  rice  vema.  The  cells  of  the  alimentary  sysii  1:1  being 
lK)th  absorptive  and  eliminative  in  their  functions,  we  .ire  jiiri'  iv.d  to 
find  that  intoxication  and  infwtion  will  bulk  very  largely  in  ;ii\  con- 
sideration of  this  part  of  our  subject. 


RELATIONSHIP  OF  DISEASES  OF  THE  ALlSfEXTARY  TU 


:m 


It  is  a  wt'll-rpoogiiizetl  principle  in  pathology  that  when  one  organ 
or  system  is  from  any  cause  inhiliitetl  in  its  action,  othvrs  will  attempt 
ti>  take  up  the  work  an«l  carry  it  on  as  pcrfec-tly  as  they  may.  This 
is  known  as  the  law  of  vicarious  function.  It  is  particularly  well  e.\- 
rin|(liHe<l  in  the  case  of  glandular  organs,  aiul  the  attempt  at  compensa- 
lioii  is  often  manifest«Hl  by  .structural  change  as  well  as  increa.se  or 
IMTversion  of  function.  Instances  might  \w.  niultiplie<l  and  are  not 
waiitipg  in  connection  with  the  alimentary  systcin.  .Vs  a  corollary 
to  this,  it  can  \tf  laid  down  that  the  excessive  seiTclion  of  any  gland,  if 
it  result  in  a  great  lass  of  the  IkkIv  fluids,  will  Im-  accompiiiied  by  diinin- 
IsIhmI  activity  of  other  .secretory  organs.  A  familiar  example  of  the  first 
(liiss  is  the  elimination  of  urea  and  other  substances  by  the  skin  and 
iniirous  membranes  in  ca.ses  of  chronic  Bright's  disease.  Here  it  is 
not  imcommon  to  get  stomatitis  and  diarrlxwi  ii  ■  :i  n-sidt.  Ulcrration  of 
the  lower  liowel  is  a  not  infrc<|uent  accompaniment.  The  exposure  of  the 
IhkIv  to  alternations  of  heat  and  cohl  is  fre(]uently  followed  by  diarrha-a 
ill  -.oine  |)eople.  This  is,  in  part,  due  to  the  interference  with  perspira- 
tion, hut,  p<xssibly  also,  there  may  l»e  a  ner^•(>us  element  as  well.  Suj)- 
[iri  ihI  menstruation,  the  absor}>ti(>n  of  abscesses,  the  retrwcssion  of 
eruptions  in  smallpox,  mea.sles,  and  scarlatina,  are  o<'casionally  followed 
liy  (liurrhcra.  f  iout  in  many  cast's  is  asscx-iatctl  with  a  IcHweness  of  the 
Inmcls;  in  fact,  diarrhcea  may  \w  the  only  notable  manifestation  of  the 
iiratic  diathesis  (diarrhoea  crthritica).  Cases  are  known  where  checking 
the  intestinal  evacuations  has  \wen  followjtl  by  the  arthritic  manifesta- 
tions. Attain,  an  example  of  the  sej'ond  group,  the  constipation  of 
(lialxtcs.  often  a.s.s<K'iat«'<l  with  dryness  of  the  .skin  and  mouth,  is  the 
rt'siilt  of  tile  jKjIyuria. 

The  diarrhoea  that  at  times  accompanies  the  ii'^cctious  di.sca.ses, 
notaMy  tiie  exaithemat,i  and  piieiimonia,  is  prol)ably  for  the  most  part 
(liif  to  attempts  at  elimination  and  jx-rvertiMl  excretion. 
Other  ways  >' ■;  vh'','h  the  stomach  and  ImiwcIs  are  affected  in  .systemic 
'  -•  circulatory  and  nervous  systems.  The  diarrhoea 
aiic  goitre  and  Addison's  disea.se  are  apparently 
That  found  in  amyloid  disease  of  the  bowels 
.<Tfen'',,"e  with  excretion  and  absorption,  whereby 
Tl:e  jniiting,  which  is  so  often  an  early  symptom 
iif  the  onset  of  acute  inftntious  di.sease,  is  due  to  etfereiit  nervous  im- 
YwW-  which  cause  excessive  irritability.  Constipation  and  diarrhoea 
may  n  -nit  from  abnormal  mental  and  nervous  states,  as,  for  example, 
ill  tile  acute  infections,  notably  meningitis,  chronic  lead  jjoisoning,  neu- 
wsthttiia,  and  hy.steria.  Involuntary  evaeiiatioiis  and  iliarrluva  m-ciir 
in  ca-c  -  of  coma,  mental  degradation,  and  hysteria. 

Ihi-  increasing  numl)er  of  .studies  that  have  been  made  in  regard  to 
the  riiiiiial  and  abnonnal  digestive  |)r(Mes.ses,  especially  in  connection 
with  !i,i.terial  activity  within  the  intestiiu-,  serve  to  indicate  our  realiza- 
tion of  th,.  growing  importance  of  this  subject.  While  our  knowl<>fIge 
I'  ^ti!l  fir  from  complete,  for  the  problems  involvtHl  are  of  very  wide 
range,  ~  ;(ficient  has  been  gathered  to  prove  that  the  absorption  of  dele- 


Mi>ca^e>  art  i 
met  witli  ii 
vasomotor 
is  [xw-ibly 
irritation  is  .s^ 


;  . 


374     TUi:  niCKI^TIVK  FUSCTIOSa  AXD  TIIKIR  Dl.STURBASCHS 

trrioii.s  .siilKstunct's  fn)iii  the  gnHtrfvinteHtinHl  tnirt  U  a  fnH|uciit  uiiil  incisi 

IN>t(>nt  fuct«>r  ill  tlu>  cuu.-uktion  of  iii!H>a.<u'  clscwhcri'  in  tlie  iHxiy.  'I'lic 
ist  of  HtfcctioiM  thut  have,  fnim  tiiiu-  to  timi*,  Inh*!!  Httrihutinl  by  vurimis 
niithors  to  ga.stn>-int<  tjnal  intoxication  or  infection  i.s  a  fonni*liililc 
ont>,  and,  in  our  juiignient,  the  relationship  in  in  some  iastanres  luiscti 
on  infonciiisive  evidence.  Yet  in  not  a  few  cases  the  etiologi<-al  asstN-ia- 
tion  can  in'  iletermined  with  considerable  certainty.  For  example,  wi- 
might  cite  the  following  affiH(i(<ns  of  the  various  systems: 

1.  Skhi. — Erythema;  urticaria;  dermatitis. 

2.  Miurlfn. — Polymyositis. 

;{.  Central  Nervous  Syatem. — Hea<lache;  mental  hebetude;  giddiiK  ^s; 
insomnia;  delirium;  ctmvulsions;  coma;  neurasthenia;  various  psychoMvs. 

4.  Urinary  Syatem. — Albuminuria;  Bright's  disease;  oxaluria;  cystiii- 
uria. 

5.  Blood  and  Circulatory  Syntem. — Chlorasis;  pc>rnicious  ancniia; 
cosinophilia ;  arteriosclerosis. 

G.  Constitutional  and  IHnihetic  Conditions. — Cachexia;  glycosuria ;  uric 
acid  diathesis. 

In  discussing  this  question  it  is  not  always  passible  to  di.stin};iii.sli 
l)ctween  the  effects  of  intoxication  and  of  infect'on.  Bacteria  arc  con- 
stantly present  in  the  almientary  tract  and  their  number  and  virulence 
are  very  rapidly  increa.sed  under  certain  cii>  umstances.  l)cranj;eMient.s 
of  the  <ligestive  secretions  and,  above  all,  impaired  motility  arc  the  most 
potent  factors  in  this  connection.  In  addition,  then,  to  th"  toxic  siil>- 
stances  that  may  be  introduced  into  the  alimentary  tract  from  without, 
or  that  may  Ix;  produced  by  disordered  function,  we  have  to  n-ckoii  with 
those  resulting  from  bacterial  metal)olism  an«l  abnormal  fcniieniution, 
and  in  many  cases  with  the  entry  into  the  system  of  the  nii(Ti)(ir;,'aMisnis 
themselves.  The  majority  of  intoxications  originating  from  the  (li<:<xtive 
system  arc  of  tlie  exogenous  type,  though  some  few  are  of  a  riiixcd 
exogenous  and  endogenous  nature  (see  also  vol.  i,  pp.  279  and  'AWh. 

The  toxic  agents  under  discussion  may,  therefore,  be  divitlcil  into 
three  main  classes:  (1)  Those  intnxluced  from  without;  (2)  tli(»sc  result- 
ing from  the  action  of  the  digestive  ferments  within  the  gastro-intotina! 
tnl)e;  (I})  the  products  of  bacterial  activity. 

1.  In  the  first  group  we  include  (a)  chemical  and  mineral  sulist.inces, 
such  as  lead,  copper,  arsenic,  acids,  alkalies,  numerous  salts,  alcohol, 
ptomaines,  and  other  nitrogenous  ha.scs  derived  from  the  pi itn  taction 
of  protein  matter;  (li)  parasites,  lK)th  vegetable  and  animal;  iiml  c) 
supn)pliy>es. 

To  take  but  a  few  of  these  by  way  of  illu.stration.  Lead,  if  alismlicd  in 
small  (|uantities  over  a  prolonge<l  pericMl  of  time,  pro«luces  iimuiia, 
arteriosj'lcrosis  interstitial  nephritis,  various  paralyses,  and  mental  .lci.'ra- 
dation.  Arsenic  causes  anemia  and  muscular  paralyses.  Alu!  I  has 
a  special  tench-ncv  to  attack  the  nervous  svstem  and  leads  to  the  .I'posit 
of  fat. 

The  pr<Klucts  of  bacterial  fermentation,  including  the  ptoinnin'  s,  of 
which  there  are  now  a  great  number  recognized,  produce  a  \a  icty  of 


nASTRO-IS'TKfiTlXAL  INTOXICATION 


37:. 


syinptoins  of  an  acute  imtim>,  hut  tlip  rhiof  fi-uturi's  are  (fa-stro-inti'stiiml 
irritutiuii,  colit,  vomiting,  anil  (liarrli<i>a;  later,  hea«lache,  miisfjilar 
wcitkiiris,  cullap.ie,  coma,  and  death. 

The  second  sulx-'ajw  includes  moultls,  yeasts,  and  bacteria  of  many 
kinds,  trichinae,  and  the  e^jp  of  various  intestinal  worms,  which  may 
contaminate  the  food. 

O!  alimentary  infection  with  Iwcteria,  typhoid  fever  ami  c-holi-ra 
miiv  Ik>  taken  as  the  types.  It  would  seem,  however,  that  a  «-onsi«lerHhl»> 
(|ui"uitity  of  the  particular  micnjiirgar '  ;r.i  miLst  l)e  infjested,  or  re|)eutc«l 
siiiall  doses  <luring  a  prolonge<l  perio«.,  liei'ore  f(eneral  infec'tiim  can  take 
pliit-e.  An  intact  mucous  membrane  cnn  apparently  ren<l»'r  im-rt  a 
rciisoiiuble  amount  of  luicteria,  as  experiments  have  shown,  but  infection 
at  once  takes  place  if  there  be  a  lowered  vitality  of  the  parts,  such  as 
may  Ik'  produce<l  by  a  nastro-intestinal  catarrh.  It  is  known,  t<Mi,  that 
oil  Occasion  Iwctena  may  pa-ss  the  barrier  interpased  by  the  mucusa 
without  pnNlucinK  a  UK-allesion,  and  set  up  ilisease  elsewhere.  Typhoid 
fcvor  without  intestinal  ulceration  can  occur,  and  tuberculosis  of  the 
liiiip*  may  result  fmm  ingested  bacilli  without  evidence  of  intestinal 
(iisturhance. 

Tlic  various  ways  in  which  the  larger  intestinal  para.sites  pHxIuce 
tlitir  ctfwts  have  already  been  discussed  (vol.  i,  p.  314). 

Thinlly,  the  saprophytes  act  by  producing  diffusible  toxias  which  may 
Ih'  ahsorlKHl  into  the  system.  They  are  of  little  importance  here.  Per- 
haps tl'.e  only  one  deserving  mention  is  the  oidium  albicans,  and  this  is 
nircly  so  extensive  in  its  distribution  as  to  cause  serious  trouble. 

2.  I'mler  the  second  category  we  have  to  deal  with  the  effects  of  dimin- 
islitMJ  or  incn>ase<l  secretion  of  the  digi-stive  ferments,  of  resorption  of 
till'  fciincnts  and  the  pro<lucts  of  ferment  action. 

Diiniiiishwl  secretion,  by  .engthening  the  time  required  for  digestion, 
ItiKJs  to  tiic  presence  of  undigested  food  in  the  stomach  and  Iwwcl,  causes 
irritation  of  the  mucosa,  and  promotes  the  activity  of  bacteria.  Thus, 
atiircpsia  may  res' '  long-continued  cases,  and  in  the  less  severe  ones, 
pastni-intestinal  irr       on,  pain,  tympanites,  and  diarrhcea. 

ily|)or.swrction  w.a  produce  pain,  vomiting,  and,  in  the  end,  malnu- 
trition. 

Tlu"  re.sori)tion  of  the  secretions,  particularly  the  bile  and  the  pan- 
en  aiic  juice,  has  already  lieen  dealt  with  in  so  far  as  the  local  effect  on 
the  liviT  and  pancreas  is  concerne<l  (p.  371).  The  resorption  of  bile 
priMliicts  systemic  effects;  the  slow  pulse,  itching  of  the  skin,  mcntnl 
(liiliK^s,  coma,  and  hemolysis  are  to  l)e  attributed  to  the  action  of  the 
n>nt;iiiicd  biliary  salts. 

Wlictlicr  the  pancreatic  secretion  is  ever  resorbed  ini'>  the  circulation 
in  siifliciciit  amount  to  produce  systemic  effects  has  not  yet  l)een  detcr- 
miiHil.  Any  result  is  probab!  -  indirect,  the  passage  out  of  the  pan- 
crc.uic  secretion  into  the  suba^.ince  of  the  organ  leading  to  chrotn'c 
irritiiiinn,  fibrosis,  and  atrophy  of  the  secreting  structures,  so  that  eventu- 
ally glycosuria  results. 

l"i  ;■  resorption  of  bile  salts  and  pigmenus  by  way  of  the  iiitestinal  mucosa 


til 
if 


if 


m^- 


III: 


37rt    THE  DIOKSTIVB  rVSCTIONK  AND  THKIR  DISTURBASCE8 

M  beli«'v«l  to  \ie  a  physiologiral  process  rhiI  u  of  no  «perial  importunct.. 
Juuiiiliw  aiul  chulemia  never  .-teem  to  be  protlureii  in  this  way,  'I'hc 
gastric  and  pancreatic  fermenta  that  are  not  utilixetl  may  abo  p<wsil)|y 
un(lerK«>  resorption,  but  observations  made  so  far  would  seem  tc»  show 
that  this  rarely  occurs  to  any  extent. 

Toxic  sulistaiK-es  are  priNiuced  in  the  course  of  the  ordinary  phvsio- 
logical  ^ro<fs.ses  of  diip-stion.     Among  these  may  l»e  mt-ntionf^l: 

(a)  Ihtt.se  derived  from  pn>toin  disintegration:  Albumoses,  pcpionr, 
indol,  skatol,  phenol,  leucin,  tyrosin,  fatty  acids,  acetone,  ammonia! 
cystin, carimn dioxide, hydrogen,  sulphuretted  and  carburetted  hvdropn, 
and  methyl  mercaptan. 

(ft)  'ITiose  derived  from  carlwhydrates:  F«»rmic,  acetic,  propwupc, 
butyric,  valerianic,  lactic,  and  succinic  acitis,  acetone,  and  viirioiis 
gases, 
(c)  Thosi'  derived  from  fats:  Fattv  acids  und  glycerin. 
It  is  unlikely  that,  under  noimal  circumstances,  any  of  thcM-  s\\\y. 
stances  are  alMorheil  in  sufficient  iiuantity  to  cause  disturbance,  for  the 
peristalsis  of  the  intestine  hurries  them  along,  anil  they  are  either  jrriid- 
ally  neutralized  as  they  reach  the  lower  bowel  or  are  quickly  elimiimtfd. 
In  cases  of  obstruction,  however,  they  might  be  expected  to  play  n  part 
by  cat  ng  irritation  of  the  mucous  membrane,  and  with  the  multipii- 
cation  oi  he  bacterial  flora  of  the  intestine  which  inevitably  occurs  in 
such  cases  they  join  their  forces  with  those  of  the  similar 'subst/inces 
resulting  'rom  putrefactive  fermentation. 

3.  The  activity  of  the  microorganisms  nonnally  found  within  the  gastro- 
intestinal tract  is  kept  within  bounds  by  the  acidity  of  the  gastric  MKrctioti, 
the  presence  of  bile,  and  the  regular  evacuation  of  the  intestinal  contents. 
The  Iwcteria  that  are  present  under  these  circumstances  may  l)c  re- 
garded as  non-pathogenic,  yet,  on  occasion,  their  numbers  and  virulence 
may  be  so  increased  as  to  produce  pathological  effects.  This  is  par- 
ticularly the  case  when  there  is  constipation,  strangulation,  or  some 
inflammatory  affection  of  the  Iwwel.  The  bacteria  may  actually  pass 
through  the  wall  of  the  intestine,  if  its  vitality  be  lowered  in  this  way, 
even  at  times  without  any  solution  of  continuity,  and  may  set  up  u  pii 
«'ral  infection,  or,  in  many  instances,  a  peritonitis.  In  the  same  way,  per- 
foration or  rupture  of  the  bowel  is  followed  by  an  infective  inflaniinaiion 
of  the  peritoneum.  The  systemic  effects  of  constipation,  irritability,  men- 
tal dulness,  headache,  malaise,  and  earthiness  of  the  skin,  are,  luxlmiht, 
attributHble  to  the  slow  absorption  of  toxins,  in  large  part  of  l>a(terial 
origin,  from  the  lumen  of  the  bowel.  Where  actual  organic  ohstrm  tion 
exists,  the  symptoms  are  mu-.h  r  »fe  intense,  namely,  pain,  heaiiuhe, 
vomiting,  intense  prostration,  red  temperature,  a  weak  circulaiion, 

coma,  and  perhaps  death.  The  higher  up  in  the  bowel  the  ohstrii.  il  »n 
is,  the  more  severe  are  the  manifestations,  for  the  absorptive  pow- 1>  of 
the  mucous  membrane  are  much  more  active  in  the  small  bowel  :lian 
in  th-  large.  In  conditions  of  health,  however,  what  might  be  tetined 
the  natural  inhabitants  of  the  gastro-intesfinal  tract  probably  e\.  r(  a 
beneficent  action  in  the  economy,  for  they  apparently  have  the  pi>\> ,  i  of 


CIRHHOSIH  OF  THE  UVKR 


377 


inhibiting  the  activity  of  furri,  i  intruders  which  inapr  mnkr  thrir  way 
into  the  Dowel.'  Tliey  may,  however,  Ikj  ovcrlwrne  in  their  reststanoe, 
Hhoiilii  alien  bacteria  be  introduced  into  the  alimentary  .lystem  in  suffi- 
ciently large  numbers,  or  if  their  vigor  l>e  diminishe«l  fn>'  i  any  cause. 

'llie  bacteria  in  Question  produce  their  t>tfects  in  twu  ways,  by  the 
excretion  of  the  products  of  their  own  metabolism  and  by  initiating  ab- 
nortnul  processes  of  fermentation.  In  this  manner  are  formnl  a  variety 
of  .substances,  such  as  the  fatty  acids,  indol,  .skatol,  phenol,  coni|N>unds 
of  the  aromatic  series,  pyridin  and  chinolin  lxHlif>s,  diamins,  toxalbumins, 
hvdrogen,  carlxinic  dioxide,  and  methane. 

The  effects  pnxlucetl  may  be  local  in  the  tract  or  its  uccessory  organs. 
If  lu-ute,  we  may  Knd  degeneration,  inflammation,  or  ulceration ; '  .ironic, 
inHiitnination,  atrophy,  and  fibrosis.  At  other  times  the  reslstii  >k.'  rriers 
ar»  broken  ilown,  to  the  extent  that  toxins  make  their  way  intr  .e  circu- 
lation and  set  up  general  toxemia.  Some  of  the  substances  altsorbed, 
ii4>tul)ly  those  resulting  from  protein  decomposition,  are  rendered  non-toxic 
h\  combination  with  sulphuric  acid,  glycocoll,  and  glycuronic  acid,  but, 
naturally,  to  this  trpnsformnf  ion  there  is  a  limit.  We  may  gain  a  fair  iilea 
of  the  amount  of  putrefactive  chan;r  y  ■  ing  on  in  the  bowel  by  estimating 
tlic  iimount  of  etiiereal  or  aromatic  ^.ulphates  in  the  urine,  as  they  are 
Iwth  absolutely  and  relatively  increa.sed  in  amount  in  this  condition.  It 
should  Im'  remarked  here,  in  passing,  that  it  is  possible  that  we  have 
hitherto  laid  tcM)  great  emphasis  on  the  role  played  by  the  protein  deriv..- 
tivfs,  for  recent  experiments  would  tend  to  indicate  that  the  pernicious 
etft'cts  attributed  to  the  pnxluets  of  protein  decomposition  are  rather  to 
Ih>  hiid  at  the  door  of  the  pota.ssium  salts. 

Tlic  interesting  and  very  important  attempts  that  have  lieeii  made 
to  t'hieidate  the  nature  of  hepatic  cirrhasis,  to  take  a  familiar  condition, 
will  serve  to  illustrate  the  important  port  pbycd  by  cer*iiin  substances, 
pnMJncts  l>oth  of  normal  and  abnormal  fermentation.  Hanot'  was 
of  the  opinion  that  cirrhosis  of  th;  liver  is  due  to  the  '  'itation  produc  ' 
In  ihf  absorption  of  certain  sub.stances  resulting  from  ui..ordered  dij; 
tioii.  Hanot  and  Boix,  in  support  of  this  theory,  showed  thp(  atrop> 
rirriiosis  of  the  \i\^T  could  be  produee<l  in  rabbits  by  the  administration 
of  lactic,  butyric,  and  valerianic  acids.  The  deleterious  etfei '  ■  of  potas- 
siiini  .salts  is  well  .shown  by  .some  ex|Hriinents  of  Lancei-  \:^.:  He 
notii t(l  that  in  Paris  cirrhosis  of  the  liver  was  .-e  ((tmino  i  in  tho.se 
oriiiking  wine  than  in  those  using  other  alcoho!  .  !  averages.  This  he 
altrihiite*!  to  the  fact  that  many  of  the  wines  contained  sulphate  of  potas- 
sium to  render  them  "dry."  Some  of  thest-  'plastered"  wines  contained 
as  iiiiich  as  four  to  six  grams  per  liter  of  this  substance.  By  fce<ling 
ral'liits,  guinea-pigs,  and  dogs  with  sulphate  of  potash  for  from  six  to 
t%'lit(  cii  months  he  could  produce  typical  portal  cirrhosis. 

\Vliile  the  attention  of  these  observers  was  concentrated  on  the  deter- 


i  m 


'  BieMtocIt,  Arch.  f.  Hyg., 36: 1900: 33.5,  and  3!(:l«)O:3S0. 

'  .Vrch.  g«n.  de  M«d.,  i:  1899: 3. 

'  Bull,  de  l'.\cad.  de  M^.,  38: 1897:202. 


37.S     THE  DIGESTIVE  FUNCTIOXS  AND  THEIR  DISTURBANCES 


mination  of  one  particiiliir  point,  it  may  bf  remarked,  in  criticism  of  tlicir 
conclusions,  that  one  cannot  exclude  the  influence  of  bacteria  in  contriltii- 
ting  to  the  result.    That  bacteria  and  their  toxins  play  an  important  role 
in  this  connection  cannot  be  doubted.    Krawkow'  has  noted  that  cirrhosis 
could  be  induced  by  giving  bacterial  toxins  by  the  mouth,    llunion,- 
also,  tried  a  number  of  feeding  experiments  on  different  series  of  aniiniils, 
giving  (1)  alcohol,  (2)  microbic  toxins,  (3)  living  cultures  of  bacteria, 
and  (4)  alternate  doses  of  alcohol  and  bacterial  toxins.    The  aiiiinals 
to  whom  the  cultures  were  administered  died  of  septicemia,  with  fativ 
degeneration  of  the  liver.    Those  fed  on  alcohol  alone  devcloix-d  fattv 
livers.     In  one  case,  in  whi<'h  alternating  doses  of  alcohol  and  toxins 
were  given,  the  animal,  after  surviving     ten  months,  exhibitc<l  sifrns 
of  hepatic  cirrhosis.    The  influence  of  alcohol  in  the  pathogenesis  of 
cirrhosis  has  been  the  subject  of  much  debate.    Some  have  held  tliat 
it  sets  up  a  gastro-intestinal  catarrh,  and  that  then  the  toxins  eluliorattd 
are  carried  to  the  liver  and  set  up  the  disturbance.     Others  think  that 
the  alcohol,  being  quickly  absorbetl,  is  carried  directly  to  the  liver 
and  leads  to  irritation   and   degeneration.      Still  others,   like  Ranioii, 
take  an  intermiHl'i»te  position,  holding  that  gastro-intestinal  catarrii 
alone  does  not  explain  the  condition,  but  that  alcohol  pn)ni()tes  the 
absorption  of  toxins  from  the  Ijowel,  and,  moreover,  lessens  the  power 
of  the  liver  to  resist  them.     Further,  Bindo  de  Vecchi'  was  able  to  \m>- 
duce  proliferation  of  the  interstitial  connective  tissue  of  the  liver  hv  intro- 
ducing certain  germs  into  the  intestine.     His  experiments  point  to  the 
pathogenicity  of  the  B.  coli.     Weaver*  obtained  similar  results  by  the 
siilK-utaneous  inj'XJtion  of  a  germ  belonging  to  the  colon  group,  whieli 
he  is()late<l  from  guinea-pigs  dying  spontaneously,  and  Hektoen,'  with  a 
bacillus  of  tin-  pseudoiliphtheria  type.    The  preponderance  of  (•vi(hii(e 
therefore,  goes  to  show  that  certain  products  of  fermentation  in  the  liowe! 
ar»>  competent  to  prinluce  cirrhosis.     Bacteria,  while  in  gener.il  tlicv  are 
likely  to  prinluce  acute  lesions  of  a  suppurative  type,  or  even  .;epli(-niia, 
can,   if  sufficiently   attenuat(>d,   lead   to  a  slow   proliferative   (•liaii<:e. 
Apparently,  however,  before  bacteria  can  act,  there  must  be  a  lowering' 
of  the  vitality  of  the  liver  parenchyma.     This  can  be  pro<luced  by  ali  iihol, 
bacterial  toxins,  and  certain  organic  fatty  acids. 

The  hemolytic  action  of  certain  microorganisms  and  their  toxins  has 
now,  for  some  years,  l>een  widely  recognized.  It  is  not  at  all  iinprolialile, 
and  there  is  a  certain  amount  of  evidence  in  favor  «)f  it,  that  certain  loriiis 
of  severe  anemia  and  the  deposit  of  iron  pigment  in  various  parts  ot'  the 
iKHly  are  due  to  gastro-intestinal  intoxication  and  infection,  lliinier,' 
for  example,  is  a  strong  upholder  of  the  view  that  pernicious  ant  niia  is 
infective  in  origin.    His  earlier  observations  tended  to  the coiu!iisii)ti  that 

'  Arch,  (le  MM.  expC-r.  et  d'Anjit.  patli.,  ISlHi:  l()(i  and  2H. 
'  I'resw"  Mi'ilicale,  April  21,  1897: 17S. 
'  r,<>  Spcriinonfnk'.  An.  53:3. 

•  Triinsi.  Chicago  Path.  Soc,  3:  KKK):  228. 
'.lour.  Path,  and  Hact.,  7:  1001 :  214. 

•  F,ancct,  London,  1:1900:221,  291),  :}71. 


CASTRO-IXTKSTISAL  ISFKCTinN 


370 


tills  iHsease  is  due  to  the  hemolytic  action  of  some  special  toxin  elaborated 
ill  and  alworlied  from  some  part  of  the  alimentary  tract.  This  t()xin  is 
not  simply  the  product  of  onlinary  fermentative  and  putrefactive  pro- 
cesses, hut  is  of  a  special  infective  nature.  Later,  he  showed  that  the 
rt'fjion  of  the  greatest  absorption  was  the  stomach,  but  to  some  extent 
the  buccal  and  intestinal  mucosa?.  The  important  etiological  factors 
ill  the  disease  are  carious  teeth,  stomatitis,  and  glossitis,  which  lead 
to  an  infective  gastritis.  Certain  local  c-onditions  in  the  stomach,  such 
iis  malignant  disease,  gastritis,  and  atrophy  of  the  mucous  membrane, 
also  predispose.  The  nature  of  the  infecting  agent  is  not  clear,  but  it 
is  possibly  of  a  mixed  kind. 

One  other  phase  of  this  subject,  in  conclusion,  demands  a  few  wonls. 
Tliere  is  now  abundant  evidence  to  show  that  microorganisms  are 
(•(instantly  gaining  an  entrance  into  the  .system  by  way  of  the  alimentary 
tract.    Uuffer,'  on  examining  .sections  taken  from  the  small  intestine 
(if  healthv  rabbits,  found  that  leukocytes  were  present  on  the  surface  of 
the  mucosa;  others,  again,  between  the  epithelial  cells,  that  had  engulfed 
hacteria.    The  Peyer's  patches  contained  immen.se  numbers  of  micro- 
(ir);anisms,    apparently    within    the    lymphoid    cells.     Bizzozero'    and 
Kutfer  found  an  analogous  state  of  things  in  the  ca.se  of  the  rabbit's 
tdiisil.     Further,  the  leuk(K-ytes,  travelling  Imck  from  the  surface  to  the 
lymphoid  follicles,  were  taken  up  by  certain  large  cells  (macniphages) 
and  eventually  digested,  together  with  any  bacteria  or  footlstuffs  they 
iiiit;lit  contain.     One  of  us  (A.  G.  \?),  also,  has  demonstrated  that 
microorganisms  can  \ye  found  in  various  stages  of  disintegration  within 
the  capillary  vessels  of  the  mesentery  in  rabbits,  cats,  dogs,  and  in  the 
liiiiiian  subject  at  postmortem.    Others,  again,  may  be  detecte<l  in  the 
meshes  of  the  tLssues,  grouped  alMiut  the  nuclei  of  what  are  presum- 
al.lv  wandering  cells,  and  within  the  lining  endothelia  of  the  ve.s.sels. 
CniiTing  the  thought  one  step  farther,  Bizzozero  and  Ribbert*  showed 
till-  presence  of  bacteria  within  the  normal  mesenteric  gland.     Finally, 
Niclidils'  and  Ford'  have  proved  that  bacteria  can  be  recovered  from 
liiiiltliv  organs  by  cultivation.      Recently,  Wrosczek   has   brought  for- 
ward "a  pretty  confirmation  of  these  studies.     Feeding  healthy  animals 
oil   t(HKl   contaminate<l   with   non-pathogenic   pigmenteil    microorgan- 
i-ms,  he  regained  these  by  cultures  from  the  internal  organs  without 
tli.ic  iiciiig  the  slightest  evidence  of  any  lesion  of  the  alimentary  tract. 
'Iliisc  {>liser\ati()ns,  taken  together,  prove  beyond  (juestion  that  niicro- 
(iii;:iiiisins  are  constantly  passing  into  the  recesses  of  the  organism  from 
ilir  ;;astr()-intestinal  mucous  membrane.     The-se  do  not,  as  a  rule,  lead 
In  iiitVction,  for  they  are  quickly  rendered  inert  by  the  action  of  the 
li  uk(.(  ytes,  the  various  endothelia,  and,  pn)bably,  the  body  juices.     Still, 

<  Brit.  Med.  Jour.,  2: 1890: 491. 

« Centralbl.  f.  d.  nied.  '.Vi.sa.,  2.'?:  491. 

'  Jour.  Med.  Hcscarch,  11 :  19<)4:  2. 

«  Deutsche  med.  VVoch.,  11:188,5:197. 

'  rnnadiaii  Jour,  of  Med.  and  Surg.,  (">:  1899: 40.5. 

'  TranR.  .\ssoc.  Amer.  I'hys.,  1.5:  1900:  380. 


Mnbu 


380     THE  DIGESTIVE  FUNCTIONS  AND  THEIR  DISTURBANCES 

a  certain  number  of  them  may  retain  a  limited  degree  of  vitality,  a  poten- 
tiality  for  harm  that  on  occasion  may  be  called  into  activity.  This  latencv 
of  germs,  termed  by  one  of  us  (J.  G.  A.')  "subinfection,"  and  noted  alsi. 
by  others,  particularly  Schnitzler,'  probably  explains  those  puzzling  cases 
of  terminal  and  "cryptogenic"  infection  occasionally  met  with.  Less 
intense  than  this  action,  we  must  recognize,  we  think,  a  "condition 
in  which,  as  a  consequence  of  chronic  inflammatory  disturbances  in 
connection  with  the  gastro-intestinal  tract,  there  may,"  for  long  periods, 
pass  in  through  the  walls  of  the  stomach  or  of  the  intestine  a  greater 
number  of  bacteria;  and  while  the  bacteria  undergo  the  normal  and 
inevitable  destruction  by  the  cells  of  the  lymph-glands,  the  liver,  the 
kidneys,  and  other  organs,  nevertheless  the  excessive  action  of  the  cells 
and  the  effect  on  them  of  the  bacterial  toxins  liberrted  in  the  pnKiss 
of  destruction  may  eventually  lead  to  grave  changes  in  the  cells  and  in 
the  organs  of  which  they  are  part— changes  of  a  chronic  nature."  IVol^. 
ably,  in  this  way  we  should  explain  many  of  the  forms  of  chronic 
fibrosis  which  occur  so  insidiously  in  the  various  organs. 

'  Jour.  Amor.  Med.  .Assoc,  S.'J:  18!)9: 15()(i  ami  1572, 
'  .\rch.  f.  klin.  Chir.,  59: 18!m:S(Mi. 


CHAPTER    XVII. 

THE  MOUTH  AND  ITS  ACCESSOKIES. 

THE  MOUTH. 
OONGENITAL  ANOMALIES. 

Abnormalities  in  the  structure  of  the  oral  cavity  and  its  associated 
parts  are  not  infrequent.  Certain  of  them  are  of  great  practical  impor- 
tiince,  inasmuch  as  they  interfere  with  speech  or  the  proper  manipulation 
of  the  food. 

Astomik,  or  complete  .ibsence  of  the  mouth,  is  very  rare.  It  is  usually 
associate<i  with  other  defects  of  <levelopment,  and  is,  of  course,  incom- 
patible with  life.  The  mouth  may  l)e  excessively  large  (mMTOstomift),  or 
exceptionally  small  (microstomia)!  The  buccal  cavity  may  be  present 
but  the  external  orifice  wanting  (atresia  oris). 

Abnormal  shortness  of  the  frenum  of  the  tongue  (tongne-tie)  is  by  no 
means  uncommon.  All  newborn  infants  should  be  examined  for  this 
eondition,  as  it  may  seriously  interfere  with  nursing.  The  tongue  may 
be  double,  or  cleft  at  the  tip  (snake-tongne). 

Among  the  commonest  and  most  important  anomalies  are  harelip 
and  cleft  palate.  Harelip  is  unilateral  or  bilateral,  the  fissure  or  fissures 
l)eing  situated  to  one  side  of  the  median  line  at  the  lines  of  junction  be- 
tween the  intermaxillary  and  the  supramaxillary  Itones.  Various  grades 
of  the  condition  are  met  with,  from  a  slight  notching  of  the  edge  of  the 
li|)  to  a  deep  cleft  sometimes  reaching  into  the  na.sal  cavity.  The 
defect  may  also  extend  into  the  hard  palate  or  even  into  the  soft  palate. 
In  the  latter  case  the  fissure  assumes  a  median  position. 

Anomalies  in  the  development  of  the  jaws,  such  as  agnathia,  brachy- 
gnattua,  ateloprosopia,  are  occasionally  met  with. 

I  )efects  in  the  teeth  are  common  but  relatively  unimportant.  Hutchin- 
son has  described  certain  peculiarities  associated  with  congenital  syphilis. 
Tlic  upper  central  incisors  are  the  teeth  affectetl.  They  are  peg- 
sli:i|)cd,  short,  and  thin,  the  top  being  smaller  than  the  crown.  There 
i^  :i  small  ct)ncave  notch  in  the  cutting  edge.  The  affected  teeth  are 
titV  n  yellow  in  color.  The  condition  is  not  absolutely  pathognomonic, 
liciiii,'  found  in  other  conditions,  notably  rickets. 


\i 


CIRCULATORY  DISTURBANCES. 

structures  forming  the  buccal  cavity  are  among  the  most  va.scular 
body.     Consequently,  alterations  in  the  quantity  or  the  quality 


382 


THE  MOUTH  AND  ITS  ACCESSORIES 


of  the  blood  are  easily  recognized  and  afford  valuable  clinieal  evidcnci' 
of  disease. 

Hypsremia.— Active  Hypwemia. — Active  hyperemia  occurs  physio- 
logically with  the  act  of  mastication,  but  as  a  pathological  condition  is 
an  evidc'ce  of  local  irritation  or  a  manifestation  of  certain  of  the  infective 
fevers. 

Koplik's  sign  in  measles  is  an  eruption  of  irregular  hyperemic  .s|H)ts 
of  bright  red  color,  often  having  a  small,  bluish-white  centre,  wliicli 
appears  on  the  buccal  or  labial  mucasa  some  hours  or  even  davs  In-fore 
the  appearance  of  the  skin  exanthem.  Occurring  as  it  does  so  earlv, 
sometimes  even  liefore  the  catarrhal  symptoms  have  developed,  it  is  a 
valuable  aid  in  diagnosis. 

Punive  Hyperemia. — Passive  hyperemia  is  met  with  especially  in 
obstructive  canliac  and  pulmonary  affections.  The  lips  and  biiwal 
mucosa  assume  a  dull  reddish-purple  color. 

Anemia. — Anemia  may  l)e  one  manifestation  of  severe  general  anemia. 
The  mucous  membrane  appears  pallid  or  even  quite  bloodless  in  such 
cases.  Anemia  of  the  soft  palate  is  freijuently  associated  with  pul- 
monary and  laryngeal  tul)erculosis. 


INFLABIMATI0N8. 


Inflammation  of  the  Hps  is  termed  cheilitis;  of  the  mouth,  stomatitis; 
of  the  tongue,  glossitis;  of  the  gums,  gingivitis. 

Stomatitis. — Catarrhal  Stomatitis,  Cheilitis,  and  Olossitis.— 'riusc 
affections  are  usually  brought  al)out  by  the  action  of  mechanical,  tlicninV, 
or  chemica!  irritants.  Excessive  indulgence  in  alcohol  or  tobacco  arc  of 
imjHirtance  in  this  conne<'tion.  Catarrhal  glossitis  is  a  constant  actorii- 
paniment  of  all  febrile  conditions,  and  catarrhal  inflammation  of  the  whole 
buccal  mucosa  is  often  obser\'e<l  in  infectious  fevers.  Tin  mucous  nuni- 
lirane  of  the  lips,  cheeks,  tongue,  and  alveolar  processes  is  nHidciiid, 
swollen,  and  covertnl  with  secretion.  The  papilla?  of  the  tongue  uiav 
swell,  giving  it  a  granular  appearance.  The  secretion  contains  liiiko- 
cytes  and  <lesf|uamatetl  epithelial  cells.  If  it  l)e  allowed  to  niiiiiiii, 
the  exudate  collects  upon  the  tongue  and  about  the  roots  of  the  tct  ili  in 
the  form  of  a  dry,  <lirty,  grayish-white,  or  brown  coating  (sordes).  Tiit' 
lips  and  tongue  often  l)c<'ome  dry,  fissure*!,  aujl  ulcerated. 

Aphthous  Stomatitis. — This  presents  all  the  features  of  the  <at;inl],il 
form,  but  is  further  characterized  by  the  formation  of  small  gravis 
yellowish-white  spots,  either  single  or  in  clusters,  usually  upon  rln 
and  tongue.  The  spots  in  question  have  a  dull,  opaque  appearand', 
are  bounded  by  a  bright  retl  hyperemic  zone.  They  may  coi 
and  form  large  patches.  Acconling  to  E.  Fraenkel,  the  proiess  is  t  » 
tially  a  fibrinous  infl.tmmation. 

The  affection  is  usually  found  in  children  who  are  badly  noiii 
and  whose  mouths  are  not  ke|)t  properly  clean.     It  has  Ikhmi  nici 
in  women  at  the  menstrual  periods,  during  pregnancy,  and  in  (in  i 


li  or 
li|)s 
nIKJ 

,,(•(' 
,■11- 

MM 
Aith 
•  ivr- 


"-Ih^ 


GANGRENOUS  STOMATITIS 


383 


pcrium.     It  is  not  uncommon  also  in  those  who  have  been  on  protracted 
sprees. 

XneantiTe  StoiutitU. — Ulcerative  stomatitis  is  an  acute  affection, 
rarely  chronic,  which  l)egins  in  the  gums  near  the  roots  of  the  teeth. 
The  tissues  are  at  first  red,  swollen,  and  oedematous,  and  may  form 
warty  projections.  The  gums  tend  to  loosen  from  the  teeth.  Later, 
the  parts  become  pale,  spongy,  and  friable,  bleeding  at  the  slightest 
toiitli,  and  eventually  necrosis  sets  in.  The  ulce;  tion  may  extend  to 
tlie  lips  and  cheeks,  and  may  penetrate  deeply,  leading  to  sequestration 
of  the  bone  of  the  jaw.  The  teeth  not  infrequently  fall  out.  Salivai  -n 
is  a  marked  feature,  and  the  breath  possesses  a  peculiarly  offensive, 
ptiietrating  odor. 

The  disease  attacks  by  preference  those  who  are  badly  nourisheil  or 
wlio  are  weakene*!  by  long-standing  disease.  It  is  foimd  in  diabetics, 
ill  jHTsoiis  suffering  from  scurvy,  and  in  those  who  have  been  poisoned 
l)v  mercury,  phosphorus,  lead,  or  copper. 

Somewhat  similar  to  this  is  ,he  affection  known  as  pyonboM  alveolaris. 
This  disease  is,  however,  more  chronic  in  its  ( ourse,  and  is  apt  progress 
insidiously  with  occasional  acute  exacerbations.  The  gums  a.  swollen, 
reddened,  and  spongy,  bleeding  readily,  and  show  »  tendency  to  retrac- 
tion. (Jentle  pressure  will  cause  thin  pus  to  exude  rrom  about  the  roots 
of  the  teeth.     In  time  the  teeth  loosen  and  falf  out. 

.Single  ulcers  under  the  tongue  are  not  uncommon  in  whooping-cough. 
.\  liKiil  ulcer,  with  irregular  Ixmlers,  situated  near  the  frcnum  of  the 
tonjiiie,  oi-curs  epidemically  and  endemically  in  certain  parts  of  Italy 
iHifja's  disease). 

Suppnrative  dtonutitis  and  Olosaitis. — Suppurative  processes,  like 
ervsi|)elas,  may  extend  to  the  buccal  cavity  from  without.  Suppurative 
gingivitis  and  glossitis  may  also  result  from  direct  trauma  and  infection. 
They  may  Im-  met  with  as  complications  in  certain  infective  fevers  and 
ill  Uriffht's  disease  Suppurative  glossitis  is  a  rare  complication  of 
typhoid  fever.  One  of  us  (A.  (}.  N.')  has  retui'ded  a  case  of  hemiglossitis 
ill  tills  disease  and  Thomas  McCrae  has  published  a  similar  instatice 
and  collected  five  others  from  the  literature.'  The  whole  tongue  or 
any  portion  of  it  may  l)e  atTecteil.  The  condition  may  be  diffuse  or 
phli';.'nion()us,  or  multiple  small  aiwcesses  may  be  found. 

Gangrenous  Stomatitis. — (iangrenous  stomatitis  {noma;  canerttm  orln; 
viiiinr  (Kjuaticus;  Wasserkrebs)  is  a  peculiarly  rapid  and  fatal  form  of  gan- 
trreiie  aifecting  the  face,  almost  certainly  of  infective  nature.  With  few 
excepiions  the  disease  is  rvM  with  in  badly  f«l  and  uncared-for  children, 
fspic iiilly  when  'lebilitated  from  disease.  It  not  infre<iuently  complicates 
one  it  the  acute  infective  fevers.  Rarely,  it  originates  independently,  or 
siipi  iMiies  upon  acute  ulcerative  stomatitis.  Children  between  the  ages 
of  two  and  twelve  are  those  usually  attacked. 
'! ! .  iitfeciion  begins  with  the  formation  of  a  livid,  swollen  patch  in 


IS-  ^ 

■li 

rill 


'  Nicholls,  Montreal  Med.  Jour.,  25: 189»i:  VH. 

'  McCrae,  Johns  Hopkins  Hosp.  Bull.,  9: 1898:  118. 


884 


THE  MOUTH  a:'D  ITS  ACCESSORIES 


the  buccal  mucous  membrane,  usually  near  the  angle  of  the  mui.th,  Imt 
sometimes  in  the  gums.  Small  blisters  form  and  the  tissues  pnseiit 
a  grayish-yellow  inflammatory  infiltration  that  quickly  becomes  ;anjrre- 
nous.  The  structures  in  the  neighborhood  are  infiltrated  and  (wleiim- 
tous.  The  gangrenous  process  quickly  spreads  until  the  whole  thickness 
of  the  cheek  is  converte-^  into  a  reddish-black  necrotic  material.  The 
condition  is  usually  unilateral,  but  may  extend  to  tl.e  opposite  side,  ;■  -d 
may  even  penetrate  so  deeply  as  to  involve  the  bones  of  the  nost-  and 

jaw.     Septic  infection  of  the  nliole 
Fio.  Hi  system  usually   sets   in    and    death 

soon  resultii.  )n  the  rare  event  of 
healing  takin.-r  place,  the  necmtie 
tissue  separates  ar  d  cicatricial  con- 
traction gradually  ensues,  often  lead- 
ing to  considerable  deformi.j.. 

No  particular  germ  lias  as  yet 
l)een  proved  to  l)e  the  specific  cause. 
Bishop  and  Rynn  and  Scliimniel- 
l)usch  have  de  nnstrated  the  pres- 
ence of  a  bacillus  resembling  that  of 
diphtheria  in  some  cases.  It  is  not 
always  to  be  found,  however. 

Specific  Stomatitis.  — Tbnuh.- 
Thnish  is  a  mycotic  stomatitis  due  to 
the  action  of  a  special  fuMj;iis,  the 
oidium  albicans.  It  is  found  usually 
in  infants  during  the  first  year  of  life, 
btit  occasionally  also  in  debilitated 
adults.  The  use  of  milk  and  starchy 
(Caae  f<HMls,  with  imperfect  cleansing;  of 
the  mouth,  favors  the  process.  The 
affection  l>egins  with  diffuse  redden- 
ing of  the  mucosa  and  the  formation  of  a  glistening,  slimy,  somewhat 
adhesive  exudate  of  grayisli  appearance.  .Small,  whitish  dots  next  aj)|)ear, 
which  stand  out  piominently  against  the  liypereraic  background.  'I'hcse 
patches  gradually  increase  and  may  coalesce  to  form  a  meinhrane. 
When  this  is  removetl,  the  underlying  mucosa  is  greatly  reddened  and 
often  eroded,  'ine  membrane  quickly  reappears  upon  the  dciiiided 
surface.  The  disease  usually  begins  on  the  tongue  and  the  inner  <iiles 
of  the  cheeks,  but  in  bad  cases  may  spread  to  the  palate,  lips,  |)har\iix, 
crsophagus,  or  even  to  the  stomach  and  intestines.  The  growth  ol  the 
fungus  begins  in  the  epithelial  layers  and  extends  to  the  deeper  strut  lures. 
Exceptionally,  mycotic  emboli  may  find  their  way  to  the  internal  \  i  i  ■  ra. 
Oonorrhceal  stomatitis  has  occasionally  lieen  observed. 
Diphtheria.  Diphtheria  of  the  month  is  usually  secondary  to  ti'^  ■■■■■•<\\- 
nary  pharyngeal  diphtheria. 

Tuberculosis. — Tul)erculosis  of   the  buccal  cavity  may  Ik-  ]ir'Marv, 
but  much  more  often  is  secondary  to  tuberculosis  of  the  lungs  or !:  i  wix. 


Noma  of  the  face  or  caitcrum  uri 
of  Dr.  A   T.  Baiin.) 


m 


BYPHJL18 


385 


or  to  lupus  of  the  face.  In  the  secondary  fonn  the  condition  is  set  u^  by 
the  passage  of  infective  sputum  over  the  mucous  membrane.  One  or 
more  small  isolated  nodules  of  grayish-yellow  color  are  found  on  the 
dorsum  of  the  tongue,  usually  near  the  tip,  which  eventually  break  down. 
A  typical  tuberculous  ulcer  of  the  tongue  is  round,  oval,  or  irregular, 
'iiui  painful.  The  edges  are  slightly  indurated  and  raised  above  the 
general  level,  inverted  or  undermined.  The  base  is  uneven  and  nodular, 
luul  covered  with  reddish-gray  granulations,  or  a  grayish  or  yellow 
slireddy  slough.  Smaller  tubercles  may  form  about  the  periphery  of 
the  main  ulcer,  which  break  down  ad  coalesce  with  it.  Primary  tuber- 
culosis occur;;  iuost  frequently  on  tlie  tongue,  palate,  and  tonsils. 

S3ni>Iuli8. — The  primary  chancre  is  occasionally  found  upon  the 
l()iij!ue,  lip,  or  tonsil,  but  secondary  and  tertiary  mnnifestations  are  far 
iiK)rc  common.  The  mildest  form  of  the  affection  in  the  secondary  stage 
is  11  simple  erythema  or  angina,  but  the  more  characteristic  appearance 
i>  the  presence  of  small,  flattenwl  patches  of  grayish-  r'ellow  color  situated 
oil  the  gums  or  near  the  angles  of  the  mouth  (mucous  patches).  Not 
infrequently,  the  superficial  epithelium  assumes  a  peculiar  bluish-white, 
pearly  appearance,  somewhat  resembling  the  corrosion  produced  by 
nitrate  of  silver  (plaques  opalines).  These  are  found  ordinarily  on  the 
lips,  cheeks,  and  tongue,  but  at  times  also  on  the  gums,  tonsils,  and 
phiirvngeal  wall.  Such  lesions  may  go  on  to  superficial  ulceration  and 
MUiill  fissures  be  prwli'.-ed.  In  young  children  i»diating  scars  at  the 
anfrlos  of  the  mouth  (■hagoites)  are  characteristic  of  syphilis.  Gummas 
arc  situated  most  frequently  in  the  posterior  wall  of  the  pharynx,  the 
|)alate,  gums,  and  tonp: 

( iuinnias  of  the  tongue  generally  occur  ab«  it  the  centre  of  the  dcrsum, 
and  <;ivp  rise  tt)  deep,  irregular  excavations,  having  thickened,  lightly 
(imtavcd,  or  undermined  edges,  and  a  base  covered  with  yellowish 
sli  mi;h.    They  are  generally  bounded  by  a  reddish  areola. 

'i'lic  ulcerative  lesions  of  tuberculosis,  syphilis,  and  epithelioma, 
atTccting  tlie  tongue,  are  not  unlike  one  another,  and  an  error  of  diagnosis 
may  e.isily  l)e  made,  a  mistake  which  will,  of  course,  have  serious  con- 
-.(lUfiHcs'to  the  patient.  Tuberculous  ulcers  are  usually  situated  on  the 
(liiisiiin  of  the  tongue  near  the  tip  or  toward  the  root;  syphilitic  guin- 
iiias  on  the  dorsum  near  the  middle;  epitheliomatous  ulcers,  usually 
on  I  lie  cd^e  of  the  tongue,  opposite  the  molar  or  liicuspid  teeth.  Epi- 
iliilionia  is  more  common  in  men  than  in  women,  and  rarely  occurs 
niidir  the  age  of  forty.  The  epitheliomatous  ulcer  has  irregular, 
r.it-i  il,  liard,  and  everte«i  edges  and  the  tissues  about  ii  are  much  indu- 
niird.  It  spreads  rapidly,  and  is  attended  with  neuralgic  pain  and  much 
siiliviitioii.  Tuberculous  and  tertiary  syphilitic  ulcers  are  not  indurated 
:ii!il  ilie  edges  are  not  everted.  Glandular  involvement  is  not  found, 
wl.ili  it  is  conunim  in  the  case  of  epithelioma.  The  '.istory  often  affords 
a  1 1 ! .  to  the  nature  of  the  lesion.  In  the  case  of  t'.berculosis  of  the  tongue 
tin;  U  usually  evidence  of  tulierculosis  in  me  lungs  or  elsewhere;  in 
un  i.iiias  of  the  toiigi"  we  have  a  history  of  specific  infection  and  of 
^ui  ::;ias  in  other  situations;    in  epithelioma,  we  have   the  irritating 


'.m 


THE  MOUTH  AND  ITS  ACCESSORIKS 


influence  of  a  pipe  or  tiwth,  or  again,  tl>e  new-growth  may  originate  from 
un  (>l)i  scar  or  fn>in  leukoplakia. 

ActinomycosU. — This   di.se&se  i.s  not  uncommon  in  cattle,   giving; 
rise  to  ihe  condition  known  as  "Ininpy  Jaw."     The  jaw  lie«»me.-,  hard 


Fia.  83 


A('tinnm,v**i».-*U  ("lumpy  jaw")  of  the  lower  jaw  of  a  cow.      Note  the  uvergmwth  of  hone  :in<l 
the  inflammatory  oflteuporosifl.      (From  the  Pathological  Museum.  McGill  Univer^'ityj 

Fio.  H4 


Ariiiiomyt'osi.s  fuiifzu^  in  pur*.      Krfj-h,  unstaineil  preparation.      .MaKnilieil  aboui 
.'■110  ilianiPterw.      (AblHitt.) 

and  wotHJcn,  or.  in  the  more  acute  form.s,  may  \ie  riddled  witli  ^iiiiises. 
Rarefaction  and  hyj)erpliisia  of  the  Ikmic  may  take  place.  The  < lipase 
i.s  occasionally  .seen  in  man,  and  is  perhaps  more  common  tli;in  lias 
l)een  .siispectetl. 

The  disease  is  due  to  infectitm  of  the  ti.ssue.s  with  a  ray  fiiiitr'i>.  the 
aftliiomjirrx  horln.  The  usual  p)int  of  entrance  is  the  muc<)ii>  niciii- 
lirane  of  the  iiiouth  and  pharynx,  especially  in  the  neinhlKnlmoii  of 
a  carious  t(K)tli.  Israel  and  Partsch  have  demon.strated  the  pri'sincc  of 
the  fungus  in  the  cavities  of  decayed  teeth.    The  actinomyces  is  1"  'iivt^l 


PROdRHStilVH  METAMORPHOSES 


387 


to  be  present  on  the  .stalka  of  certain  kinds  of  gra>M.  Infe(>tion  hus  fol- 
lowed the  practice  of  picking  the  teeth  with  a  stalk  of  hay,  or  with  a 
needle.  A  few  instances  are  on  record  in  which  granulomatous  tumors 
have  been  formed  upon  the  tongue  (Claisse').  When  the  jaw  is  attacked, 
the  appearances  produced  are  not  unlike  thwte  of  periasteal  sarcoma, 
hut  when  the  looser  tissues  of  the  neck  are  reached  growth  is  very  rapid, 
following  the  line  of  the  fascia.  From  the  face  and  neck  the  process 
may  invade  the  meninges  and  the  brain  and  cord,  or  the  thoracic  organs. 
If  an  incision  be  made  into  the  mass,  before  suppuration  has  occurrwl, 
minute  yellowbh  dots  are  to  be  seen,  which  are  the  actinomyces.  If 
there  be  a  discharge,  careful  search  should  be  made  for  the  fungi,  which 
u|>p(>ar  as  yellowish  masses  (sulphur  graias)  the  size  of  a  pin-head  or 
smaller.  These  may  be  picked  out  and  examined  with  a  low-power 
lens,  or  a  film  may  be  made  and  stained  by  Gram's  metho<l.  In  human 
actinomycosis  the  filaments  are  apt  to  lack  the  characteristic  clublied 
appearance. 

PBOORUSIVK  MKTAMOKPHOSES 

( )i-casionally,  the  scjuamous  epithelium  covering  the  tongue  becomes 
thickened  and  gives   rise  to  plaques  of  a  firm,  somewhat  glistening 
ap{H>arance  (lankopUkia  or  paoriuii 
lingua).   Some  attribute  this  condi-  *''<'•  ** 

tioii  to  chronic  inflammation,  not- 
iil)ly  syphilis.  The  affection  occa- 
siomilly  goes  on  to  the  formation  of 
epithelioma. 

The  lingual  papillte  may  be 
hy|)crtn)phie<l  so  that  the  tongue 
has  a  warty  appearance,  being  lined 
hy  intersecting  furrows.  Exception- 
ally, the  filiform  papilla*  become  so 
eloni;ated  as  to  resemble  hair,  and 
may  <;ivi'  the  upper  surface  of  the 
t()iii;iic  a  greenish  or  blackish  fun-y 
appca ranee  (so-called  hairy  tongne). 

Tumors. — Hemangioma  and  lym- 
phangioma are  met  with  in  early 
life.  The  former  is  usually  found  on 
the  lips,  where  it  forms  bluish-red, 
scMit w  hat  elevated,  blotches.  The 
MH  lltil  mMTOglossia  and  macro- 
cheilia  are  examples  of  diffuse  lym- 
pliaii;:icctasis  affecting  the  tongue 
ami  lips  respectively.  These  struc- 
tun-  arc  greatly  enlargetl,  owing  to  increase  in  all  the  component 
elciiii ,  ts,  fibrosis,  or,  again,  actual  new-growth  of  lymph-vessels.     In 

'  Presse  Med.,  Paris,  1897:  789. 


Macrufflosaia.      (Ur.  Shepherd's  case,  .\i(intreal 
(ieneral  Hospital.) 


Ii1 


3K» 


THE  MOUTH  AS'D  ITS  ACCESSORIES 


macrofflossia  the  tongue  ma;  be  so  much  enlarged  that  it  pn)jci't.i 
beyond  the  lips.  It  often  beromes  dry,  fiiuurud,  and  ulcerated,  o«in(( 
to  exposure  to  the  air  and  the  pressure  of  the  teeth.  From  its  size  it 
may  interfere  with  feeding  and  respiration.  Jlicroscopically,  the  or^taii 
shows  increase  in  fibrous  tissue  and  contains  numerous  small  cavities 
lined  with  endothelium— the  dilated  lymph-channels.  Actual  cysts  inny 
he  formed.  Among  the  benign  new-growths  appearing  at  birth  or  s<k)ii 
after  may  be  mentioned  the  flbnma,  lipoma,  myzoma,  and  tantoma. 

Teratomas  usually  develop  from  the  palate  or  vault  of  the  pharynx. 
They  arise  either  from  embryonic  "cell  inclusions"  or  are  to  l)e  regnnlcd 
as  examples  of  polar  hypergenesis  (vol.  i,  p.  218).  Tumors  having  (he 
structure  of  thyroid  substance  occosionully  have  l)een  met  with  in  (lie 
base  of  the  tongue,  originating  from  "rests"  of  thyroid  cells  situiUttl 
along  the  courst^  .if  the  foetal  thyniglossal  duct. 


lia.  86 


(iiant-celled  sarcoma,  from  the  periosteum  o(  the  jaw.     Winckcl  No.  6,  without  ikuI  .r 

The  malignant  tumors,  sarcoma  and  carcinoma,  are  more  eoniinon  in 
adult  life.  The  term  epulis  is  a  clinical  one  applied  to  a  lumor  .situaitd 
on  the  jaw,  which  springs  usually  from  the  gums.  Some  of  tliiin  liavc 
the  structure  of  a  fibroma  (fibrous  epulis);  others  are  sarcomaioiis 
(myeloid  epulis);  still  others  are  epitheliomatous  (epitheliomatous  epulis). 
Myeloid  or  giant-celled  sarcomas  originate  in  the  [M-riusteuni  or  iniiie 
marrow,  and  form  rounded,  nodular  growths  of  rather  firm  consi-i  nee. 
On  section,  they  often  have  a  brick-red  color,  owing  to  henioiiliifre. 
Other  forms  of  sarcomas  arc  not  infrequently  met  with. 


pmaRF.asiVE  metamokphoses 


38<) 


Epithelioma  is  found  ufmn  the  lip,  ton^'     ,  or  gums.     It  begins  as  a 
small,  elevated  papule,  or  as  u  firm,  cirtrum^icrihed,  whitish-gray  iniiltn- 


MlKM 


Fio.  S7 


n 


l!pith<>liuiiiB,  itartiiiK  from  the  lip.     Winckel  uhj.  No.  3,  without  ucuUr. 
(Fmm  the  collection  o(  Dr.  A.  O.  NichoIlK). 


Fia.  88 


l.pithelial  pearl  or  "celi-nest"  from  an  epithelioma  of  the  lip.     Winckel  No.  6, 
without  ocuUr.     (Fium  Dr.  A.  G.  NiehoUt'  collection.) 


I    -fin 


300 


THE  MOUTH  ASH  ITS  ACCESSORIES 


lion  of  the  tisNiirM.  'Vhe  Aurfacr  ulcerates  ami  the  ulcer  quk-kly  eiilurp-s, 
invading;  the  iiei){hlMiring  structures  and  tlie  reffknial  lyniph-ntMlii. 
Kpitheliuina  of  thie  upper  jaw  has  a  s|N>cial  tentieiicy  to  involvt-  iIh* 
antrum.  Histologically,  epitheliomas  iirr  of  the  s<]uamoaH-<-elle«l  variiiv. 
Finger-like  down-growths  of  the  superficiul  epithelium  are  to  lie  mtii, 
which  »Tv  united  by  lateral  processes  in  suf-h  a  way  as  to  form  a  sort 
of  meshwork.  Here  and  there,  epithelial  "pearls"  or  cell-nesu  may  lie 
seen.    Houml-celled  infiltration  b  common. 

Ojntl. — ('ysts  are  not  uncommon  in  the  mouth.  They  arc  asunllv 
of  the  nature  of  "retention"  cysts  and  are  caa>ted  by  tlie  blocking  of  (lit- 
duct  of  one  or  other  of  the  ghinds  discharging  into  the  buccal  cavity. 
DanMid  ejnto  are  also  met  wth. 


0«ri»t.— Caries  is  the  most  important  affection.  This  begins  with 
the  formation  of  an  opaque,  white,  or,  more  often,  greenish  or  grccriish- 
biack  speck  upon  the  enamel,  the  result  of  disintegration  and  destriH'ion 
of  the  enamel  prisms.  The  process,  if  not  interfered  with,  .-*  'ily 
advances  until  the  centre  of  the  tooth  is  excavated,  and  the  whole  miiIi 
eventually  undergoes  decalcification.  It  thus  l)ecomes  soft  and  is  ii|)t 
to  break.  Very  conmionly  <'aries  is  accompanied  by  inflammation  of  llit- 
pulp  (piUpitiit),  or  of  the  alveolar  periosteum. 

Fio.  SB 


lieail  of  a  wocxlcbuek:  (howlac  hypertrophy  of  Uw  ineiior  tmth  from  lesMned  wear; 
the  eaiue,  fracture  of  the  lower  jaw.     (Patholocical  Uuieum.  McGill  Univeraily.) 

Hypertrophy. — Excessive  growth  of  the  teeth  occurs  as  a  nsiili  i)f 
insufficient  attrition.  Loss  of  the  opposing  teeth  or  mal-apposition.  as 
from  fracture  of  the  jaw,  are  the  usual  conditions  at  work.  Tin-  fisks 
of  the  wild  boar  are  a  familiar  example. 

Tumors. — Among  tumors  may  be  mentioned  the  odontoma,  odontin- 
oidi,  fibroma,  myxoma,  and  lareoma.  The  odontoma  is  formed  (lining 
the  pcritxl  of  gn)wth  and  arises  from  the  pulp  or  forms  exrros.  i  -.avs 
about  the  crown  or  root.  Odontinoids  develop  later  in  life  fmiM  ihe 
dentin.  Sarcoma  and  the  other  connective-tissue  tumors  usually  arise 
from  the  periasteum  of  the  jaw  or  about  the  teeth.    Rarely,  the;.  -!:iit 


PAl..\Tf:,  PHARYXX,  ASt>  TOSSILS 


»1 


friiin  the  pulp,  liiiriiiK  th«>  |N>riiMl  of  ili-vfli>piiii>nt.  h'iilk.<u>ii  Iihm  culhtl 
ulletition  to  n  miiltiliMMilNr  c-pt  or  cy.HtiDlt'noiim,  liiicii  with  (■vliiiilri<-ul 
fpillifliuin  hihI  (tmUining  tt^th,  whk-ii  ii«>vfl<MM'  fmiii  rnihryoiwl  UmkIi 
UM'vln. 

aWUMMAJlOV. 

Inflammation  may  occur  in  the  pulp  (pulpHiii)  or  iirouiHl  the  riMit 
of  (lie  tooth.  'Vhe  cinulition  i<<  clue  to  iiifn-tion.  Acconlin);  to  Miller, 
aciil  fennentation  of  the  particles  of  f<NMl  clin);itiK  alM>ut  the  teeth  a.<Mi.>«t 
till'  |>athof{enic  action  of  the  Imcleriu.  IVpsin  uml  various  vcfcetalile 
acids  are  said  to  lie  respmsible  for  the  de^ruction  of  the  tientin 
(Shienker).  ITie  inflanimation  nuiy  l>e  arutr  or  rhnmlr,  itiippurafiir, 
or  non'imppuraiitr.     Acute  suppuration  may  iHt-ur  in  the  pulp  of  the 


w^ 


IhlnnrniiM.    ((iarreim»ii.) 


tiNtili  or  deep  down  in  the  periixsteum  .surrounding  it.  'l  leads  to 
iiiHaiiiniation  of  the  alveolar  process  and  the  fonnation  of  a  hn-al  al)scess. 
If  not  rclievc<l,  fistulie,  necrosis  of  the  Immic,  phlepnon  of  tiie  ne<'k  ami 
floor  (tf  the  mouth,  or  even  ^neral  septicemia  nuiy  result.  In  chronic, 
noii-siippiirative  inflammation  of  the  pulp  and  |>eriixsteum,  granulation 
Mssiic,  new  bone,  and  dentin  may  l)e  prwluced. 


5  t| 


'III. 

iiiilik 

[H'Clllli 

more 
liotli 
t()ii>i 
limn 

Til,. 
ph.,i.i 
niicli  ,•! 
Iiloiidt 
leuls. 


PALATE,  PHARYNX,  AND  TON8IL8. 

■  inucnis  membrane  of  the  palate,  pharynx,  and  tonsils  is  not 
ihiit  of  the  other  [xirtions  of  the  liuc;-al  cavity,  but  has  these 
iirities,  namely,  that  its  character  as  u  nuicous  membrane  is  still 
|iron()imce<l  and  that  it  is  particularly  rich  in  lympho!<l  elements, 
M  till-  shape  of  follicles  and  the  larger  aggregations  known  as  the 
.  Con  "quer.tly,  exudative  pnx-esses  are  of  more  importance 
ire  desquamative  ones, 
tonsils  appear  to  have  an  important  function.  While  the  lym- 
« <  il-'  are  themselves,  to  a  limitetl  degree,  phagcK-yiic,  poiymorpho- 
r  Icukwytes  in  considerable  numliers  make  their  way  from  the 
'^M'is  to  the  surface  through  (he  epithelial  covering.  These 
' I's  are  strongly  phagix-ytic  and  their  activity  suggests  that  the 


HI 


392 


THE  MOUTH  AND  ITS  ACCESSORIES 


tonsils  form  one  of  the  barriers  against  the  invasion  of  the  system  by 
pathogenic  microorganisms. 


INniMMATIONS. 

Pbarjmgitis. — The  term  angjns  or  pharjmgitis  is  a  general  one  used 
to  designate  inflammation  of  tlie  posterior  part  of  the  buccal  cuvitv, 
pharynx,  tonsils,  and  palate.  The  condition  is  comparatively  coimnoii, 
and  is  usually  the  result  of  irritation  from  mechanical,  tlierniic,  or 
chemical  agents.  It  is  found  also  in  association  with  certain  of  (he 
infectious  diseases,  such  as  scarlatina,  measles,  acute  rlieumatisni, 
<liphtheria,  and  variola.  When  the  tonsils  are  chiefly  or  alone  involved 
the  affection  is  called  tonsiUitia,  or  unygdalitis. 

The  inflammations  of  this  region  may,  according  to  their  severilv 
and  duration,  be  divided  into  acute  and  chronic;  or,  according  to  tlieir 
morbid  peculiarities,  into  catarrhal,  herpetic,  phlegmoiimtn,  and  mem- 
branoua. 

Acute  Oatarrhal  PhuyngitiB. — Acute  catarrhal  pharyngitis,  or  anijinu. 
is  characterized  by  redness  and  swelling  of  the  mucous  membrane,  wliidi 
l)ecomes  glazed  owing  to  the  irt^ibition  of  the  secretion.  Later,  tUvn 
is  an  abundant  discharge  of  a  mucoid  or  mucopurulent  exudate,  soiiif- 
times  tinged  with  blood.  Microscopically,  the  secretion  contains 
mucus,  pus  corpuscles,  blood  cells,  and  desquamated  and  degenerated 
epithelium.  In  the  more  severe  cases,  small  abrasions  may  l)e  noted 
on  the  back  of  the  pharynx.  The  lymph-follicles  are  often  also  iivper- 
plastic  and  appear  as  small,  rounded  or  oval,  elevated,  aiifl  reddish 
no<hiles,  projecting  through  the  membrane. 

Phlegmonous  Phaiyngitis. — In  this  form  the  inflammatory  process  is 
less  marked  upon  the  surface  than  in  the  deeper  parts.  The  cases  are 
due  to  infection  with  pyogenic  microorganisms,  in  some  instances  assisted 
by  traumatism.  Not  infrequently,  they  arise  as  secondary  complications 
of  certain  of  the  infective  diseases,  such  ar  scarlatina,  diphtheria,  erv- 
si|H'las,  and  .syphilis.  The  mucosa  is  of  a  deep,  purplish-reil  (olor, 
swollen,  tense,  and  shiny,  presenting  occasionally  superficial  vesii  les. 
In  the  erysipelatous  form  the  infiltration  is  diffuse  and  the  exudate  >ero- 
purulent  rather  than  purulent.  In  other  cases  the  process  is  kxali/ed 
and  quite  large  abscesses  may  form.  Retropharyngeal  abscess  soineiimes 
results  from  tuberculous  caries  of  the  cervical  vertebra^.  Peritonsillar 
abscess  is  a  common  complication  of  acute  tonsillitis  and  may  oc  <  ur  on 
one  or  both  sides.  Such  collections  of  pus  may  burst  into  tiie  pli.nynx, 
or  may  erode  the  internal  carotid  artery  or  one  of  its  branches,  and  iioise 
fatal  hemorrhage,  or,  again,  if  deep  down  may  be  absorbed  with  ll"' 
formation  of  a  scar.  If  the  discharge  of  the  abscess  occur  ditrirm  liie 
nighc,  suffocation  may  result.  General  septicemia  may  also  oxer. 
Gangrene  is  a  rare  terminal  event. 

Membranous  Pharyngitis. — Membranous  or  "croupous"  pliai  iritis 
may  ari.se  directly  from  traumatism,  as,  for  example,  the  iiiiiaiaion  of 


DIPHTHERIA 


393 


irritating  gases  (steam,  ammonia),  but  much  more  commonly  it  is  due 
to  infection  with  pathogenic  microorganisms,  such  as  the  Streptococcus 
pyogenes,  Bacillus  diphtherite,  Pneuniococcus,  and  Bacillus  coli.  Apart 
from  diphtheria,  membranous  pharyngitis  is,  as  a  rule,  met  with  as  a 
complication  of  certain  infective  fevers,  such  as  scarlatina,  measles, 
typhoid,  and  variola. 

Diphtheria. — True  diphtheria  may  be  taken  as  the  type  of  this  form 
of  pharyngitis.  Here,  the  inflammation  is  due  to  the  action  of  the 
KU'bs-Loeffler  bacillus.  The  affection  begins  with  marked  congestion 
iiiul  swelling  of  the  mucosa,  which  quickly  assumes  the  character  of  a 
incmbranous  inflammation.  In  the  earlier  stages  small,  grayish  or 
j;iayish-white  opalescent  spots  appear  on  the  tonsils,  uvula,  or  other  parts 
of  the  pharyngeal  wall.  These  gradually  become  distinctly  membranous 
iiiul  of  a  dirty  yellow  or  yellowish-brown  color.  They  are  bounded  by 
a  liyperemic  zone,  and  may  be  slightly  separatetl  and  elevated  at  the 
(•(Ifjcs  from  the  underlying  tissues.  If  the  meml.raiie  be  removed  a 
siiptTficial  erosion  is  left,  which  blee<ls  readily.  On  this  area  the  meni- 
l)rane  may  reform  with  great  rapidity.  In  the  severer  cases  the  patches 
iK-eotne  confluent,  and  thick,  laminated  sheets  of  membrane  are  formed 
oil  the  posterior  portion  of  the  pharynx,  which  may  extend  into  the  trachea, 
larynx,  an<l  bronchi,  into  the  nasal  passages,  or  even  to  the  skin.  In 
the  most  virulent  cases  extensive  necrosis  takes  place,  and  large  gangrenous 
extfivations  may  be  found  about  the  pillars  of  the  fauces.  The  tonsils 
and  lymph-nodes  of  the  neck  are  usually  enlarged. 

By  examining  a  series  of  sections  taken  at  different  periods,  it  has  been 
iirKJe  out  that  the  mucous  membrane  is  at  first  congested  and  more 
or  less  infiltrated  with  inflammatory  products;  the  superficial  epithelium 
(lrH;ti)(rates  and  is  cast  off  either  wholly  or  in  part;  the  cellular  exudate 
ciKifiulates,  forming  a  fibrinous  deposit  both  in  the  superficial  layers  and 
1(11  the  exj)osed  surface  of  the  part  affected.  This  material,  composed  of 
Iriikocytes,  fibrin,  and  degenerating  tissue,  gradually  undergoes  a  form 
of  coafiiilation  necrosis  and  fuses  into  a  more  or  less  homogeneous  mass, 
till'  (liphtljeritic  membrane.  In  the  deeper  parts  the  bl(H)dvessels  and 
Iviiipliatics  are  distended,  there  are  numerous  areas  of  cellular  and 
liliriiious  infiltration,  and  the  glands  are  blocked  with  exudate  and  tlesqua- 
iiiiitcd  cells.  In  cases  that  recover,  the  membrane  is  exfoliated  in  large 
nIhtiIs  or  en  masse,  esj)ecially  when  antitoxin  has  been  used,  or,  again, 
iiiiiy  lie  gradually  absorbed.  The  lost  epithelium  is  regenerated,  and 
111  iilinif  lakes  place  without  scarring. 

I'lic  s|)ecific  bacilli  are  usually  superficial  and,  as  a  rule,  do  not  enter 
till'  ( irciilation,  at  least  to  any  great  extent.  Severe  symptoms  are, 
hciucvcr,  not  infrequently  present,  resulting  from  absorption  of  the 
ti'\iii.  Death  may  occur  during  the  active  stages  of  the  disea.se  or  tluring 
ciiiivalrscence,  from  vagus  paralysis.  A  commoner  form  of  paralysis 
i^  'liat  affecting  the  muscles  of  the  throat,  especially  tho.se  of  the 
p.ii.cir.  Paraly.sis  of  accommodation,  monoplegia,  hemiplegia,  and 
pii;i|)|c};ia  may  occur.  In  the  more  intense  cases  of  intoxication  prae- 
I'    llv  all  the  mu.scles  of  the  body  may  l)e  involved  with  the  exception 


m 

fa 


394 


THE  MOUTH  AND  ITS  ACCESSORrES 


of  the  (linphrapm.     Another  amplication  of  diphtheriii  is  alw<t'.s.s  foriiiii- 
tion,  the  result  of  set-ondary  infection  hy  pyogenic  rnicniorganisins. 

The  memhranous  pharyngitis  ilue  tc)  sfreptwotri  is  likely  to  In*  more 
acute  than  diphtheria  in  reganl  to  its  inimetliate  symptoms.  It  is  not 
followed  by  paralyses,  hut  the  cocci  penetrate  deeply  and  are  apt  to  l,c 
carried  to  distant  parts,  setting  up  a  generalize*!  septicemia  or  multiple 
abscess  formation. 

Ohronie  Pluryngitii.— Chronic  pharyngitis  may  arise  insitliou.sly  or 
may  result  from  a  succession  of  acute  attacks.  "'I'he  abuse  of  tolmcc., 
and  alcohol  are  common  causes.  Many  cases,  t<K).  rcpresj-nt  the  exten 
sion  of  a  chronic  rhinitis.  The  muc«)us  membrane  is  more  or  less 
congested  and  presents  numenius  distende<i  venules.  Often,  it  has  a 
granular,  warty  appearance,  due  to  hy|)erplasia  of  the  lymphoid  follicles 
(ehronie  gnnulu  pharyngitU).  The  secretion  is  mucoid,  muc-opunilent, 
or  purulent,  and  often  adheres  in  the  .  )rm  of  dry  scales  or  crusts,  wlii.  h 
decompose  and  emit  an  offensive  odor.  In  o'ther  ca.ses,  secretion  i> 
scanty,  and  the  mucous  membrane  is  of  a  reddish-brown  color,  thin. 
smooth,  and  shiny.  This  is  known  as  chronic  atrophic  pharyngiti* 
(pharyngitis  sicca). 

Acute  Tonsillitia.— In  acute  tonsillitis  the  inflammation  niav  !„■  a 
superficial  one  or,  again,  may  involve  the  pareiichvma  of  the  "glaii<l.s, 
causing  considerable  swelling  of  the  psirts.  The  tonsils  are  swollen,  re.l! 
and  hot.  and  covered  with  an  abundant  secretion  of  creamv  miico|)iis. 
When  the  tonsillar  crypts  are  distendetl  with  secretion,  vellowish-wliite, 
roun<led  spots  can  l)e  seen  on  the  surface  of  the  tonsils,  and  the  WJiKJiiion 
is  then  commonly  known  as  follicular  or  lacunar  tonsillitis.  In  se\tn' 
cases,  the  inflammatory  process  may  go  on  to  suppuration,  either  in  ilie 
tonsil  or  in  the  cellular  tissue  about  it  (quinsy,  peritonsillar  abscess i. 

Histologically,  in  acute  tonsillitis,  we  find  marked  congestion  of  tlic 
glands,  hyperplasia  of  the  lymphoid  elements,  exudation  on  the  surta( r. 
and  des(|uaniatioii  of  the  epithelium. 

Occasionally,  in  addition  to  the  ordinary  manifestatiotis  of  catiiriluii 
inflammation,  miiuite  vesicles  are  formed  upon  the  mucous  nuinl.niiic 
which  rupture,  leaving  painful  ulct>rs— herpetic  tonsillitis  or  pharyngitis. 
Chronic  Tonsillitis.— In  chn)nic  tonsillitis  the  organs  are  pernuim  niK 
enlarged  and.  except  for  their  size,  often  appear  to  Ik-  normal.  Snm'- 
times  there  is  a  dusky  redness  of  the  palate  and  fauces.  The  <r\|)i-  ^iiv 
small  and  the  surfac-e  sincMitli.  The  enlargement  may  l)e  so  gre;it  ,i^  to 
interfen-  with  swallowing,  respiration,  and  sjieaking.' and  is  irnpoiiMui 
also  in  that  it  tends  to  |H>rjH'tuate  the  inflannnation.  owing  to  tli.  iii- 
creastnl  susc-eptibility  of  such  tonsils  to  irritation.  Children  u;  i,  :i 
rheumatic  taint  seem  to  l)e  specially  liable  to  this  disonler.  Cli!  li.- 
tonsillitis  and  pharyngitis  pretlisjwse' to  bronchitis  and  other  lun>:  :!..- 
tions. 

In  another  form  of  chmnic  tonsillitis  the  tonsils  are  not  tiil:);.r,|, 
but  the  crypts  .nre  more  roomy  that!  normal  and  an-  (illeil  with  M-rv.  :. 
desqiuunated  cells,  f.KHl  particles,  and  microorganisms  of  varion-  1^  i>. 
This  material  liecomes  inspissateil  and  may  U'  extrudeil  spontaih.     ly 


PAROTITIS 


39.1 


or  hv  pressure  in  the  form  of  cheesv,  wliitish-yellow  |>iup>,  which  have 
a  (>eculiar,  tharacteristic,  offensive  otJor.  Sometimes  the  masses  are 
rviaine*!  and  Ijecome  infiltrate*!  with  lime  salts,  forming  t-oncretions. 

Hvperplasia  of  the  tonsils  and  of  the  phannfteal  or  Luschka's  tonsil  is 
oftfii  met  with  in  children,  and  seems  to  Ije  in  many  cases  the  result  of 
a  ( hronic  inflammatop>'  pnM-ess.  Adenoid  TegeUtions  are  papillomatous 
or  [xilypoid  growths  oc'urrinjj  in  the  vault  of  the  pharv'nx  and  posterior 
nares.  When  of  any  extent,  breathing  may  \w  interfere*!  with,  and 
children  so  affected  complain  of  headache  and  earaclie,  breathe  through 
the  mouth,  and  are  apathetic  and  !>ackward  at  school.  The  condition 
is  often  associate*!  with  enlargement  of  the  pharyngeal  tonsil  anil  sore 
thntat.  Deafness  am!  inflanunution  of  the  middle  ear  may  result  from 
iiitrrference  with  the  Eustachian  tubes  through  pressure  or  catarrh.  In 
l(>n;:-standing  cases  the  chest  shows  a  characteristic  deformity. 

Histologically,  the  ctMidition  is  due  to  hy|)erplasia  eitherof  the  lymphoid 
elements  or  of  the  connective  tissue.  In  the  former  case  the  adenoids 
are  soft  and  friable;  in  the  latter,  firm  and  tough. 

Tuberc'iosis. — Tulterculosis  of  the  tonsils  and  pharynx  can  occur 
a^  a  primary  infection,  but  is  almost  always  secondary  to  pulmonary 
i>r  iirvngeal  tul>ercuh>sis.  Owing  to  their  expose*!  position  the  tonsils 
are  liable  to  infection  of  all  kinds,  esj)ecially  from  the  fonl,  and  it  has  been 
|j<i^~ilile  tt)  prcnluc*  experimentally  tul>erculosis  in  these  glands  by  feeding 
aiiiiiiajs  on  infectetl  material.  In  tulnTculosis  of  the  pharynx  the  muct)sa 
is  injeeteil  and  c<intains  numerous  small  tuliercles,  that  ultimately  break 
ilowii  and  form  shallow  uli-ers.  These  may  in  time  coalesce  and  lead 
to  fxteiisjve  loss  of  substance. 

Syphilis. — ."Syphilitic  sore  throat  usually  takes  the  form  *>f  a  catarrhal 
i'ljiiiiiimatliin  that  is  difficult  to  distinguish  from  the  simple  variety, 
or  nf  niiii-ini.t  or  ofxiliiir  platjiiis.  (iuvnnaK  are  not  uncommon.  The 
lir'nniirif  chancre  has  l>een  found  upon  the  tonsil. 

Tjrphoid. — .Suwrficial  ultenition  of  the  [Koterior  pharyngeal  wall 
is  i[(it  very  uncommon  in  typhoid  fever. 

Actinomycosis. — ("erviral  and  prevertebral  actinomya-;  may 
ori;.-iiKite  in  the  tonsils  and  the  pharyngeal  mucous  membrane. 


,-m 


:  ilU  , 


PROORKSSIVE  MKTAMORPHOSES. 

Tumors.-  ConnectiTe-tissue  tumors,  carcinoma,  sarcoma,  and  teratoma 

i«  (  ur  .11  tiiis  region,     ."^arcoma  of  the  tonsil  is  jKcasionally  met  with. 


THE  SALIVABT  GLANDS. 

1 !»  ~e  are  glands  of  acinous  structure,  and  in  the  human  subject  are 
of  -in  Ills  or  mixed  seroiLS  an«l  mucous  type.     Their  ducts  discharge  into 

th,„  !.■.,.,.;,!  c-jvity. 

Pitrotitis. — Acute   Parotitis.— Acute  parotitis  and  analogous  inflam- 
lUiii  ■.  .-  iif  the  other  salivary  glands  are  usually  <lue  to  infection  with 


'!-  -f  I'.; 


396 


THE  MOUTH  AND  ITS  ACCESSORIES 


inicrodrganisms  from  the  mouth.  They  may  also  complicate  muiiv  of 
the  infective  fevers,  such  as  typhoid,  diphtheria,  pyemia,  cholera,  ami 
syphilis.  Parotitis  has  been  observed  as  a  complication  of  certain 
abilominal  conditions  and  after  operations  on  the  abdominal  visptra. 
When  pyogenic  organisms  are  at  work  suppuration  of  the  glands  mav 
follow,  or  even  gangrene.  In  such  cases  salivary  fistula  sometimes 
result.  Milder  inflammations  may  lead  to  increased  secretion  and  later 
to  fibrous  induration  of  the  gland  with,  possibly,  stenosis  of  the  (hut. 
In  such  cases  concretions  composed  of  phosphate  or  carbonate  of  lime 
are  not  uncommonly  found  within  the  duct  (sialoliths),  sonittiiiMs 
causing  or  associated  with  cystic  dilatation  of  the  ducts  and  acini. 

Ipidemie  Parotitia. — Epidemic  parotitis  (mumps)  is  an  infectious 
disease,  characterized  by  great  swelling  of  the  parotid  gland  and  to  some 
extent  of  the  subma.\illary  and  sublingual  glands,  associated  with  siifrlit 
febrile  disturbance.  The  infecting  agent,  which  has  not  as  yet  l)een 
absolutely  determined,  presumably  enters  through  the  excretoVy  duct. 
In  the  course  of  two  or  three  days  the  inflammation  subsides  aiid  the 
gland  gradually  resumes  its  normal  state.  The  inflammatorv  exudate  is 
mainly  serous.  Suppuration  rare';-  occurs.  The  affection  is  occasionallv 
complicated  by  orchitis  or  oophoritis. 

Angina  Ludovici.— .\ngina  Ludovici  is  a  somewhat  rare  and  jwculiar 
form  of  phlegmon  or  septic  cellulitis,  occurring  in  the  floor  of  the  mouth 
and  sides  of  the  neck.  The  affected  parts  are  swollen,  dusky  red  in 
color,  and  present  a  brawny  induration.  Abscess  formation  and  gai)j;retie 
may  supervene.  Cases  are  not  infrequently  fatal  from  general  septi 
cemia.  Angina  of  this  type  may  originate  in  inflammation  of  the  suIh 
maxillary  gland,  but  is  more  common  as  a  result  of  trauma  or  infection 
from  carious  teeth.    Cases  occasionally  are  met  with  in  scarlatina. 

Parasites. — Parasites  are  rare.    Echinococcus  has  l)een  recorded. 

Tumors.— .\mong  tumors  of  the  parotid  maybe  mentioned  fit  oma, 
myxoma,  chondroma,  adenoma,  rhabdomyoma,  uicoma,  endothelioma, 
and  carcinoma.  The  most  common  tumo-  of  the  parotid  gland  is  mixed 
in  character,  consisting  of  chondroma  toge  her  with  fibrous  and  rnvxo- 
matous  elements,  and  is  probably  to  be  attributed  to  the  overcrow  th  of 
misplaced  embryonic  tissue,  ft  has  a  distinct  tendency  to  niKlcrjro 
sarcomatous  transformation.    Carcinoma  is  rare. 


CHAPTER    XVIII. 

THE  (ESOPHAGUS. 

Affections  of  the  (esophagus  are  relatively  uncommon.  Some  of 
them  are  of  great  clinical  importance,  however,  inasmuch  as  they  may 
interfere  with  the  passage  of  food  into  the  stomach  and  thus  lead  to 
malnutrition.  Owing  to  he  special  function  of  the  oesophagus  it  is 
peculiarly  liable  to  suffer  from  the  effects  of  mechanical,  chemical. 
and  thermal  irritation.  It  may  also  be  affected  by  disease  of  neighbor- 
ing; structures — larynx,  trachea,  mediastinal  and  peribronchial  glands, 
and  vertebrae. 

OOHODirrAL  AVOMALm. 

Malformations  may  occur  alone  or  associated  with  other  defects. 
The  most  common  event  is  for  the  upper  third  of  the  tube  to  end  in  a 
Idind  cul-de-iM,  often  dilated,  while  the  lower  portion  forms  a  fistulons 
coiamunieation  with  the  trachea  or  a  bronchus.  Any  part  of  the  tube 
may  l)e  absent  either  completely  or  the  defective  portion  may  be  repre- 
■iented  by  a  fibrous  cord.  Local  areas  of  stenosii  have  been  met  wi'h. 
l{arely,  the  lumen  is  partially  occluded  by  a  diaphragm-like  fold  of 
miicdiis  membrane. 

A  localized  dilatation  of  the  oesophagus,  the  so-called  "fore-stomach" 
or  "antrum  cardiacum"  has  been  observed.  It  is  decidedly  rare.  In 
uanliac  monsters  the  oesophagus  may  be  completely  wanting.  Partial 
or  complete  reduplication  is  found  in  double  monsters. 


'^ 


ALTERATIONS  OF  THE  LUMEN  AND  SOLUTION 


F  OONTINUITT. 


Simple  contracture  of  the  lumen  of  the  oesopi  s  from  spasm  is 
occasionally  observed  in  hysterical  persons  and  h\  pochondfiacs,  and 
aU)  ill  chorea,  epilepsy,  and  hydrophobia.  Stenosis  of  the  oesophagus 
mav  Ik-  developmental  or  acquired.  In  the  latter  form  the  lumen  may 
lit'  ii  irrowed  from  extrinsic  or  intrinsic  causes.  Thus,  pressure  from 
enlarged  mediastinal  glands,  aneurisms,  tumors  of  the  lung  and  pleura 
niiiy  itrinsr  it  about.  Local  inflammatory  swellings,  phlegmon,  growths 
of  t'lo  thrush  fungus,  tumors,  cicatricial  contraction  of  the  wall  from 
traina,  corrosive  poisoning,  syphilid,  and  diphtheria  are  among  the 
inir  isip  causes.  Foreign  bodies  may  also  lodge  in  the  tube  and  obstruct 
its  !-i'iien. 


398 


THE  (ESOPIlAdUS 


w 


l:i. 


DUatatiOD. — Dilutation  nmy  be  developnientul  or  act|iiin>(,  Ihe 
first-meiitiutieil  variety  i.s  rare.  The  condition  is  ^neral  throii^jlioiit 
the  tnl»e. 

A«|iiire«l  dilatation  i.s  usually  secondary  to  stenosis  and  nniv  Ik- 
^neral  or  local,  (ieneralizeil  dilatation  is  either  cylindrical  or  fiml. 
form  and  results  from  stricture  or  ciininic  ii-sopha^itis.  The  a'so|ili,i;;us 
may  l)e  enormously  diluted,  the  lumen  measuring;  .30  cm.  or  nion-  in 
circumference.  The  muscular  ccMits  usually  hypertmii''^  in  these  ciiscs. 
Rarely, "  idiopathic"  dihitation,  without  steuixsis,  is  oh.s( ,  vd.  It  Ims  hceii 
attributed  to  spasm  of  the  uuiscle  at  the  cardiac  end,  or  to  n-iiixiilion 
of  the  UHiscular  filx-rs  of  the  wall.  A  similar  ccmdition  can  Im-  |)r«.- 
duced  cx[)<Timcntally  in  the  dog  by  cutting  both  vagi  in  tiic  ritck. 
Kraus'  has  descriiied  a  case  of  this  kind  in  the  human  subject,  wlure, 
at  autopsy,  fl  f  vagi  were  found  to  be  diseased. 

Local  dilatations  or  diverticula  are  of  two  kinds,  premurc  dinrlinila 
and  fraction  ditrrticula.  The  first  form  is  due  to  pressure  fn)in  wiiliin 
the  lumen;  the  second,  to  external  force  pulling  out  the  wall. 

Pressure  diverticula  are  rare.  They  generally  are  situated  on  the 
posterior  wall  at  the  junction  of  the  pharynx  and  oe.sophagus,  at  the 
point  where  the  muscular  wall  is  ncrmally  weakest.  Local  buljiin;;  is 
first  bn)ught  alMHit  by  trauma,  the  swallowing  of  large  Imluses  o?  I'immI. 
which  gradually  increases  until  a  sac  is  formecl  extending  downward 
iH'tween  the  (esophagus  and  the  vertebra'.  Microscopic  examination 
shows  that,  as  a  rule,  the  muscul-  <•  AIhts  are  lacking  in  the  wall  of  the 
sac,  so  thct  the  condition  might  be  regarded  as  a  hernial  protrusion  of 
the  mucosa  and  siibmucosa  through  the  muscularis.  In  somr  few  c  ases 
the  muscular  fil)ers  have  been  found  to  be  continuous  in  the  wall.  In 
the  latter  case  the  condition  is  usually  regarde<l  as  an  ectasia  due  to  a 
disturbance  of  the  closure  of  the  fetal  cleft  at  this  point.  Food  tends 
to  enter  the  sac  and  Income  hxlged  there,  where  it  deco!niH)ses,  thus 
giving  rise  to  maceration  of  the  epithelium,  idceration,  inflaniination  of 
the  «'.sophagus  and  neighlwring  structures.  Pressure  symptoms  on  the 
rest  of  the  fcsophagus  are  common. 

Traction  diverticula  are  not  uncommon.  They  are  usually  to  \»-  t'oiinrj 
on  the  anterior  wall  al)out  the  level  of  the  bifurcation  of  the  triiclica.  Iliev 
result  from  iiiHainmatifm,  usually  tul)ercidoiis  in  nature,  of  the  ntii;hlioi-- 
iiig  lymph-iMxIes,  which  become  adherent  to  the  o'sophageal  wall  and, 
from  subsefjuent  cicatricial  contracti(,n,  exert  traction  upon  it.  I  lie  ^ar 
is  comparatively  small  and  finmel-shaped.  The  remains  of  the  diMased 
gland  can  Ih-  detected  at  the  apex.  Such  diverticula  may  be  >in-le  or 
nuiltiple.  Perforation  of  the  sac  may  take  place,  leading  to  siippiiiMiive 
pcrio'sophagitis  and  extension  to  the  plenne,  jK'ricardiiini,  and  liin^rs. 
The  wall  of  the  sac  may  consist  of  all  the  elements  of  the  (iso|,l„!i.'eal 
wall,  or  the  innscularis  .nay  l)e  j)artly  or  completely  defective. 

Rupture. — Uupture  of  the  (esophagus  occurs,  but  is  rare.  !■  may 
resiill  from  (rauma  or  increased  intcnud  pressure.     It  is  .said  i  ■  iiave 

'  r.cvili'ii  Festschrift. 


(ESOPUAd/TlS 


399 


(Kcurred  from  severe  vomiting  after  a  full  meal  and  when  in  a  state  of 
intoxication.  Probably,  in  such  cases  some  pathological  condition  in 
the  (esophagus  has  existed  previously  to  retider  this  accident  possible. 
Perforation. — Perforation  of  the  (esophageal  wall  may  result  from 
traumatism,  the  rupture  of  simple,  syphilitic,  and  cancerous  ulcers,  the 
pressure  of  foreign  bodies  within  the  lumen,  from  suppuration,  or  tuber- 
culous caseation  in  the  neighboring  parts,  or,  again,  from  aneurism. 


OIBOULATORT  DUTUBJBANOU. 

Hyperemia. — Owing  to  the  comparative  scarcity  of  bloodvessels 
ill  tlie  (esophagus,  hyperemia  is  seldom  a  striking  condition. 

Active  Hyperemia. — Active  hyperemia  may  In-  due  to  the  irritating 
|)r(>|)erties  of  certain  articles  of  food,  alcohol,  and  so  on.  It  occurs  also 
ill  iiewlKjrn  children,  in  the  early  stages  of  inflammation,  and  in  va-ious 
infective  diseases. 

Passive  Hypeiemia. — Passive  hyperemia  occurs  in  all  cases  of  general 
(Kiijffstion,  in  obstructive  disturbances  of  the  circulation  in  the  heart, 
liiiins,  and  liver.  In  [H)rtal  cirrhosis  of  the  liver,  the  veins  of  the  lower 
portion  of  the  (esophagus  often  l)econie  enonnously  distended  (ecuopha- 
ijral  rarirm),  and  may  form  nodular  or  papillary  masses  projecting  into 
the  hinien.  The  appearance  produced  is  very  similar  to  that  in  rectal 
hemorrhoids.  The  veins  are  dilated  and  tortuous,  sometimes  reaching 
the  size  of  a  lead  pencil.  Rupture  of  these  varices  may  lead  to  serious 
ami  even  fatal  hemorrhage. 

Hemorrhages. — (Esophageal  hemorrhages  may  be  caused  also  bv 
tiaiiinatisin,  ulceration,  or  malignant  new-growths.  The  effu.sed  bltKMl 
may  Ik-  vomited  up  or,  again,  digested  and  pa.ssed  on  into  the  intestine. 
All  i.ortic  aneurism  may  erode  into  the  (esophagus  and  rupture  there. 


HrrLAMMATIONS. 

(Esophagitis.— Oatairhal  (Esophagitis.— Catarrhal  nesophagitis  is  the 
coiiimoiiest  form  of  inflammation.  It  is  due  to  the  action  of  thermal  or 
(111  iiiical  irritants  in  the  ingesta,  to  extension  of  inflammation  from  the 
pharviix  or  stomach,  or  arises  as  a  complication  of  certain  of  the  infective 
feveis,  measles,  scarlatina,  typhoid,  and  variola.  It  is  characterized  bv 
<iiii-i  stion  of  the  mucosa  and  exfoliation  of  the  superficial  epithelium, 
top  tlier  with  increase  in  secretion,  which,  however,  is  usually  scantv  on 
iU'  ,,iiMt  of  the  paucity  of  mucous  glands.  Shallow  erosions  conunoidv 
re-i  It,  >itiiated  for  the  most  part  on  the  top  of  the  longitudinal  folds', 
wliii  li.  when  healing,  leave  small  scars. 

i'  I  lie  catise  persist  or  l)e  frequently  brought  into  play,  chronic  catarrh 
vMii  ie>iilt.  This  condition  is  found  also  in  tiie  (esophagus  alM)ve  a 
-I'  ■-!>,  and  as  a  result  of  prolonged  passive  congestion.  The  mucosa 
I- '  I  livid  red  color,  the  epithelium  is  thickened,  resulting  in  the  fmna- 
ti'       I  papillomatous  or  polypoid  outgrowths  or  pla(|ue-like  patches  of 


400 


THE  (ESOPHAGUS 


it 


m  '1  ;;' 


leukoplakia.  The  surface  is  covered  with  teiiaciout  mucus  or  nuK'opiis. 
The  muscular  wall  is  thickeiie<i,  both  from  hypertrophy  and  from  pro- 
ductive fibrosis.  The  lumen  is  usually  dilated,  but  may  l)e  nurnnvid. 
Superficial  ulceration  is  common. 

foUienUr  flbophagitU. — In  follicular  cesophagitis  the  mucous  ^liuuls 
are  involve*!.  The  lumina  are  obstructed  and  there  is  au  e.\c«'ssivc 
production  of  mucus,  which  leads  to  the  dilatation  of  the  glands  and  din  is 
into  small  cysts.  Hound  about  the  glands  there  is  a  small-celled  inlilim- 
fion.  This  may  result  in  abscess  fonnation  and,  from  rupturt'  of  ilif 
abscess,  ulceration. 

PUeKmonoaidioplugitii. — Ph\ef'inonom,ordiffuiieguppHratiira:t(iiilni- 
{fiti.%  nuiy  be  primarily  due  to  the  action  of  foreign  Inxlies  or  (■<^^^l>^i^t■ 
substances,  but  most  commonly  arises  by  extension  of  suppurative  inflaiti- 
mation  from  neighboring  structures,  such  as  the  pharyn.x,  stonincli, 
jKriirsophageal  lymph-n«Hles,  the  vertebral  column,  and  tin-  cricoiil 
cartilage.  It  occiirs  also  in  advance«l  pulmonary  tul)erculasis  witlioiit 
anv  obvious  cause,  and  occasionally  supervenes  upon  the  folliciiliir 
form.  The  affection  begins  as  a  purulent  infiltration  of  the  sultiiiucosa. 
leading  to  the  formation  of  localizeil  or  diffuse  collections  of  pus.  Tlif 
mucosa  is  retldened  and  underniineil,  and  fistulous  openings  may 
l>e  formed  in  its  substance,  which  give  vent  to  the  pent-up  c.Niuiatioii. 
The  tissues  about  the  a-sophagus  are  sometimes  involved  and  tlii' 
abscesses  may  discharge  into  the  lar\-nx  or  trachea,  or,  more  ran-iy, 
into  the  mediastinum  or  pleuni. 

PostuUr  IKsophagitii.— Pustular  oesophagitis  is  the  name  given  lo 
an  eruption  of  papules  in  the  mucosa  of  the  u'sophagus  occurring  in 
sniailj)ox.  .\s  in  the  skin,  the  papules  become  pustules,  and  wlitn  ilicv 
fiipture  form  small  ulcers. 

Membruious  (Esoplugitis. — Membranous  oesophagitis  accompanied  i)v 
sujierficial  necrosis  is  not  very  uncommon  in  variola,  measles,  scarliitina, 
typhoid,  typhus,  pyemia,  cholera,  chronic  Bright's  disease,  pntinnoiiia. 
tuberculosis,  and  the  gastro-intestinal  catarrh  of  ini'ants.  The  (iliriiicnis 
deposit  is  rarely  generalij^ed,  but  usually  confined  to  the  tops  of  the  t'olils. 
riceration  may  occur  with  stenosis  of  the  lumen  of  the  (vs(.|iIim^'iis 
from  cicatricial  contraction.     True  diphtheria  of  the  (esophagus  i>  ran'. 

Exfoliative  OBsophagitis. — P'xfoliative  oesophagitis  {<rsophagil)'i  '/'««'- 
ram  mperficialis)  is  characterized  by  the  desquamation  of  tlie  linini: 
epithelium  in  large  Hakes  or  even  as  a  complete  cylinder.  Tiie  eiioln^ry 
is  not  dear.  Some  cases  may  be  due  to  tlie  action  of  wrrosive-  ilie 
disease  usually  occurs  in  neurotic  individuals. 

Corrosive  (Esophagitis. — Corrosive  oesophagitis  is  that  form  <\<n-  u\ 
the  action  of  corrosive  poisons,  chiefly  aciils  or  alkalies.  Coiid  hiriitd 
Ive,  carbolic  and  sulphuric  acids  are  the  agents  commonly  ai  •"■rk. 
The  lesion  produced  is  a  necrotising  inflammation.  The  e|)it!ii  liian 
is  swollen,  shretldy,  and  des<)uamating  in  patches,  or  in  the  nim.  .  ycre 
cases  is  converted  into  a  yellowish,  grayish-white,  or  bia(ki>ii  i  -  liar. 
The  tissues  are  cnrngested,  extravasations  of  blood  are  to  be  i.nl  in 
the  submucosa,  and  a  line  of  demarcation  is  formed  between  i!.    livnig 


;  !'l! 


FOREION  BODIES  AND  PARASITES 


401 


Fio.  Bl 


and  the  dead  tissue.  The  necrotic  portion  is  eventually  rast  off,  if  the 
patient  live.  Suppuration  occurs,  and,  as  healing  takes  place,  serious 
i-ontracture  of  the  lumen  results. 
The  inflammation  may  extend  to  the 
neif;hborinf;  tissues. 

Tuberculosif .  —  This  is  always 
second"'^'  to  advanced  tuberculosis 
in  r.tliei  parts.  Most  commonly  it 
is  due  to  extension  of  the  disease 
fn)m  the  peritracheal  lymph-nodes, 
from  the  lar>'nx  or  pharynx.  Less 
i)ften,  it  results  from  swallowing  in- 
fectefl  sputum.  Miliary  tuberculosis 
of  the  oesophagus  also  occurs,  but 
is  rare.  Tuberculous  ulceration  is 
usually  superficial,  but  perforation 
may  take  place.  The  borders  of  the 
uioers  are  thickened,  an<l  small  tuber- 
ties  can  1)6  made  out  in  the  sub- 
stance, 'i'he  liases  are  smooth  or 
irrejiular.' 

Syphilis. — Ulceration  of  the  oeso- 
phajius  may  occur  both  in  the  sec- 
onilary  and  tertian* stages.  Gumma- 
tous infiltration  is  the  most  frequent 
lesion.  It  lends  to  ulceration,  per- 
foration, and  cicatricial  contraction 
of  the  lumen. 

ActinomycosiB.  —  Tl :  affection 
is  r;m\  Primary  actinomycosis  of  the 
oNopliajjus  has  been  described  in  a 
few  cases.  Extension  to  the  thoracic 
viscera  is  the  rule ' 

rarasites.— Thrush.— This  is  most 
eoniiiionly  met  with  in  poorly  nour- 
islud  children  and  in  those  suffering 
troiii  prolonged  disease  and  cachexia. 
As  ii  rule,  the  infection  extends  from 
tile  mouth  or  pharynx,  but  some- 
tini.  ^  arises  independently.  It  may 
Ix'  associated  with  tuberculosis  of 
liie  iisophagus.  Trichinosis  has  also 
liceii  (iKscrv-ed. 

Foreign  Bodies.— The  chief  foreign  bodies  that  are  at  times  found 
111. lie  or  less  completely  obstructing  the  oesophagus  are:  Iwnes,  fish, 

^ '  luiliol  Cone,  Johns  Hopkins  Hosp.  Bull.,  80: 1897: 229. 

I'')iicet,  Province  M&licale,  Lyon,  9: 1895:205;  Bull,  de  I'Acad.  de  M^d.,  15: 


Stricture  of  the  cenphagua  in  a  child, 
due  to  nrallowing  lye;  above  the  ttenoaed 
portion  the  tube  i*  dilated.  (From  the 
Pathological  MuMum  of  McGill  University.) 


is'.ir.. 


26 


402 


TWA-  acsoPHAoua 


!i 


ill. 

r 


nettles,  leeches,  hiicI  tahv  teeth.  Phleginonou.'^  uvsophaKitU  t-oiiiiiiiiiily 
resulu.  IlunI,  ungulur,  or  sharp  substance!*  of  course  do  more  duiimp' 
to  the  wall  than  ilo  others,  and  may  lead  to  ulceration,  altscess  furni- 
■tion,  or  even  f^anfpvne,  sometimes  followed  by  perforation.  .Spiic 
matter,  at  times  mixed  with  food,  may  thus  be  discharged  into  tlie 
mediastinum,  pleura,  pericardium,  or  into  a  bronchus  or  a  large  vessel, 
such  as  the  aorta. 


aiTKOORUIIVI  MBTAMOKPHOm. 

Atrophy. — Atrophy  of  the  wall  may  occur  in  general  mnrasmiis  miil. 
Iwally,  a.s  a  result  of  pressure.  N'anous  fonns  of  degeneration  iirc  nut 
with  also.  They  are  rare  and  have  l)een  but  little  .stuilied.  The  most 
important  are  nteroMs.  Pressure  from  foreign  bodies  impacted  in  the 
lumen,  or  from  aneurisms  or  tumors  from  without,  lead  to  ischeinia, 
atrophy,  and  eventually  loss  of  substance.  What  may  Ik-  teriiied  a 
"be<lsore"  of  the  a-sophagiis  is  occasionally  met  with  in  cachexia  mid 
proloiigtHl  fevers  us  u  result  of  pressure  of  the  larynx  U|Km  the  orjiaii. 

A  ronnd  or  peptic  nicer,  analogous  in  all  re.spects  to  the  |H-pti('  nicer 
of  the  stomach,  has  l)een  describeil.     It  is  rare 

(Baophagomalacia. — (Ksophagomalacia  has  l>eeii  ol>erve(l  as  an 
agonal  manifestation  in  cases  of  cerebral  disea.se.  It  is,  however,  not 
uncommon  as  a  pastmortem  phenomenon  as  a  result  of  the  <lip'stioii 
of  the  tissues  by  the  gastric  juice  which  has  regurgitute<l  tlin>ui;li  the 
canlia.  The  epithelium  is  macerated,  desquamated,  and  the  tinisi  iilar 
coat  may  be  discolored,  softene<l,  or  liquefie<l.  Perforation  of  the  wall 
sometimes  occurs  with  escape  of  the  .stomach  (-ontents  into  the  pleura. 

Gangrene. — Gangrene  of  the  cpsophagus  may  l)e  a-s-scKJated  w  itii  noma 
of  the  cheek  or  pharA'nx,  gangrenous  tonsillitis,  or  gangrene  of  the  hnijr. 
It  may  also  result  from  the  action  of  corrasive  substan(rs  uiitl  st  >»■«■ 
inflammation. 

PB00RE8SIVE  METAMORPHOSES. 

Hypertrophy. — Hypertrophy  of  the  muscular  wall  is  prtHlnceil  liv  :iiiy 
cause  that  tends  to  oh.striict  the  free  passage  of  Uhh\  into  tlie  sti,Mi;i(li. 
Muscular  spasm,  carcinoma,  aiul  strictures  are  the  most  iin|«'it;int 
conditions  to  lie  mentioned  in  this  coiniection. 

Leukoplakia. —  Leukoplakia,  similar  to  that  occurring  n|>nn  tlic 
tongue,  is  common.  ^Iultiple,  small,  nmndetl,  or  oval,  plinin'-likc 
elevations  of  a  pearly  white  color  areobser\'e<l  upon  the  mucosa.  Mi'  lo- 
.scopically,  they  consist  in  a  simple  local  hyjHTplasia  of  the  s(|'i hmoiis 
lining  epithelium.  They  are  found  in  ca.ses  of  passive  congesiii  !(  and 
in  alcoholics. 

Tumors.^New-growths  are,  on  the  whole,  not  cojnnion.  1  inv 
originate  in  the  nesophagus  itself  or  in  the  neighlwring  parts.  ;i','!  .ire 
rarely,  if  ever,  metastatic.    The  benign  growths  are  usually  .siii;!!  and 


DERMOID  CYSTS 


403 


of  Imt  little  practical  iin|Mirtaiice.  'ITie  most  ciimmoii  are  the  polypoid 
iir  ptpUlMj  flbromM,  uml  the  Intnmnnl  flbroBM.  UpomM,  ibtxobiu, 
myomu,  and  p«lyp«id  »d«iiom«  (one  case)  are  recimied. 

Sanoflu.— I'riinan-  sarcoma  of  the  (i>sopha){m  is  «juite  rare.  Spindle- 
cflled,  round-celled,  and  alveolar  forms  are  described,  and  alw  K  mpho- 
sarcoma.  As  >*  rule,  .sarcoma  invades  the  oe.wphagus  by  exten.siiin  frr»ni 
some  of  the  i.  irinff  stnicturen. 

Oixtinoma  —  i'he  most  important  growth  is  carcinoma,  which  mav 
!>»•  primary,  or  set-ondury  to  carcinoma  of  the  canlia  of  the  .stomiiih, 
plmrynx,  or  thyroid  (tliind. 

I*rimur>-  carcinoma  of  the  ii'sophajfiis  is  usuullv  of  the  #»/««/«<»«.•- 
nlhl  type,  adrnitcarciiinma  l>einj{  distinctly  rare,  'i'he  latter  form  may 
ori^'iiiute  fmm  the  mucous  jjlamls  or  fn/m  developmental  cvsts  lincil 
with  cDliimnar  cells,  which  are  .sometimes  present  in  the  wall!  Clund- 
iihir  carcinoma  mav  l)e  simple,  me<lullary.  or  .scirrhous  in  lv|ie.  We 
hivf  rnH  with  one  instanc-e  of  •»  j(landular  cancer,  appnj.xiniatinjf  the 
virrlioii-  form,  which  formal  a  small,  isolatetl  );n>wth  and  htl  to 
coii.phte  obstruction.  The  favorite  site-  for  caninomatous  );n»wtlis 
art-  !it  the  narniwest  part;  of  the  lumen  and  where  there  is  traiisjiioiial 
ppiihiliMm.  They,  uierefore. occur  most  often  at  the  level  of  the  cricoid 
(!irtil,i).'e,  opposite  the  bifunation  of  the  trachea,  and  at  the  entran«r 
into  ilif  stomach.  The  tumor  tends  to  encir«le  the  linnen  and  thus 
liiiMliKfs  stenosis,  u  condition  that  is  not  entirelv  relieved  even  when 
nlrrriKion  takes  place.  In  .some  parts  there  mav  \w  sufficient  pn>- 
lif.riiiioii  of  connective  tissue  to  form  a  .scirrhous-like  j;n»wth.  but  in 
otli.rs  the  Tuass  is  softer  and  more  fungatinft.  The  mucous  incm- 
I'ratif  ill  the  neijrhlH)rho«Kl  is  usually  inflamecl  and  the  (i-sophajreal 
wall  iiliovf  the  stricture  is  hypertrophied  ami  the  lumen  ililate*!.  'I'lie 
mw-;;r(.wth  may  extend  through  the  wall  of  the  cesophapis  to  the 
tradita,  bronchi,  liinj;.  mefliastinum,  pleura.  |)ericanlium,  or  lar^jc 
)lo(H  I  vessels.  Metastases  occur  in  the  regional  Ivmph-n.Mles.  the  liver 
liiiiu's,  iiiul  Inmes. 

CaniMonm  occurs  nvxst  often  in  males,  lietween  the  a^es  of  fiftv  and 
siM.v  y.iirs,  particularly  often,  it  is  sai<l.  in  smokers  and  drinkers.  " 

Dermoid  Cysts.— Dermoid  cysts  are  verv  rar:-.  Thev  occur  at  a  ixiiiit 
i"ar  111,,  junction  of  the  n-sopha'/us  and  pharviix."  The  conpM.ital 
evsh  iine,!  with  columnar  epithelium  sometimes  foiind  jr.  the  (i-sophaccal 
wall  are  „f  teratoid  nature.  They  repn>sent  the  remains  of  the  ori-rinal 
TOini.Hiuicatioii  between  the  crsophagus  and  trachea 


it' 


III 


. 


CHAPTKK    XIX 

THE  STOMACH 

AXOMALIIS 

Oongsnitel  AnomaUei. — Ooapltu  abMnct  ot  the  Hioiimfh  Ims  intn 
re|M)rfed  in  ttmnection  with  olhor  >{rave  anomalies,  siicli  u.«  a(r|ihiilus. 
It  is  rare.  Tlie  or^an  may  be  ul>norinuliy  iiuU,  even  in  <)lli«'rwis«' 
well-«l»'vel(»petl  iniliviiluiils.  The  pyloric  ii|K'ninj{  may  lit-  iimipli'tclv 
or.  mure  often,  partially  oeclndad,  an<l  attached  to  the  (luiHieinnn  liv 

I .... ».' 


Huur-glaiH  «li>iui«ih.     (Fruin  the  Pathological  Muaeum  of  McUill  I'nivcr-iiy  i 

"onl.     Diverticttla  are  rare.     The  .stomach  may  lie  diviilcil  inin 
nln-rs  by  intersectinj;  septa.     It  may  also  be  composcil  it  .   ■« 
01..  in^  to'a  constriction  al>i)ut  the  niiHdie  (hour-glass  deformity  I. 

In  CO...,.  transfHJsition  of  tlie  viscrra  the  .stomach  may  Iw  reversed, 
the  pylorus  beiiij;  situated  to  the  left.  Occasionally,  the  stoiiiacli  ,i  -niio 
a  Tertic»l  position,  jMxssibly  a  persistence  of  the  embryonic  coiii|!im!i 

Another  type  of  conj^enital  displacement  is  that  found  in  coin  miuui 
with  defect  <)f  the  diaphrajjin.  There  may  1)6  absolute  dffc(  t.  v.  r'.\  t«f 
coiiiiiiuiiication  U'tween  the  thoracic  and  abdominal  cavities  co.  ler.ital 
false  bernia);  the  diaphragm  may  lie  congenitally  weak  at  son  .  i">int. 
so  that  violence  or  muscular  strain  sub.se<|uently  applied  iiim\  -'it 
to  give  way,  with  protrusion  of  the  alxlominal  viscera  into  tii'     ,n  inc 


ANOMAUES 


4()F> 


(•uvi|y  (Miniitd  tolM  htnto);  or  there  may  lie  thinning  of  the  diaphngm 
M>  thut  the  ulMlotiiiiiHl  oiyans  are  dislocated  into  the  thoracic  cavity, 

I'lO.  S3 


I  ".*^uul  d..pJ,n«ni«.o  ternia  in  man,  «te,l  Hf,y.^„„  y„„:  partly  f.W,  ,h,r.  I»i„.  ,. 
.1   ",   ,  „  '■"»'»'''•;«""-  I*""""  'l«-  l*rilo„r«l  anU    pleural  cavi.i,,,  fr„m  -he  «!,/,  of 

..„„„«  ■  ,  ,v..„„«   over!  the   .t„m..l,   and  left  kidney  a.   th.y  lay  in  the   pleural  cavity       Tie 
mii-.  I.     I  tl,e  ,|,ap|,ra«m  i.  «l,a.le,l  .liirlc.  1  leurai  caMty.       llie 


i  la.  94 


IIV! 


ic  8tenod,of  tb.  pyloru..     (From  th.  Pathological  Mumibd  of  MoGill  Uiuveriity.) 


400 


ti:k  stomach 


Ixit  aw  coiitaiiuHl  in  a  sac  of  diaphragm  or  pritoiieum  (true  diaphrag- 
matic hernia).  The  seioiid  variety  int'iitioiiel  is  the  most  eoinmon,  224 
of  Leichtenstern's  252  cases  behiK  of  this  type.  True  diaphrajjiiiatir 
licriiia  is  a  rare  form,  occurring  in  only  11  per  cent,  of  all  cases.' 

Oongenital  Hypertrophic  Stenosis  of  the  Pylorus.— Congenital  liyiKi-- 
tn)pliic  stenosis  of  the  pylorus  is  somewhat  rare,  although  undoiilit- 
tnlly  more  frKpient  than  has  been  thought.  There  may  l)e  a  pre- 
existing congenital  stenosis  of  the  orifice  with  sub.se(juent  hypertrophy 
of  the  niascles.  The  micro.scopic  examination  of  the  pylorus  shows 
merely  hyperplasia  of  the  muscle  with  some  fibrosis.  There  may  jilso 
be  slight  catarrh  of  the  nuicosa.  The  affection  is  important,  ;is  it 
occurs  in  infants  usually  under  four  months  old,  and  may  lead  tinlcuth 
from  starvation  if  unrelieved.* 


i    ! 


AOQTTIRED  DISPLACEMENTS. 

Displacement  of  the  stomach  may  be  upwani  {vuk  sitpro),  down- 
ward (gastroptosis),  or  to  the  side.  In  all  cases  the  cardia  is  a  lixtd 
-int,  the  pylorus  or  some  other  portion  moving  upcm  this  as  on  a  iiiiifjc 

coninion  form  is  that  in  which  the  middle   portion  of  the  orpiii 

j;s  downward,  the  pylorus  and  the  cardia  remaining  in  their  iiorMiai 
position. 

Dislocation  is  sometimes  due  to  causes  inherent  in  the  stonuicli  IimII', 
such  as  (filatation  or  contraction,  but  is  often,  also,  the  result  of  cNtniisic 
factors.  A  loa<led  colon,  the  weight  of  tumors,  the  traction  of  adiusioiis, 
will,  on  occasion,  tend  to  drag  the  organ  ih)wn.  The  pressun-  of  corstis 
or  an  enlarged  liver  may  force  it  downwanl. 

Castroptosis  is  nearly  always  part  and  parcel  of  a  general  prolapse  of 
the  abdominal  viscera' (splanchnoptosis).  The  term  Glcnard's  liiseasi' 
origiiiallv  referred  to  pmlapse  of  the  intestines  alone  (enteroptosisi, 
but^has  been  used  more  comprehensively  to  include  cases  of  ciittroiiioMs 
combined  with  prolapse  of  other  organs  as  well.  Besides  the  Moinadi  :im(I 
intestines,  the  liver  and  the  right  kidney  may  be  displaced  (hepatoptosis, 
nephroptosis). 

In  (lli'iiard'n  disra.sc  there  is  a  peculiar  .symptom  complex.  ii<i\niis 
dyspepsia,  and  atony  of  the  stonuich,  constipation,  or  coiislii'iinon 
aileriiating  with  diarrhea,  dragging  .sensations  in  tiie  back,  amiiiiii, 
and  ill  the  later  stages,  neunisthenia.  Anatomically,  there  is  rrlj\jiion 
of  tiie  iiepatic  and  hepatopyloric  ligaments.  Gl^nard,  who  oiii;i'inllv 
(lcseril)ed  the  condition,  thought  he  had  discovered  the  anatoini.  .1  Ikisis 
of  neurasthenia,  but  this  view  is  not  generally  accepted.  Hoint  1. 1  und 
Charcot  considered  that  the  prolnp.se  wius  rather  the  result  than  ihr  ■  hiso 


'  I'.  M.  In,  Diuplira(?matic  Hernia,  Mtjiit.  Mctl.  Jour.,  21:  !>*!'.')-•>:  I'M 
^HolU'sfoii   and   Croftoii-Atkins,  Congenital   Hypertrophy  witli  Sten. 

Med.   .(our.,  2:1!)(K):17(W.      See,  also,  Scudder,    Boston   Mml.  and  Sm.' 

VM)r,:VM. 


Hril. 
urn.. 


DILATATION 


407 


of  the  neunustlienia,  due  to  the  loss  of  iniisciilur  mid  nervous  tone.  The 
causes  of  spliindinoptosis  iir»',  pressure  ujjim  the  ulMluniiiiul  contents 
from  aJwve,  as  from  corsets;  the  cnunpiu);  effect  of  a  long,  narrow,  or 
phthisical  chest;  an  enlarged  liver;  relaxation  of  the  supporting  ligaments; 
weakening  of  the  alMlominal  walls  from  pregnancy;  the  pressure  of 
tumors  or  cysts;  nervous  depression;  and  conditions  which  tend  to  drag 
the  viscera  down. 


ALTERATIONS  IN  TI-S  f-lZZ  ANI>  £  lAPE  Or  THE  LUMEN. 

Contraction  of  the  stomach  is  tounu  i.\  :•:  rtain  forms  of  chronic  gastritis 
and  in  diffuse  scirrhus  carcinoma.  The  cavity  of  the  stomach  in  the 
latter  case  may  not  In-  large  enough  to  contain  more  than  a  cupftd  of 
Hiiid. 

Hour-glass.— Hour-glass  contraction,  when  acquire*!,  may  l)e  due  to 
the  cicatrization  of  an  ulc-er,  torsion  of  the  st(miach,  tumors,  hernia, 
or  adhesion  to  displacefl  viscera. 

Dilatation. — Dilatatiim  of  the  stomach  is  a  not  uncommon  condition, 
riic  two  main  factors  in  its  cau.sation  are  a  deficiency  of  muscular  tone 
and  ditticidty  in  evacuation  of  the  organ.  The  affection  often  comes 
(in  slow  ly  and  insidiously,  and  it  may  l)e  long  before  clinical  symptoms 
manifest  themselves.  Overeating  and  drinking  are  {wtent  causes  and 
act  In-  bringing  about  a  gradual  distension  of  the  organ,  with  sometimes 
(irsci'ut.  In  not  a  few  ca.ses  the  .stomach  is  considerably  eidarged, 
'  ••  -s  ai)le  to  digest  and  discharge  its  contents  in  the  recular  space  of 

v.'....I i:.:„..    :.   ^ i  i  .    •  ■       "  .     .  .    "^  . 


Illlt 


time.  .Such  a  condition  is  termed  megaloifastria,  and  probably  should 
1)1  ditt'crcntiated  fmm  true  dilatation,  in  which  the  muscle  is  overstretched 
ami  fimctionally  weak.  Among  the  causes  that  act  by  obstructing 
till'  Dnflov  of  the  gastric  contents  may  Ih>  mentioned  carcinoma  of  the 
inli.nis,  stenosis  and  hypertmphic  stenosis  of  the  pylorus,  pyloric  spasm, 
cxnriial  prt>ssure  of  new-growths  or  enlarge<l  glands,  the  traction  of 
iMil.iMiniatory  adhesions,  gastroptosis,  and  tight  lacing. 

A  ( Dusiderable  numl>er  of  cases  of  aruif  (lilafatioii  of  the  stomach  are 
tiiiw  on  record,  and  the  condition  is  pnibably  much  mon-  common  than 
iia^  i;fneraliy  been  realized.  Acute  dilatation  c(mies  on  with  gn-at  sud- 
iliiiiicss,  and  utdess  promptly  relieved  by  appropriate  measures  usuallv 
m\>  a  rapidly  fatal  course.  The  chief  eiiological  factors  of  a  predispos- 
in;:  nature  are:  (1)  oj)erations  under  general  anesthesia;  (2)  severe  and 
l)n>lnii^-(.,l  disease;  (."?)  indiscretions  in  diet;  (4)  <lisease  or  deformity  of 
till  vjiiric;  and  (.'))  traumatism.  A  few  cases  have  come  on  without 
iiliuMiis  cause.  Now  and  then  one  will  suprvene  u|M)n  chronic  dilata- 
ti'i"  The  diri'ct  causes  a])pear  to  l)e  primary  paresis  of  the  gastric 
mil  ( nlatnre,  and  obstruction  to  the  onflow  of  the  gastric  contents.  In 
ii!"iiii  half  the  recorde<l  cases  definite  mechanical  obstruction  has  lieen 
fiMiiM,  iHcasionally  at  the  pylorus,  but  much  more  fretpientlv  in  the 
<lii"  !'  Minn,  just  l)elow  the  bile  papilla.  Kinks,  the  traction  of  at'lhesions. 
i"i'i  ilie  pressure  of  misplace<l  organs  may  bring  this  alK>ut.     The  mast 


40S 


THE  STOMACH 


constant  anatomical  lesion,  however,  is  compression  of  the  duodenum 
by  the  root  of  the  mesentery.' 
VolTnlos  of  the  stomach  has  been  observed.' 


OIROULATOKT  DUTURBANOU. 


The  amount  of  blood  in  the  stomach  varies  widely  within  physioloj,'ical 
limits,  depending  upon  the  degree  of  functional  activity  for  tiie  time 
being.  Consequently,  postmortem  appearances  must  be  interpreted 
with  some  degree  if  naution. 

OBdema. — (Edema  is  rare,  even  in  inflammatory  processes. 

Anemia. — Anemia  occurs  as  a  manifestation  of  general  systemic 
anemia,  and  in  association  with  atrophy  of  the  mucosa.  In  the  latter 
case  it  is  difficult  to  determine  whether  the  atrophy  b  the  result  of  the 
anemia  or  vice  versa. 

Hyperemia. — Active  Hypeiamia. — Active  hyperemia  occurs  physio- 
logically during  digestion  and  imparts  a  delicate  rose-pink  color  to  the 
mucosa.  It  also  results  from  the  action  of  irritating  or  corrosive  sub- 
stances. In  such  cases  the  congestion  is  very  intense  and  is  present  in 
irregular  patches,  localized  especially  to  the  tops  of  the  rugse. 

Passive  Hyperemia. — Passive  hyperemia  is  found  in  connection  with 
portal  obstruction,  particularly  that  occurring  in  cirrhosis  of  the  liver, 
and,  more  remotely,  with  vascular  obstruction  in  the  heart  and  lungs. 
The  pyloric  portion  is  the  part  chiefly  affected.  The  mucosa  is  of  a  dull, 
purple  red  color,  ami  the  veins  are  often  distended.  Extravasations  of 
l)lood  occur,  so  that  patches  and  spots  of  a  yellowish  or  brownisii  color 
are  not  infrequent.  In  long-st.mding  cases  the  mucous  membrane 
becomes  markedly  pigmented. 

Hemorrhages. — -Hemorrhages  into  the  stomach  wall  are  (|uite 
common.  .Vccording  to  Birch-Hirschfeld,  they  are  found  in  about  .)0 
per  cent,  of  cadavers.  He  regards  them  as  due  to  severe  and  pro- 
tracted vomiting  just  before  death.  In  general,  the  extravasations  are 
due  to  increased  vascular  tension  or  disease  of  the  vessel  walls.  Thev  arc 
found  in  cirrhosis  of  the  liver,  leukemia,  pernicious  anemia,  the  liciiior- 
rhagic  diatheses,  scurvy,  acute  yellow  atrophy  of  the  liver,  and  in  ^muv 
acute  infections;  also,  in  poisoning  from  phosphorus,  strycliniiif.  utid 
morphine;  and  in  severe  vomiting. 

Hemorrhage  into  the  cavity  of  the  stomach  may  be  due  Ui  iln' 
erosion  of  a  vessel  from  a  simple  or  cancerous  ulcer,  trauinatisiii,  nr. 
rarely,  leukemia,  hemophilia,  or  vicarious  menstruation.  Whci!  the 
bleeiling  is  at  all  extensive  the  blood  is  usually  vomited  (lii'm(ifcinr-i>'U 
or,  again,  may  be  passed  by  the  bowel  (melena).  When  ri(  iiitly 
effused  the  blood  is  acid,  bright  red,  pure  or  mixed  with  food;  v  Iitii 


'  Nicholls,  Acute  Dilatation  of  the  Stomach,  Intemat.  Clinics,   I,ipi>iin 'H.  i' 
VM)H:  SO. 
'  Pendl,  Wien.  klin.  Woch.,  1904 :  476. 


GASTRITIS 


409 


the  hemorrhage  is  of  some  standing,  however,  the  blood  assumes  a 
turbid  brown  apparance  like  coffee-grounds,  owing  to  the  action  of 
the  gastric  juice.  t  is  worth  while  pointing  out  that  all  blood  vomited 
does  not  necessarily  result  from  gastric  hemorrhage.  It  may  be  due, 
fur  example,  to  bleeiling  from  the  nose,  mouth,  or  oesophagus,  the  blood 
being  subsequently  swallowed,  or  to  the  oozing  from  an  aneurism.  In 
young  infants  pus  and  blood  from  a  suppurating  breast  may  be  swallowed 
and  later  on  regurgitated,  an  occurrence  that  sometimes  gives  rise  to  an 
erroneous  diagnosis. 

Hemorrhages  into  the  mucosa  lead  to  weakening  of  the  local  resisting 
powerof  the  stomach,  and  areas  so  affected  are  not  infrequently  converted 
into  shallow  ulcers,  owing  to  the  eroding  actior.  of  the  gastric  secretion 
(hemorrhagic  erosion). 

Thrombosis. — Thrombosis  of  certain  of  the  gastric  vessels  is  met 
witli  occasionally.  It  is  thought  by  some  to  be  the  primary  condition 
leading  to  the  formation  of  the  peptic  ulcer.  It  occurs  occasionally 
in  connection  with  se%'ere  bums  of  the  skin. 

Embolism. — Embolism  is  said  to  be  not  uncommon. 


INFLAMMATIONS. 


Gastritis. — Inflammation  of  the  stomach  in  the  vast  majority  of 
instances  is  due  to  the  irritating  action  of  substances  that  have  been 
iii<;ested;  some  few  cases  are  attributable  to  the  agency  of  the  toxic 
substances  circulating  in  the  blood;  a  few,  also,  to  the  extension  of 
iiifiainuiatory  processes  from  neighboring  parts. 

In^'ested  substances  act  as  irritants  largely  owing  to  their  physical  or 
chpinical  properties.     "  -'ffs  may  on  occasion  act  as  the  excitants  of 

(jastriiis  (dyspeptic  g,v  \n  excessive  amount  of  food  is  a  common 

cause,  owing  to  the  ina.  .'  the  stomach  to  digest  and  pass  it  along 

(|ui(  kly  enough.  This  is  particularly  apt  to  occur  when  the  function 
of  ihf  stomach  is  impaired,  as  from  muscular  atony,  pyloric  stenosis, 
can  iiKitua,  or  filuous  induration.  Should  fcxMl  from  any  of  these  causes 
1)1'  n  tiiined,  it  undergoes  abnormal  fermentation.  Putrid  gases,  irri- 
tatiii};  fatty  acids,  and  bacterial  toxins  are  produceil  in  notable  quan- 
tities 1111(1  lead  to  severe  disorders.  Pus,  infected  sputum,  and  foul 
ni:iiirial   from  the  buccal   cavity  may  also  induce  gastritis. 

1  he  most  severe  cases  of  gastritis  are  brought  about  by  corroxire 
IHHmti.i,  the  conditions  resulting  varying  according  to  the  character 
of  the  destrurtive  substance  and  the'length  of  time  that  has  elapsetl 
sill'  e  its  ingestion.  Strong  corrosives  lead  to  extensive  necrosis  of  the 
lime,  HIS  luembrane.  The  slough  prcxluced  by  sulphuric  acid  is  hard,  dry, 
hnitle,  ;ind  of  a  grayish  color.  Nitric  and  hydrochloric  acids  give  a 
yel!,.v  is:!,  tint.  Caustic  alkalies  product-  u  transparent,  pulpy,  digested 
api";i ranee.  The  morbid  appearances  resulting  depend  considerably 
upon  the  amount  of  f(X)d  in  the  stomach  at  the  time,  being,  of  course, 
mori   intensely  marked  in  the  fasting  organ.    The  effects  of  caustics 


410 


THE  STOMACH 


ar»'  usimliy  more  pn>iiuiiiice(l  at  tUe  fuiuius  and  posterior  wall,  mid 
csiH-cially  on  the  tops  of  the  ruga-.  The  remainder  of  the  inncosa  nmv 
Ik*  free  from  necrosis,  iiut  may  show  sij^ns  of  a  more  or  less  intense  inlliiin- 
mation,  often  hemorrlia';ie  in  eharaeter. 

Hematogenous  Outritii. — IIemati>genou.<'  gastritis  arises  more  esp<-('i;illv 
in  the  ctmrse  of  infections  and  intoxicaf.ons,  as  in  septiwmia.  ty|)li()iil 
fever,  puhnonarv  tnljercuiosis,  and  variola.  Metastatic  abscess  foiniii- 
tion  is,  however,  rare. 

Oastritia  per  Eztenaionem. — (Jastritis  per  exIennUmem  may  result  from 
any  localized  inflammatory  condition  in  the  neighborhood  of  the  stomach. 
Simple  adhesion  to  adjacent  stnictims  may  occur  or  perforation  of  the 
stomach  wall,  with  discharge  of  inflannnatory  pnnlucts  into  tlie  (aviiv. 
Fistulous  connnunications  with  other  visceni  may  thus  arise.  Cliolc- 
lithiasis,  empyema  of  the  gall-bladder,  suppurative  pancreatitis,  may  Ik- 
mentioned  in  this  connection.  A  perinephritic  absc-ess  has  Ix-cn  known 
to  rupture  into  the  stomach.  One  of  us  (A.  G.  X.')  has  recorded  an 
apparently  unitpie  case  of  this  kind  in  which  the  patient  vomited  |>iis 
and  bl(M»d  for  three  days  before  death. 

Acute  Catarrhal  Oaatritis. — Acute  catarrhal  -astritis  is  characl.iizcd 
by  swelling  and  hyperemia  of  the  mucous  mei.  >rane,  together  with  the 
prcHluction  "  a  viscid  adhesive  exudate,  consisting  of  mucus,  dcMjiia- 
mated  ep-  'elium,  and  leukocytes.  Here  and  there,  small  hem()rrliai,'cs 
may  be  seen  and  also  superficial  erosions. 

Histologically,  the  .secretory  cells  of  the  glands  are  cloudy  and  arc 
desquamatir  while  goblet  cells  are  very  numerous.  The  epithi  liiiiii 
t)f  the  peptic  glands  is  more  granular  than  usual  and  is  often  dctadifd 
from  the  ba.sement  membrane.  On  the  surface  can  he  seen  a  siriiijry 
deposit  of  mucus,  entangled  in  which  are  clumps  of  gastric  ei)itliiliiiiii, 
red  bhMKl-cells,  and  lenkcK-ytes.  There  is  a  roinid-celled  inlilinitioii 
between  the  tubules  and  in  the  submuco.sa,  and  the  interstitial  IiIimhIvcs- 
sels  are  congested.  The  endothelium  of  the  lymphatics  also  niav  ^how 
signs  of  proliferation.  These  changes  are  usually  confined  to  tli<'  rci:i(^ri 
of  the  pylorus,  b.it  may  be  generalized. 

Membranous  Oastritis. — A  more  inten.se,  though  somewhat  ran-,  khi- 
dition  is  membranous  gastritis.  In  its  typical  form  it  occurs  hkj-,  f;-,- 
queiitly  in  chihlren.  The  membrane  lies  in  small  patches  on  il.c  tups 
of  the  ruga-,  or,  mow  rarely,  covers  the  whole  stomach,  forrniiii;.  ms  it 
were,  a  cast  of  the  interior.  The  membrane  is  '')o.sely  attached  in  ilic 
nuicosa  and  is  of  a  grayish  color,  or,  again,  is  bn)wiiish  from  li<  luor- 
rhage. 

Membranous  gastritis  occurs  most  commonly  in  newlM)rn  chililnii. 
in  ca.ses  of  septic  infection  of  th.e  uuibilical  coni,  and  in  ti;osc  ^iilt<  rini; 
from  scarlatina,  measles,  .diphtheria,  and  variola,  rar»'ly  in  other  inf -c  live 
fevers.  True  fiiphthirid  of  the  stomach  occurs,  and,  curiously  ei  ..Mtrli. 
the  infection  may  pass  from  tlie  throat  to  the  stomach  withoiii  :i!i.  kiiijr 
the  (esophagus.     Necrosis  and  suppuration  may  cause  a  nion   ■'<■  less 

»  XichoUs,  Mont.  Med.  .lour.,  27: 1898: 119. 


1.34=. 


CHI 


?  CATARRHAL  GASTRITIS 


411 


.Mensive  loss  i>f  siihstanw  in  the  mucosa,  ami  deeply  enxiinj;  tik-ers 
may  Ik'  forimtl. 

Phlegmonous  Outiitis. — I'hle^inonous  gastritis  is  rare.  It  occurs 
idiopathically,  particularly  in  tlrunkanls,  and  occasionally  in  general 
pveniia.  More  or  less  localized  pus  collections  are  fomied  in  the  stomach 
w  all  which  may  reach  a  co  isiderable  size  and  rupture  into  the  cavity  of 
tlie  organ. 

roUicnlar  Outritis. — Follicular  gastritis  is  also  rare.  It  is  due  to  inflam- 
mation of  the  lymph-follicles,  which  are  present  in  small  numbers  in  the 
suMnach.     Suppuration  may  occur,  giving  rise  to  small,  roun''ed  ulcers. 

Chronic  Oatairhal  Outritis. — Chronic  catarrhal  gastritis  may  result 
from  repeated  acute  attacks,  but  not  infre(|uently  -rises  independentlv. 
It  is  most  common  in  those  addicted  to  excess  in  alcohol  or  tobacco,  in 
(ases  of  long-standing  passive  congestion  of  the  stomach,  and  as  an 
lucompaniment  of  gastric  ulcer,  carcinoma,  antl  dilntation.  It  may 
also  complicate  certain  ctMistitutional  affections,  such  as  anemia  Brighi's 
disease,  tul)erculosis,  and  gout. 

Fi'5.  9.1 


'I'liiiple  odenoniatous  P"lyp»  Cii.lenitis  polypi.sa)  of  sloiuach:    O.  iluiHlenuin;  P,  pyloric  ring. 

(Orth.) 


Several  different  forms  have  been  described,  but  they  are  all  probably 
In  lie  regarded  as  stages  in  one  and  the  same  pnicess.  Tiie  mucous 
iiirmhrane  is  of  a  brown  or  grayi.sh-brown  color,  owing  to  the  dejMJsit  of 
:ni  inm-containing  pigment  derived  from  the  blood  m  the  secreting  cells 
:i!.l  interglandular  tissues.  Congestion  is  not  necessarily  present,  and 
III  i\,  in  the  later  stages  at  least,  lie  completely  lacking,  except  in  those 
I  lis  originally  due  to  passive  hyperemia  of  .systemic  origin.  The 
TiM.itisa  is  covered  with  a  thick,  adherent  layer  of  mucus,  mixed  with 
I'  'kocytes  and  altered  desquamatetl  epithelial  c-ells.  In  not  a  few  cases 
niniitroiis  flattenefl,  elevated  plaques  are  pnxluced  (ttat  mamelonm),  and 
i!;'  proliferation  of  the  interglandular  fibrous  tissue  may  be  so  great  that 
i'  :(v  outgrowths  result  {gasirifis  poli/fHiDU.).  In  still  another  class  of 
'  tl"  productive  change  is  most  marked  in  the  glandular  elements, 
•  I  :li;it  outgrowths  resembling  adenomas  are  produced.  The  last  two 
I    I  >  are  often  grouped  togeth  t  under  the  term  hypertrophic  gutritis. 


412 


THE  STOMACH 


Hi! 

I 


h  I 


Again,  the  overgrowth  of  the  intenstitiul  connective  tissue  miiy  lead 
to  sclerosis  and  contraction  of  tiie  organ  (atrophic  gutritii).  Here, 
the  mucosa  is  thin,  hard,  and  of  a  grayisii  i-oior.  The  other  coats  niuv 
also  show  fibrous  hyperplasia,  so  that  the  thickness  of  the  stomach  wall 
is  greatly  increased  while,  at  the  same  time,  its  capacity  is  diminished. 

Microscopiadly,  the  most  striking  feature  is  a  ceihilar  infiltration  in 
the  interstitial  areolar  tissue,  more  esj)ecially  in  the  outer  layers  of  the 
mucosa.  This  leads  to  more  or  less  separation  of  the  gland-tubules. 
The  uucts  are  catarrhal,  often  tortuous,  dilated,  or  even  cystic,  tlic 
secreting  celb  being  increase<l  both  in  size  and  number.  These  changes 
lead  to  tliickening  of  the  nnicous  membrane  giving  it  an  irregular 
appearance. 

Specific  Forms  of  Gastritis.— Thnuh  is  occasionally  present  in  small, 
i.S()late<l,  whitish  patches  on  the  nmcosa,  in  cases  where  the  fauces  are 
e.xtensively  involved. 

Tubercnloiis.— Tuberculous  infection  of  the  stomach  is  rare,  proii- 
ably  owing  to  the  fact  that  the  acid  character  of  the  gastric  secretion  is 
inimical  to  the  growth  of  the  tubercle  bacillus,  as  of  other  germs.  Tulier- 
culosis  of  the  stomach  in  hinnan  beings  is  almost  invariablv  associated 
with  advanced  tul)erculosis  elsewhere,  usually  in  the  lungs.  '  Van  Wart' 
has  rec-orded  one  case,  however,  which  is  an  exception  to  the  rule. 
Orth,  by  feeding  rabbits  on  tuberculous  material,  was  able  to  prodiur 
typical  lesions  in  the  intestines  in  seven  cases  and  in  the  stomach  in  one. 
Alice  Hamilton^  has  recorded  three  cases  of  tuberculous  ulceration  of 
the  stomach  and  has  collected  10  more  from  the  literature.  Tubercii'oiis 
ulcers  are  generally  multiple  and  situated  near  the  pylorus.  Some  are 
little  more  than  superficial  erosions  of  the  mucosa,  tlie  discovery  of  tiie 
specific  bacillus  alone  deciding  the  nature  of  the  case,  while  others  iiavi- 
a  more  typical  appearance,  with  infiltrated  edges  and  an  irregular  base 
containing  caseous  tulxrcles.  It  is  remarkable  that  in  main  cases  ilie 
intestines  escape  the  uifection. 

Syphilis. —This  disease  is  also  rare.  Kcchvmoses,  heinorrli:ii;i( 
erosions,  and  chronic  gastritis  have  been  described  among  (!ie  le•.i,lll^ 
occurring.  The  most  characteristic  niariifestatioii  is  thegunini.i.  uliirii 
may  give  rise  to  ulcers  that  may  perforate.  Cicatricial  contractiir.  ^  of 
the  affected  part  may  also  result. 

Typhoid.— Typhoid  ulcers  are  reported,  but  are  still  rarer  ili  ii 
tuberculosis. 

Actinomycosis.— Actinom,  -osis  is  also  excessively  rare. 

Inflammation  of  »he  stomach,  more  jjarticularlv  the  ulcerative  p  .1 
phlegmonous  forms,  may  extend   through  all   the  coats  and   iin  .!.■■ 

adjacent  structures  (pt'riguntrilix).      If   the  infection   be  a  mil.! 

simple  fibrinous  a<lhesion  takes  |)lace  between  the  contiguous  sinfa. .-. 
as,  for  example,  those  of  the  stomach  and  liver  or  anterior  abdoHuhii 
wall,  with  suKsefpiont  organization.  Or,  if  the  condition  lu  lu.a 
.severe  and  of  a  septic  nature,  local  abscesses  may  be  formed  aboiii  i!i.' 

•  Johns  Hopkins  Hosp  Bull.,  14: 1<.»03: 235.  » Ibid.,  8:  1S'J7:  7... 


PARASITES  AND  ABNORMAL  CONTENTS 


413 


E  I 


stomach.  Perfonition  o(  the  stomach  wull  and  adhesion  to  a  hollow 
viscns,  such  as  the  colon,  may  lead  to  the  formation  of  a  fistulous 
track.  Communication  may  thus  be  opened  up  uetween  the  stomach 
and  the  pleura. 

Parasites  and  Abnormal  Oontents.— Any  of  the  ordinary  intestinal 
|)arasites  may  find  a  lodgment  in  the  stomach.  The  Pentastumuin 
ilniticulatitm  and  the  Echinococcus  are  met  with  in  the  stomach  wall, 
Imt  are  rare. 

It  is  not  uncommon  to  find  foreign  bodies  in  the  stomach  which  have 
>;()t  in  with  the  food  or  have  >  ^n  swallowed  hy  accident  or  design. 
Hiittons,  neeilles,  ^poons,  scissos,  hairpins,  nails,  false  teeth,  knives, 
forks,  coins,  stomach  tul)cs,  and  many  other  articles  are  at  times  swal- 

Fio.  06 


H;iir  bail  in  the  stomarh.      The  hiiir  turms  a  complete  cast  of  the  stomach  and  duotlenum. 
(Case  of  Dr.  Jaine:^  liell,  Koyal  Victoria  Hospital.  Montreal.) 

inwnl  In-  insane  and  hysterical  patients  or  by  circus  performers,  and  may 
.'M'  rise  to  serious  trouble.  Haii-balls  (phytol)ezoar)  are  fretpiently 
li '1111(1  in  cattle  and,  rarely,  in  human  beings,  Schopf  has  collected 
i''  lasfs,  and  1  has  been  reported  in  Montreal  by  .lames  Bell.^  The 
liiiir-hall  is  composed  of  the  patient's  own  hair,  or,  as  in  one  ca.se  reported, 
ii  Miixture  of  that  of  the  patient  and  that  of  a  pet  doji.  felted  into  a  com- 
!'iit  mass  by  the  muscular  action  of  the  stomach.  The  individual 
ii ';r>  foinposing  it  may  be  quite  long  and  vary  somewhat  in  color.  As 
'  iN-,  ttit'v  an'  somewhat  darker  than  the  patient's  hair,  probably  owing 


'  Wicn.  klin.  Wwli.,  NovemlM3r  If.,  1S99. 
'  Montreal  Med.  Jour.,  32: 1900 .  Mi. 


414 


TIIK  STOMACH 


Ut  clicinical  action  in  the  stomach  cavity.  Tlie  hair  may,  in  time,  aci  u- 
miihite  to  such  an  extent  as  to  ftirm  a  complete  cast  of  the  interior  i,< 
the  .stoHiacli  an<l  ihuMlennm.  IiiHammation  of  these  viscera  not  in- 
fre<iuently  results,  which  nniy  lead  to  perfonition. 


li 


III 


RKTROORBSBIVK  MITAM0RPH0U8. 

Atrophy.-  Simple  atrophy  is  met  with  in  cachexia  from  any  cnnsc, 
marasnuis,  prnicious  anemia,  and  as  a  senile  change.  The  stoiniu  li 
• .  small,  the  wall  thin,  an<l  the  nmcoiis  memhrane  thin,  pale,  sni<M)ili, 
and  shiny.  The  glands  are  jirannlar  and  diminishe<l  in  size.  DiffiiM' 
or  patchy  fatty  defeneration  is  a  not  uncommon  associate<l  conditii.n. 

Degeneration.— Fatty  Degeneration.  Fatty  de^reneration  (xcurs  in 
typhoid  fever,  septicemia,  variola,  jK'rnicious  anemia,  leukemia,  and  in 
poisoninji  with  phosphorus,  arsenic,  and  lead. 

Hyaline,  Oolloid,  and  Amyloid.  Hyaline,  colloid,  and  amyloid  (runs- 
formation  are  not  uncommon. 

Calcification. — Calcification  of  the  nnicosa  has  been  ohscrvnl  in 
cases  of  rapid  absorption  of  the  lime  salts  from  the  hones  in  (oriosivc 
sublimate  |)oisoniii^. 

Postmortem  Oastromalacia.  A  brief  reference  should  be  w.uU- 
to  the  conditi(Mi  known  as  postmortem  pistn>malacia.  'I'lie  condiiion 
is  not  common  in  our  ex|)erieiice  in  bodies  sectioned  within  Iwcntv- 
four  hours  of  death.     In  other  cases,  local  airas  of  softeninj;,  nsiiiilK 

situated  on  the  posterior  wall  of  the  fundus  or  at  the  cardia,  may  be  I'o 1, 

wliich,  from  their  ap|)earance  and  special  characters  are  to  hv  attribiiicil 
to  the  action  of  the  gastric  secretion,  assisted  probably  by  processes  cl' 
dec()in[)(>siti()ti.  These  areas  are  gelatinous,  of  a  dirty,  reddish-brown 
or  fjreen  color,  and  often  jjive  rise  to  perforation  and  escafH-  of  the  stonim  li 
contents.  Much  difference  of  «)pinion  has  Im-cu  expressed  over  iln 
<luestion  whetiier  or  not  this  softening  is  exclusively  a  jiostniortt  iii 
appearance.  The  determining  factors  appear  to  be  the  condition  of  ilic 
secretory  function  of  the  stomach  at  the  time  of  death  and  the  leni,'tli  i.f 
time  that  has  elapsed  since  death.  It  is  quite  possible,  however,  ili:ii 
in  certain  diseases  where  the  resisting  powers  of  the  mucosa  is  diiiiini>li. d 
the  phenomenon  may  be  an  agonal  one. 

Peptic  Ulcer. — Of  more  practical  importance  is  the  so-called  peptic 
ulcer,  found  both  in  the  stomach  and  ducMlenum.  ^Vhen  in  the  'lu..- 
flenum  it  is  never  situated  below  the  bile  papilla,  being  confined  to  ihit 
portion  acted  on  by  the  gastric  juice. 

The  typical  peptic  ulcer  is  roimd  or  oval,  extending  nirm-  or  I  -- 
deeply  into  the  wall  of  the  viscus.  It  has  a  characteristic  t'nui n  1 
shape,  the  edges  being  terraced,  more  or  less  sharply  cut,  and  gnnluiilv 
narrowing  as  the  base  is  approached.  In  chronic  cases,  lio«.  r, 
the  edges  may  be  rounded  and  the  whole  wall  thickened.  Thi  il.r 
is  occasionally  deeply  pigmented,  owing  to  the  action  of  the  l'  'if 
secretion  ujKjn  the  blood.     Sometimes  a  number  of  superficial  cr.      ns 


PEPTIC  ULCER 


4i; 


tt'iitling  to  coule.s(t>  are  found,  a  circumstnnce  tliat  tlirow:«  .hoiiu*  light 
oil  (he  etiology  of  the  (fjiiditioii.  Micmscopitally,  a  n-ct-nt  uhrr  shows 
liiit  little.  Except  for  the  loss  of  .siibstaiuv  and  the  ternice<l  conditior 
of  (he  edges  there  may  be  no  further  change,  or  at  most  only  a  fine  granii- 
lation  of  the  cells.  Only  exceptionally  13  there  a  marke<i  inflammatory- 
reaction.     Even  in  ulcers  of  long-standing  the  reactive  phenomena  are 

Fio.  97 


Peptic  ulcer.     (From  the  Patholugical  Muxeuin  of  McGill  University.) 


Ii.v  I.  I  means  pronounced.  There  is  merely  slight  diap<'desis  of  \en\ny- 
rvt,.,  tlie  inuscularis  shows  fatty  changes,  and  the  vessels  exhibit  pro- 
litViiiiiifr  endarteritis. 

1''  I'tie  ulcers  are  single  or  multiple,  and  when  in  the  stomach  are 
I!  iiiiv  situated  at  the  pylorus,  preferably  on  the  lesser  curvature. 
1 1"  may  be  mere  superficial  erosions,  round  or  oval  excavated  ulwrs, 
o)  iniy  \w  so  large  as  to  girdle  the  stomach,  'i'he  causes  are  many, 
liii;  M  cm  to  dejKjnd  mainly  on  defective  circulation  in  the  j)art,  the  result 


41fi 


THE  STOMACH 


I    4 


of  thruiiilwsiM,  einlMilisin,  or  di.scii.si'  of  the  vi'Sitel  whILi.  Small  an-a>  of 
hemorrliH^  or  iiiieiiiiH  |>rtHli.s|H>.sf  to  ulcer  fortnution.  The  not  infr:-- 
nueiit  iisHociution  of  ((utitric  and  duo<lt>nal  ulcers  with  severt>  hums  of 
the  .skin  is  well  recojjuized.  Here,  the  condition  aptn-ars  to  lje  uiudopms 
to  the  necn)tic  chaufjes  that  occur  in  the  lymph-nixies  from  the  actinii  of 
toxic  sulxttances  derived  fnmi  the  injured  region.  Once  the  proti-ctinj; 
mucous  memltra'ie  is  damaged  or  destroyed,  the  digestive  action  of  rlu- 
gastric  secretion  comes  into  play  and  leads  to  further  loss  of  suhstiiiice. 

Peptic  ulcers  are  essentially  chronic  and  give  rise  to  a  variety  iif  syiii|>- 
toms.  Uept>ated,  small  liemorrhag«?s  will  produce  systemic  antinia; 
larger  ones  may  cause  death.  Pain  after  food  and  <lysj)eptic  symptoms 
are  quite  common,  but  the  <-ondition  not  infrequently  is  entirely  laltnt 
and  unsus|iected.  A  serious  event  is  perforation  of  the  ulcer  resuiliiig 
in  general  peritonitis.  An  ulcer  on  the  {wsterior  surface  may  jx-rforaie 
into  the  lesser  peritoneal  sac,  a  relatively  favorable  event.  This  may  lead 
to  fibrous  perigastritis.  Rarer  seijuels  are  perforation  into  the  colon, 
spleen,  gall-bladder,  through  the  alMlominal  wall,  into  the  left  pleural 
cavity,  into  the  left  lun/  and  into  the  pericardium.  In  chnHiic  ulctra- 
tioii,  fibrous  adhesiim  lietween  the  affecte<l  part  and  neighlnmng  or^rans, 
such  as  the  pancreas,  liver,  and  adjacent  lymph-nodes,  is  a  coiiiuion 
event.  Finally,  ulcers  may  heal,  with  the  production  of  minute  Hliroiis 
scars  or  larger  stellate,  contracted  cicatric'cs.  Stenosis  of  the  pylorus 
and  hour-glass  constriction  of  the  stoinacli  are  some  of  the  results  of 
tills  occurrence.     Can-inoina  may  develop  at  the  site  of  an  old  ulcer. 

Simplo  %  'ion.-  Then'  is  one  form  of  ulceration  of  the  stoiiiiicli, 
'■)un(l  n<  f  ir  ,uently  at  autopsies.  al)out  which  a  woni  or  two  slionld 
t)e  s:ii(l,  esjK'cialiy  as  tiie  condition  is  one  that  has  not  as  yet  altnicicd 
much  attention.  The  ulcers  are  very  numerous  an<l  take  the  foriii  of 
small,  irregular,  siudlow  pits,  giving  the  mucosa  a  somewhat  "niotli- 
eaten"  ap|K'aratice.  Tiiere  is  no  infiltration  and  no  surroiUKJiii};  con- 
gestion. The  lesions  resemble  simple  ero-sions.  Little  is  known  ;il(oiit 
the  etiology.  Perhaps  they  are  pnMluceil  after  death  by  the  selt-(lii,'es- 
tion  of  the  stomach,  but  then*  is  .some  evidence  for  thinking  tli:ii  iliey 
may  Ik-  an  agonal  manifestation. 


PROOKE38IVE   METAMORPHOSES. 

Hypertrophy. — Hypertrophy  of  the  niu.scular  wall  of  the  >i(ini:irh 
is  met  with  in  a.ssociation  with  stenosis  of  the  pylorus,  chronic  ^.'ii^iriti.s, 
and  tinnors.  The  whole  wall  may  be  affected  or  merely  the  poriioii  nciir 
the  pylorus.  The  congenital  hypertrophy  of  the  pylorus  has  alniniv 
been  ref»'rred  to.  Most  cases  are  probably  to  be  classetl  as  hyj  'rtnnliies 
fmm  overwork.  In  chmnic  gastritis,  there  may  l>e  an  overprowth  of 
the  mucosa  in  the  form  of  flattened  sessile  nodides  (elat  mni>i<l 'nw] 
or  polypoid  or  |)apillary  excrescences  ((juiffrilin  iK>lyf>oKa).  A  mhh^  >^llat 
similar  cotidition  is  found  occasionally  in  the  neighborhood  of  (Ironic 
ulcers.  The  pmliferation  in  these  cases  may  begin  in  the  iiin ;  titial 
fibrous  tissue  or  in  the  glands. 


CARCIXOMA 


417 


Tomon.  -( 'oi»iuttive-iiv*ue  tiew.(;rowttu  an-  rare  ami  it)in|)«rativ»|y 

imp«jrtont.  ribronuf,  Upoau,  and  ayomu  have  beeji  met  wiili. 
Wi-  have  seen  one  case  of  a  pedmiculateil  Jibromyoma  sprinffinjj  fn>ni 
the  <en)U.s  siirface  at  the  fiintiiis.'  LjmpluBglOBU  beneath  the  wroiis 
iiivfrinj;  of  tlie  !>tuniach  has  fjeen  recorded. 

Stfcoau  U  rare.  Comer  and  Fairbank'  have  wllecteil  .>S  fases. 
"  .astrii-  sarcomas  may  lie  subserous  and  pethmciilatetl.  S.ine  of  theni 
.  i.ritiiin  un.stri|)ed  muscle  fil>ers  and  are  called  b\-  some  observer*  BuUg. 
Dint  myomu.  In  one  such  <-a,se  Korinski  found  fibers  of  unstri|H'd  muscle 
III  ilic  metastatic fn^mths  in  the  liver. 

Stiondarv  san-omas  an-  iK-casionally  met  with. 

<  >f  the  epithelial  ne»->;rowths.  adUnoffla  is  .S4iid  tointur.  butearcinoiu 
i-  liy  far  the  most  fni|uent  ai:d  im|M>rtant. 

Fio.  W 


>.-.  ..i'lar>-  mfiMolic  iarcoma  of  the  ntoinsch.     (From  the  Patl.>l,«ical  .Vu«euin  ..f 
McGill  L'nivereit.-.) 

Carcinom*.— Carcinoma  of  the  stomach  usually  arises  after  inid.lie 
III'  ni«i  IS  somewhat  more  conunon  in  men  than  ii)  women,  the  relative 
|'ru|,nitioii  iK-inj;  .-,2  to  4,S  [>er  cent.  The  growth  mav  ..riginate  from  an 
^1  jKiniitly  healthy  mucosa  or,  occasionallv.  in  an"  old  peptic  ulirr. 
\\iiii  n.^Mrd  to  |K)sition,  more  than  one-half' the  cases  are  .situated  at  or 

" 'Ii'j  F>ylonis.     Next  in  frequency  is  the  le.s.ser  curvature,  and  next, 

ii'iia.  (rastric  carcl.,  ,  las  vari-  ^vnsiderably  in  external  appear- 
-.iiie  »»eiiij;  soft  and  funjjatinj;,  some  pupiHoiiiatoiis,  some  ulccr- 
aiid  others  scirrhous  or  gelatinous. 

'  Nicholls,  Mont.  Med.  ..our.,  32: 1!IO,"j!.32ti. 
»  Practitioner,  72:1904:  810. 


Ill 
tl,.. 

i|ih 

iilin 


418 


THE  STOMACH 


III 


(fiMtric  carcinoma."*  fal'.  into  five  dass«» — mrthtlhiry,  tutrnitmrdniwin. 
m-irrlutu*,  eoUoid,  anil  mfuamnn*     In   \'.UA  ttutes  irf  ^a-Htric  cttn-iniiina^ 


rm.  m 


UiRoiw  wirrlii>iii>  larrinoin*  <>f  Ihe  >l>imsrli      Nnir  ihe  irrat  thii  Itriiinit  i>f  ilie  »;>ll 
(Krorii  itip  I*atliol(«h'al  Mu«riim  i>f  Mrtiill  rnixiTniiy.) 


Siirrhou"  carcmnma  of  the  pyloric  pnriion  of  the  ctomarli.     (From  ilii'  I'athi  I ■.:' 
Museum  o(  McGill  University.) 


<i)llectt'<l  bv  Fenwirk  and  Fenwick,  SM  were  niediiilary,  417  mm    "H^ 
and  .'is  coiloiil.' 

•  Cancers  and  Tumors  of  the  Stoiiiucli,  I'Joa. 


CAKCINOMA 


410 


ITie  iMdallMjr  form  !•♦  characterizecl  timtroMi-opitolIy  bv  the  f<.miatio» 
of  a  soft  -.jjonKV  mass,  with  .smo«)th  surfaw,  but  divi.lwl  i„to  flatt.iu.l 
ncles.  It  M  usually  situatnl  nrar  the  pvlorus.  When  of  aiiv  size  it 
may  ult-erate.  owing  to  laik  of  nutrition.  Histolofjicallv.  tli.-  n.'w- 
fc't|)wth  consists  chieHy  of  masses  of  cylin.lrienl  or  isoilinmetric  <rlls.  with 
relatively  little  connective  tissue.  Fibr^jus  induration  of  the  .stonuuh 
wall  IS  a  frequent  arconipanitr'^nt. 

The  «l«i»ewelnoiu  forms  ye.  soft,  fungous  masses,  having  a 
.T".-  «'"**''  papillomatous  abearance.  .Micnwcopically,  the  ..i.i- 
rhehttl  cells  are  arranged  in  atypi<al  glandular  masses,  plrser^ing  a 


II 


Fki.  lol 


<  ir  ,r...,„,.„f,h,.,.„aa.h.    '<'.ti"n  i.  tak.n  .hr..u«h  the  mu«ulnr  cc«t.     Hri.hert  obi   7„  with,,,,, 
.....lar.     (Kr,.m  the  c,..le..,i„„  „1  the  l-.,h,.lo,ic»l  Department  „,  McUill  l'„;' tr:,;:v  )     

Mi.-ir  ..r  less  complete  resemWant..  to  the  gland-tubulcs  from  which  thev 
n.  1  her.-  ,s  a  small  amount  of  stroma,  often  infiltrated  in  placrs 
"iin  round  cells.  *^ 

Scirrhous  cwcinom*  may  involve  the  whole  wall  of  the  stomach  or 

■  i  hbrous.     Ihe  mucous  membrane  may  be  intact  over  the  growth, 
it  ,s  not  infrequently  absent.    In  the  diffuse  form  the  stomach  mav 

; '  <-n  racte.1  that  its  cav.ty  can  contain  only  about  a  cupful.    Scirrhus 

■  '; .  in  loms  may  lead  to  r.cutricial  stenosis,  with  dilatation  of  the  organ. 

-  'io^'Kally,  the  mam  portion  of  the  growth  is  formed  of  dense  con- 
;.    '•■''•''"'.  the  epithelial  elements  In-ing  .scanty.     Fibrous  induration 
"■    !»■  muscular  coat  is  a  marked  feature. 


rl 


^ir 


420 


THE  STOMACH 


Colloid  eareinoBM  is  found  in  nodular  masses  or  as  a  diffuse  infiltrn- 
tion  of  the  stomach  wall.  When  incised,  the  tumor  is  composed  almost 
entirely  of  gelatinous  material,  sometimes  collected  into  cysts.  Micro- 
scopically, it  b  a  cylindrical-ceiled  carcinoma,  as  a  rule,  but  the  marked 
feature  is  the  tendency  to  colloid  change  exhibited  by  the  cells,  not  only 
the  epithelial  cells,  but  those  of  the  stroma  as  well. 

Sqaunoiu  epitholioma  is  rather  rare.  It  occurs  at  the  cardia,  and  prol>- 
ably  originates  in  the  mucosa  of  the  lower  end  of  the  oesophagus,  whence 
it  invades  the  stomach. 

Carcinoma  of  the  stomach  may  infiltnite  all  the  coats  of  the  organ  and 
even  bring  about  adhesion  to  neighboring  stnictures,  pancreas,  colon, 
liver,  omentum,  which  may,  in  turn,  be  invaded.    It  is  not  uncomnum 


Fig.  102 


u 

1     i 


Colloid  car.inoma  of  the  flomsch.  Winckel  No,  3.  without  oriilar.  Tlie  lari-iriotna  nli-  :m- 
Krrally  dene*"*™'"!  """l  i"^^'^  htta  replaced  by  colloid,  which  can  be  recognized  as  loiiu.  r-iiiniiv 
fibrils.     (From  Dr.  A.  G.  NicholU'  collection.) 

to  find  dilated  lymphatics  on  the  senMis  surface  of  the  stomach  filleil  wiili 
carcinoma  cells.  The  lympli-notles  about  the  les.ser  curvature,  tlie  n  i  n.- 
peritoneal,  inguinal,  thoracic,  and  supraclavicular  nodes  are  in  inni' 

involved.     In  a  large  proportion  of  cases  metastasis  takes  place  tin jrli 

the  bloo<l-vascular  .sv.stem,  somewhat  in  contravention  of  the  jri  i.  riil 

i.ur 


rule.     Secondary  growths  are  common  in  the  liver,  invasion  takiiij;  ] 
through  the  radicles  of  the  portal  vein. 

Medullary  and  especially  colloid  cancers  tend  to  invade  the  |HTiti.i> 
and  give  rise  to  numerous  and  widely  distributetl  secondary  irn. 
resembling  in  type  the  parent  growth.  The  omentum  is  often  iiilili  > 
and  distorted,  ami  may  .sometimes  be  recognizetl  as  a  transveiM 


iiin 

.lil.S 

iiul 


CARCINOMA 


421 


crossing  the  upper  part  of  the  abdomen.  Peritonitis  may  also  supervene. 
One  of  us  (A.  G.  N.')  has  reported  u  somewhat  unusual  case  of  diffuse 
scirrhous  carcinoma  of  the  peritoneum  and  omentum,  with  contraction 
of  the  mesentery  and  chronic  peritonitis,  originating  in  a  scirrhous  car^ 
cinoma  of  the  stomach. 


^^.rrh.,u8  .arcinoma  of  the  »t«i„.K.|>,  ,„„e„tun,,  a„,l  peritoneum.  In  thi.  au»  the  new-gi«wth 
.:.-  .hm.«Hl  thr„,«hout  the  rtomaih  wall  an,l  lead  to  a  peculiar  condition  of  carcin^rrf  The 
,..n  „„..,nn  w.th  ,erofibrinou,  peritonitis.  The  g,..t  omen.utn  and  me«„tery^™  curioj^y 
l-k-rH  and  contracted.     The  nodule,  show  very  well  in  th.  figure.     (NiebolU.     cJ^ZZ 

Wlu-n  situated  near  the  pvlonis,  gastrectasis,  with  all  that  that  implies 
-nttntion  of  food,  fermentation,  gastritis,  e.xc-essive  vomiting— super- 
V.1U.S.  L  Iferation  may  lead  to  en)sion  of  a  vessel  and  fatal  hemorrhajre 
"I  Ik  perforation  and  peritonitis. 

'  Nicholls,  Jour.  Amer.  Med.  Assoc.,  40: 1903:696. 


imm  ] 


i\ 


CHAPTER    XX. 

THE  INTESTINES. 
OONOKNITAL  ANOMALIU. 

Total  tbisnee  of  the  intestines  and  similar  gross  defects  are  found 
only  in  connection  with  other  serious  malformations.  Partial  or  com- 
plete defect  of  the  appendix  has  been  observed.  Inverted  poiitions  of 
the  various  portions  are  recorded,  both  with  and  without  inversion  of 
the  abdominal  or  thoracic  viscera.  An  abnormal  eoorie  of  the  colon  is 
common.  It  may  pass  diagonally  across  the  abdomen,  without  formin;; 
a  hepatic  flexure,  or  there  may  be  accessory  loops.  Perhaps  the  most 
frequent  form  is  a  downwanl  loop  of  V'-shape,  which  is  found  in  9.5  per 
cent,  of  autopsies.  Hetnial  protnuions  may  take  place  through  a  fissure 
of  the  abdominal  wall,  a  patent  inguinal  canal,  or  a  defect  in  the  dia- 
phragm. 

Congenital  narrowing  (stenosis)  or  imperforate  area.s  (atresia)  occur. 
Sometimes  portions  of  the  bowel  are  defective.  Thus,  the  anus  with 
more  or  less  of  the  reciuin  may  lie  absent;  or  the  anus  may  open  into 
a  sac  which  does  not  communicate  with  the  colon  above.  Membranous 
septa,  transverse  or  longitu<iinal,  may  be  present.  Defects  of  the  lower 
bowel  and  urogenital  sinus  are  rather  common.  Thus  there  may  1k' 
a  large  cloaca  into  which  the  bladder  and  rectum  discharge.  The 
bladder  may  be  divided  and  the  large  intestine  absent,  so  that  the  ileum 
empties  into  the  bladder.  In  less  extreme  cases  there  may  be  merely 
incomplete  closure  of  the  septum  that  exists  between  the  rectum  ami 
urogenital  sinus.  The  rectum,  when  defective,  may  end  blindly  or  liis- 
charge  into  the  bladder,  urethra,  vagina,  or  perineum. 

A  common  anomaly  is  the  Meckel's  divertienlnm,  found  in  our  exf)ori- 
ence  in  about  2.7  per  cent,  of  autopsies.  It  is  found  usually  in  the  ileutii, 
within  a  meter  of  the  ileocecal  valve.  The  diverticulum  is  cyliuilricnl, 
funnel-shaped,  or  larger  at  the  distal  end.  The  apex  is  sometimes 
rounded,  bifid,  or  lobulatetl.  The  average  length  is  about  7  cm.  The 
diverticulum  is  situated  away  from  the  mesenteric  attachment,  aixi 
represents  the  remains  of  the  omphalomesenteric  duct.  All  degrees  of 
patency  of  this  duct  may  exist.  Thus,  it  may  remain  open  for  its  whule 
length,  giving  rise  to  what  is  known  as  an  ompbalomesenteric  fistula; 
it  may  be  open  at  the  umbilical  end — omphalic  fistula;  it  may  be  rlo^i  <!  at 
both  ends,  forming  a  cyst,  when  situated  in  front  of  the  peritoiiuin 
called  a  preperitoneal  cyst,  when  attached  to  the  intestine  cnlle!  an 
enterocystoma.  Not  infrequently  the  Meckel's  pouch  is  attache*!  w  the 
umbilicus  by  a  fibrous  cord,  the  remains  of  the  involuted  duct. 


ACQUIRED  DIVERTICULA 


423 


Mructurally,  the  diverticulum  consists  of  all  thelavers  of  the  intestine 
although  the  muscular  coat  may  be  somewhat  thinned  at  the  apex.  It 
may  have  free  communication  with  the  bowel,  or  may  be  partiallv 
slmt  off  by  a  valve.  ■/         t~        : 

The  importance  of  the  condition  lies  in  the  fact  that  the  diverticulum 
may  Jjecome  strangulated  and  inflamed,  or,  again,  may  perforate 
Where  the  fibrous  attachment  persists,  coik  of  intestine  mav  be  caught 
iiiiil  :>trangulated.  ' 

Cong«nlt«l  Hypertrophy  and  Dilatation.— Congenital  h^•pertrophv  and 
.iilatation  of  the  c-olon  {megacolon,  Hirschspnmg's  disease)  is  a  pe'culiar 
(•(.ndition  affectmg  mainly  the  ascending  colon,  but  sometimes  also  to 
a  lesser  degree  the  transverse.  The  cau.se  is  unknown,  though  many 
rases  are  undoubtedly  developmental  peculiarities.  In  one  reported 
In  torniad,  the  colon  contained  22  kilos,  of  feces.  The  irritation  of 
the  retained  feces  leads  to  inflammation  and  ulceration  of  the  bowel 
an.)  sooner  or  later  to  a  fatal  termination.  The  condition  has  been 
.')und  at  birth,  but  fre<juently  develops  during  eariv  childhood. 


AOQUIHID  AN0MAUI8  OF  THE   LUMKR.     • 

Acute  Dilatation.— .\cute  dilatation  of  the  intestines  (e.Jeroplegia)  or 
a.ute  paralvtic  distension,  is  strictly  comparable  in  regard  to  causes  and 
ft-^MJts  with  acute  dilatation  of  the  stomach.  Manv  cases  arise  from 
a(  lite  (.l.sfruction,  as  from  foreign  bodies,  adhesions,  volvulus,  or  hernias 
Am  mi{K.rtaiit  etiological  factor  is  infection,  either  local  or  svstemic.  The 
infliie.ue  of  local  infection  is  seen  in  the  cases  that  occur'in  connection 
\yith  peritonitis,  appendicitis,  cholecystitis,  or  other  inflammatorv  condi- 
tion, uf  the  abdominal  viscera.  The  gastro-intestinal  paralvsis' accom- 
pariving  pneumonia,  scarlatina,  and  meningitis  is  probablv  to  be  attriii- 
ut.il  to  the  influence  of  toxins  circulating  in  the  blood.  "Blows  on  the 
"l"l;"iien  and  falls  have  been  followed  by  this  condition.  Some  cases 
iii;n  m .  liave  followed  upon  anesthesia.  Some  few  have  come  on  apparentlv 
«itlicMit  cause,  and  have  been  attributed  to  ner%ous  influences.  A  no't 
'"'"H.i.lerahle  number  follow  surgical  operations  on  the  abdominal 
M.'rr„   no  doubt,  as  experimental  work  has  shown,  the  result  of  pro- 

ri    ''?"'i'L?K  a"d  the  exposure  of  the  intestinal  coils  to  the  air. 

Chrome  Dilatatlon.-rhronic  dilatation  begins  insidiouslv  and  mav 
t^iK.  months  to  develop.  Perhaps  the  most  common  cause  is  partial 
"i.M  nution  of  the  lumen  of  the  intestine.  The  intestinal  wall  is  lisuallv 
11} I"  nn.phiefl  as  well  as  the  cavitv  dilated. 

Acquired  DiverticuU.-Acquiied  diverticula  of  the  intestine  are  not 
'"'l'  '""i">n.  1  hey  differ  from  the  true  diverticula,  of  which  the  Meckel's 
'y;'  ryi^e.  m  that  they  are  often  multiple,  situated  between  the  lavers 
".  .  :  mesentery  .,r  near  to  the  mesenteric  attachment,  and  are  usu'allv 
'.  i".se,l  of  one  or  two  coats  of  the  bowel,  the  muscular  laver  being 
wanting  In  many  ca.ses  the  condition  is  reallv  a  hernia  of  the 
-a  into  the  serosa,  or,  again,  the  serasa  mav  be"  the  onlv  constit- 


III! 


424 


THE  INTESTINES 


ami 


uent.  Must  cases  are  as.s(K-iate<l  with  chrunie  pulmonary  uffeitioiis  in 
old  people.  The  strain  of  coughing  is  apparently  the  exciting  luiisc, 
the  bowel  wall  giving  way  at  its  weakest  point,  namely,  when-  the 
mesenteric  veins  leave  it  at  the  mesenteric  attachment.  After  miiitllc 
life  there  seems  to  be  a  physiological  tendency  to  weakening  at  tlicse 
points.  Other  cases  are  associated  with  ulceration  of  the  mucosti. 
Hansemann*  has  recorde<l  one  in  which  there  were  about  400  diver- 
ticula, varying  in  size  from  that  of  a  hemp-seed  to  that  of  a  pigeon's  vfi^r. 

Stenosis. — Stenosis  of  the  lumen  may  be  brought  about  by  cicatrizing' 
processes  in  the  wall  of  the  intestine,  as  in  tuberculosis,  syphilis,  dysen- 
tery, or  uremic  ulceration;  new-growths;  compression  of  or  traction  of 
the  bowel  from  without,  as  from  tumors,  healing  peritonitis,  or  a  cnii 
of  intestine  loaded  with  feces.  These  are  common  causes  of  chronii' 
obstruction. 

VoItoIiu. — Volvulus  occurs  generally  between  the  ages  of  tliirty 
and  forty  years.  In  this  condition  the  bowel  is  more  or  less  com- 
pletely obstructed  owing  to  a  twist  and  kink  about  its  long  axis.  In 
other  cases,  a  loop  of  intestine  is  twisted  upon  itself  much  as  in  the 
case  of  a  handkerchief  used  as  a  tourniquet,  or,  again,  one  coil  of  lK)wel 
may  be  twisted  about  another.  Half  the  cases  occur  in  the  sigmoid 
fle.xure.  The  next  most  common  site  is  in  the  small  intestine.  >IcFiir- 
land  notes  having  met  with  one  case  involving  a  Meckel's  diverticulum. 
Volvulus  occurs  in  the  movable  portion  of  the  intestines,  and  is  thou};lit 
to  be  brought  about  by  excessive  peristalsis  caused  by  unequal  filliiif; 
of  the  coils  of  the  intestines  or  by  contusions.  An  abnormally  loiij; 
me-sentery  would  no  doubt  predispose. 

Intarrasception  or  Invagination. — Intussusception  or  invagination  is 
the  condition  in  which  one  portion  of  the  bowel  slips  into  another,  inueh 
as  one  might  invert  the  finger  of  a  glove.  It  is  comparatively  fre(|nent 
and  is  usually  met  with  in  the  young,  34  per  cent,  of  cases  ocenrrinj; 
in  children  under  the  age  of  one  year.  Irregular  peristalsis  and  niusciiiar 
spasm  are  l)elieved  to  l)e  the  direct  causes.  Active  purgation,  (liarili(r:i, 
intestinal  irritation,  intestinal  ulcers,  and  polypi  are  believed  to  |)re- 
dis|M)se.  Intussusception  may  l)e  acute  or  chronic,  single  or  iniiliiple. 
Multiple  intussusceptions  of  the  lx)wels  are  quite  common  at  iiuto|)>i(-^, 
and  are  probably  an  agonal  manifestation.  "^I'hey  are  readily  (listinlrMi^ll- 
able  from  pathological  intussusception  from  the  fact  that  they  are  remlily 
reduced  and  there  is  no  sign  of  St  ere  constriction  of  the  Ikiwc!  or  of 
inflammation.  They  are  frequently  ascending,  while  the  true  intii-siis- 
(•:'ptions  are  almost  invariably  descending,  that  is  to  .say,  the  upper  jionioii 
of  the  bowel  is  invaginated  into  the  lower.  Various  grades  of  inviiiiin;!- 
tion  occur,  and  if  unrelievetl  the  condition  tends  to  become  iii;i:rM\;iicil. 

The  following  varieties  are  recognized:  The  ileocecal,  in  which  ;i  I'.irt 
of  the  ilemn  and  the  ileocecal  valve  enters  the  colon;  the  iln-mlic, 
in  which  a  jwrtion  of  the  ileum  passes  thniugh  the  valve;  the  /'■  ',  in 
which  the  ileum  is  alone  involveil;  the  colic,  involving  the  colon  .i  ne; 


Virch.  Archiv,  144: 1896:400.     See  also  Fischer,  Jour.  Exp.  Met!.,  ■ 


:  I'H.i  .:;:a 


ACQUIRED  ANOMALIES  OF  POSITION  425 

iiiMl  the  cdicorectal,  involving  the  rolon  and  rectum.    The  portion  of  the 
intestine  involved  forms  a  .saus..^'e-like  tumor    vith  a  curved  outline. 
( )n  further  examination  of  the  mass  three  layers  of  bowel  are  recogniz- 
able, an  outermost  or  receiving  layei^the  intusmtcipieiu;  an  inner- 
most or  entering  layer,  and  a  middle  or  returning  layer,  both  together 
constituting  the  initunucep(um.    At  the  point  where  the  intussusceptum 
enters  the  intussuscipiens  there  is  generally  a  constriction,  termed  the 
neck.    The  part  of  the  intussusceptum  farthest  away  from  the  neck 
<  called  the  apex.    Intussusception  may  also  be  double,  the  originallv 
iiivaginated  portion  being  carried  bodily  into  the  intestine  below.    As 
the  condition  progresses  the  inner  and  the  middle  layers  increase  at  the 
expense  of  the  outer.     As  a  result  of  the  constriction  the  circulation  is 
interfered  with  and  often  entirely  arrested.     In  the  early  stages  there 
IS  slight  reddening  of  the  affected  parts,  with  possibly  the  exuilation  of 
a  little  plastic  lymph.     Later,  the  parts  are  greaUy  swollen  and  con- 
jrested,  and  the  various  layers  are  glued  together  with  inflammatory 
exudate.    Finally,  necrosis  and  gangrene  result,  and  the  patient  often 
(lies  fron-  obstruction,  peritonitis,  or  shock.     If  operative  measures  be 
iindertr  ken,  the  invagination  can  usually  be  reiluced  in  the  large  majoritv 
of  rase.-,  [94  per  cent.)  during  the  first  twenty-four  hours,  but  the  longer 
operation  is  delayed  the  more  difficult  does  this  procedure  become. 
B.v  the  fourth  day  only  about  one-third  can  be  relieved.    The  amount 
of  intestine  invaginated  is  often  of  great  extent.    The  ileum  has  been 
known  to  pass  through  the  ileocecal  valve  and  appear  at  the  anus. 
.\ii  uncommon  event  is  separation  of  the  necrotic  portion  and  spon- 
taneous healing.    One  instance  is  on  record  (Hermes)  in  which  60  cm. 
of  tlie  1k)u  el  came  away  and  the  patient  recovered.     In  the  Pathological 
.Museum  of  McGill  University  are  seventeen  inches  of  small  intestine 
Ijassed  per  anum  by  a  boy  who  had  all  the  svmptoms  of  strangulation  of 
tilt;  l)o«el  and  recovered.     In  such  cases  iiiflammatorv  Ivmph  fonns  a 
iiiiioM  at  the  point  of  constriction,  which  subsequentiv  becomes  organiml. 


ACQUIRED   AKOMALIES   OF   POSITION. 

Tlu-  term  hemk  or  ruptnra  is  applied  generally  to  denote  the  dislo- 
<ati.m  ..»  one  or  more  viscera  with  partial  or  complete  passage  through 
tlH'  limiting  body  wall.  In  a  more  restricted  sense  it  is  applied  to  the 
imcstmes  and  associated  stnictures. 

Hernias  of  the  intestines  may  be  external  or  internal.  In  the  former 
I  i>  u.iestines  enter  the  inguinal  or  femoral  canals,  the  umbilicus,  the 
■""'"minal  wall,  or  the  obturator  foramen,  and  eventually  present 
•\"  nially  l)eneath  the  skin  and  subcutaneous  tissues.  In  the  latter 
^^llI<  hare  rarer  the  intestine  passes  through  openings  in  the  omentum,' 
111.  M„t,rv,  the  foramen  of  Winslow,  or  into  pockets  of  the  peritopeal 

'l'!><-  cliief  cau.ses  operating  to  bring  about  hernia  are  weakness  of  the 
1"  HMiual  sac  at  some  particular  point,  either  acquired  or  congenital. 


m 


I 


426 


THE  INTESTINES 


as  in  patency  of  certain  canals  that  are  usually  closed;  and  internul 
pressure,  brought  about  by  strain  or  the  weight  of  the  contained  visccm. 
In  some  few  cases  a  tumor  or  local  adhesion  may  exercise  traction  ujioii 
the  peritoneum  and  lead  to  the  production  of  a  sac. 

The  structures  entering  into  the  hernia  are  various.  As  a  rule,  tliev 
are  the  small  intestine,  mesentery,  and  omentum;  less  often,  the  ceciiiii, 
large  int»>stine,  or  other  vbcera,  such  as  the  stomach,  spleen,  liver,  ovarv, 
uterus,  and  urinary  bladder.  As  the  intestine  or  other  organ  pn)lu|)s(  s 
or  descends,  it  carries  before  it  a  prolongation  of  the  peritoneal  membrane. 
This  covering  is  absent  only  in  cases  in  which  the  membrane  is  turn,  or 
when  portions  of  the  intestine  tluit,  like  the  cecum,  are  extraperitont'ullv 
situated  are  prolapsed  through  an  opening  in  the  fascia  and  muscles  uf  the 
abdomen.  In  the  early  stages  the  sac  is  represented  merely  by  a  shallow 
concavity,  but  later,  owing  to  pressure,  is  converted  into  a  globular  or 
pear-shaped  receptacle  communicating  with  the  abdominal  cavity  liy 
a  narrow  neck.  Occasionally,  only  a  small  portion  of  the  intestinal  wail 
is  caught  in  the  sac,  the  main  portion  of  the  loop  being  free  {Lltln'n 
hernia).  In  such  cases  there  maybe  the  same  evidences  of  obstruction 
as  in  the  onlinary  type. 

Eztemal  Hernias. — Inguinal  hernia  is  the  most  common  form  of 
hernia,  and  is  more  fre<iuent  in  men  than  in  women.  The  etiological  fac- 
tors are,  congenital  weakness  or  patency  of  the  inguinal  canal,  ordcsccni 
of  the  intestines  or  other  viscera  with  the  peritoneal  membrane  tliron};li 
the  canal.  If  the  organs  in  question  pass  through  the  internal  rin<;  and 
enter  the  canal,  but  without  escaping  from  the  external  ring,  the  condition 
is  termed  an  incomplete  inguinal  bemia.  If  it  passes  outside  of  the  external 
ring  it  is  called  a  complete  inguinal  hernia.  If  the  descending  or<;aiis 
enter  the  scrotum  it  is  a  scrotal  or  inguinoscrotal  hernia.  In  women  die 
hernial  protrusion  may  twcur  into  the  labium  majus,  forming  an  in- 
goinolabial  heinia. 

Several  subvarieties  are  recognized.  Thus,  if  the  organs  present  at 
the  external  abdominal  ring  without  having  traversed  the  canal,  it  is 
called  a  direct  inguinal  bemia.  If  they  pass  in  the  ordinary-  way  thmn;:!) 
the  cunal,  the  hernia  is  termed  an  indirect  or  oblique  inguinal  hernia. 
Hernias  are  further  divided  into  eztemal  and  internal  inguinal  hernias, 
according  iis  the  prolapsed  organs  pass  to  the  outer  or  inner  .side  of  ilie 
deep  epigastric  artery. 

Femoral  hernia  is  also  comparatively  frequent,  and  is  more  connnon  in 
women  than  in  men.  In  this  form  the  intestines  are  prolapsed  alonu  ilie 
course  of  the  feniond  ve.s.sels  and  make  their  appearance  on  the  inner 
side  of  the  thigh  just  below  PoiipHrt's  ligament. 

Obturator  bemia  is  not  common.  It  occurs  at  the  obturator  fo?;i!i;(n, 
along  the  course  of  the  obturator  artery  an<l  nerve. 

Umbilical  bemia  may  be  congenital,  but  |>erhaps  is  more  fre(|ni  '  in 
women  who  have  borne  children.  Prolapse  takes  place  thron-i^  ihe 
umbilical  ring  or  into  the  cord.  The  hernia  is  often  large  and  imi  iliy 
contains  intestine  with  omentum.  Rarelv,  the  liver  mav  Ix-  extnn!  '  .is 
well. 


i STERNAL  IIERNI.iA 


427 


Fro.  104 


Abdominal  hania  is  a  term  applic  d  to  prolapse  of  the  viscera  through 
the  abdominal  wall  in  regions  other  than  at  the  usual  foramina.  The 
hernia  often  takes  place  between 
the  recti  muscles  in  an  abdomen 
rendered  lax  by  childbearing,  or  into 
the  scar  of  an  operation  wound. 

Ischiadic  hernia  occurs  at  the  great 
.saerosciatic  foramen. 

Perineal  hernia  is  rare.  It  takes 
plu(i>  between  the  bundles  of  the 
levator  ani  mUvScle. 

Lumbar  hernia  consists  in  a  pro- 
trusion of  the  intestine  into  the 
spiice  bounded  by  the  crest  of  the 
ilinni,  the  external  oblique,  and  the 
latissinnis  dorsi  muscles. 

Vaginal  hernia  is  very  rare,  and 
consists  in  a  descent  of  the  bowel 
Intween  the  rectum  and  uterus. 

Internal  Hernias.— The  most  fr«- 
(pient  form  is  said  to  be  that  in 
which  the  intestine  passes  through 
a  iiole  in  the  mesentery.  Hernias 
inav  also  occur  through  the  foramen 
t>f  Winslow,  through  opening;-  in  the 
onicniuni,  into  the  fossa  c^odeno- 
jejiuiahs,  the  .subcecal  fossa,  and 
the  fossa  intersigmoidea.  Diaphrag- 
m»tic  hernia  may  wcur  as  a  result  of 
c(>n);iiiital  defects  in  the  diaphragm 
or  as  a   result  of  traumatism  (see 

p.  m). 

According  to  the  structures  enter- 
m'A  Hito  the  hernia,  various  types  are  recognized.  An  enterocele  contains 
sonic  |)art  of  the  intestine;  an  epiplocele,  a  portion  of  the  omentum-  a 
cystocele.  a  portion  of  the  bladder;  a  cecocele,  a  part  of  the  cecum; 
a  rectocele,  a  portion  of  the  rectum;  a  hysterocele,  the  uterus. 

Hernias  probably  never  are  cureti  spontaneously.  When  the  pro- 
lapMil  organs  can  Ije  replacetl  in  their  normal  relations  the  hernia  is 
spoken  of  as  redocible;  when  the  hernial  contents  cannot  be  returned 
the  henna  is  irreducible.  Hernias  may  be  temporarily  irreducible, 
ottiMiT  to  the  presence  of  gas,  fluid,  or  feces,  or  permanently  irreducible 
troM,  ilic  formaticm  of  inflammatory  adhesions.  If  a  hernia  has  lasted 
an^  I.  ii,'th  of  time  secondary  changes  set  in,  chiefly  of  a  mechanical  or 
innaiiiuiatory  nature.  The  hernial  sac  liecomes  thickened  and  its  con- 
smiHMt  .enients  fuse  together  so  that  it  may  no  longer  be  possible  to 
<ijstit,„„sl,  the  original  layers.  The  inner  surfac-e  is  smooth  and  pearly, 
la \ erseil  by  elevated  ridges.     The  coils  of  intestine  and  omentum 


Hernia  through  the  umbilical  region  of  the 
liver,  apiieodix,  and  part  of  the  colon;  child 
aged  eight  .aonths.    (Dr.  A.  E.  Vipond'i  cue.) 


of! 


fl!  II 


428 


THE  ISTESTINES 


in  acute  coiu'itioiis  may  Ite  adherent  to  each  other  or  to  the  wall  df  tin-  sac 
with  fibrinous  lymph  or,  in  old  cases,  by  firm  fibrous  bfii.ds.  The 
mesentery  is  often  shortened  and  deformed  from  old  inilammiuor)' 
thickening.  Acute  infection  with  inflammatory  exudation  may  occur 
in  an  incarcerated  or  strangulated  hernia,  or  in  any  long-stunding 
case.  The  mobility  of  the  intestines  gradually  becomes  so  much  im- 
paired that  the  intestinal  contents  cannot  be  passed  on  and  seven* 
derangement  of  the  circulation  sets  in  (incarceration).  Pressure  may  lie 
exerted  through  the  elasticity  of  the  tissues  forming  the  neck  of  the  sac 
or  from  the  weight  of  feces  within  the  coils.  If  the  pressure  be  .so  great 
as  to  hinder  the  venous  return,  the  intestine  becomes  greatly  congested. 
The  coils  assume  a  purplish-red  color,  and  are  swollen  and  cedemutous, 
though  they  may  for  a  time  preserve  their  lustre.  If  the  condition  lie 
not  relieved  the  hernial  contents  become  greatly  inflamed  and  finallv 
gangrenous.  The  bowel  then  presents  an  intense  blackish  or  bluish-reil 
appearance,  with  possibly  suppurative  foci  here  and  there  which  lead 
to  perforation.  At  the  point  of  constriction,  which  is  usually  the  neck, 
the  tissues  are  of  a  pale  grayish-white  color  {ttrangulation). 

Intcatinal  Obstruction. — Intestinal  obstruction  results  from  any 
condition  which  impedes  or  prevents  the  passage  of  the  bowel  contents'. 
The  chief  etiological  factors  are  hernia,  strangulation,  intussusc-eption, 
volvulus,  paralysis  of  the  liowels,  stenosis  and  atresia,  tumors,  and  ab- 
normal contents.  Hernia  and  strangulation  are  the  most  frequent 
causes.  In  an  analysis  of  1000  operative  cases,  Gibson'  found  35  per 
cent,  were  due  to  hernia,  19  per  cent,  to  constrictinp  bands,  19  per  cent. 
to  intussusception,  and  12  per  cent,  to  volvulus.  In  Leichteti-stern's 
series  of  1 134  cases,  35  per  cent,  were  due  to  strangulation.  The  fil)rous 
adhesions  resulting  from  peritonitis  may  cut  off  pockets  from  the  general 
alxlominal  cavity  or  form  bands  and  !■  -  through  which  coils  of  the 
intestine  may  become  prolapsed.  Slits  in  the  mesentery  or  great  omen- 
tum, and  an  attached  ^leckel's  diverticulum,  sometimes  act  in  tlit-  same 
way.  Owing  to  peristaltic  action  or  to  distension,  the  prolap.sed  Imwel 
may  become  kinked  at  some  point  and  obstruction  ensue.  The  intestine 
may  also  lie  obstructed  by  the  pressure  of  tumors,  cysts,  wandtring 
organs,  or  the  traction  of  cicatricial  bands.  Polypi,  cysts,  tuniDis,  and 
healing  ulcers  may  obstruct  the  bowel  from  within. 

The  lumen  of  the  bowel  may  be  occluded  by  the  accumulation  of  feces 
which  have  become  inspissated.  Large  gallstones  have  l)een  known 
to  enter  the  bowel  and  fill  up  the  lumen.  Intestinal  worms  seldom 
cause  trouble  but  tangled  clusters  of  ascarides  have  sometimes  In!  to 
obstruction.  Foreign  bodies  occasionally  are  introducetl  tliniiiirli  the 
rectum,  but  usually  enter  through  the  mouth,  either  by  acdiieni  or 
design.  A  great  variety  of  substances  have  been  found,  fruit  stoti'  s  and 
seeds,  hair,  false  teeth,  needles,  pins,  hairpins,  and  tacks 

Below  the  point  of  obstruction  the  Itowel  is  empty  or  iieailv  >  •  -  hile 
alx)ve  it  is  distended  enormously  by  gas  and  fecal  accumuhiiioi!.    At 

'Annals  or  Surgery,32:1900:4)36  and  676. 


HEMORRHAOE 


4a» 


the  otfluded  part  the  mucosa  is  often  eroded  and  the  bowel  wall  anemic 
as  a  result  of  pressure,  while  the  proximal  portion  of  the  intestine  is  con- 
gested, inflamefJ,  eroded,  or  necrotic.  Not  infrequently  a  considerable 
amount  of  transudate  is  found  free  in  the  abdominal  cavity.  In  chronic 
cases  the  intestinal  wall  is  considerably  thickened  as  well  as  dilated, 
owing  partly  to  functional  hypertrophy  anu  partly  to  inflammatory 
infiltration.  In  obstruction  of  the  bowel,  the  virulence  of  the  contained 
mirrobes  is  greatly  increa-sed,  while  at  tHe  same  time  the  resisting  power 
of  the  tissues  is  low,  so  that  not  uncommonly  peritonitis  results,  even  in 
the  alwence  of  any  solution  of  continuity  of  the  bowel  wall. 


OnOXTLATOST  DISTUUAirOU. 

HyperemU.— Acllw  Hypewml*.— Active  hyperemia  occurs  physio- 
logically during  digestion,  and,  pathologically,  as  a  result  of  irritation, 
infection,  or  dilatation  of  the  vessels  under  the  influence  of  ner\'ous 
stiin-ili.  The  intestines  are  also  congeste<l  in  cases  of  peritonitis.  The 
mucosa  l.ecomss  markedly  reddened,  but  the  conilition  quickly  passes  off 
after  death,  so  that  the  appearances  at  autopsy  may  not  be  very  striking. 

Pwrive  H7F<wainia.— Passive  hyperemia  arises  in  the  course  of  obstruc- 
tion in  the  general  systemic  circulation,  as  well  as  from  hepatic  cirrhosis 
or  similar  interference  with  the  portal  circulation.  Ixical  passive  con- 
ftestioii  is  eIso  met  with  as  a  result  of  the  compression  of  the  mesenteric 
veins  111  the  conditions  of  hernia  and  strangulation.  The  affected  bowel 
in  these  cases  is  swollen,  oedematous,  purplish-red,  or  blue  in  color, 
and  the  serasa  is  possibly  slightly  roughened.  In  chronic  congestion 
the  mucosa  may  be  somewhat  pigmented. 

Varices.— Varices  occur  occasionally.  The  commonest  site  is  the 
r«tum  the  condition  being  induced  by  stasis  in  the  inferior  hemorrhoidal 
vein.  I  he  varices  are  to  be  found  within  the  rectum  or  externally  around 
the  .ii.us,  ,n  the  form  of  small,  globular  or  polvp..id  .swellings  of  a  dull, 
bluish  color  (hemorrhoids).  The  chief  causes  are  sedentary  habits, 
chrome  constipation,  the  pressure  of  tumors  in  the  pelvis  or  of  the  preg- 
nant uterus,  and  obstruction  within  the  portal  circulation.  The  hemor- 
rioi.ls  often  become  inflamed  and  ulcerated,  and  may  lead  to  hemorrhage. 
KepcMtcd  loss  of  blood  in  this  way  sometimes  gives  ri.se  to  severe  anemia, 
thfMause  of  which  may  sometimes  be  overlooked. 

(Edema.— (Edema  results  from  active  or  passive  hyperemia,  acute 
an.l  .hronic  inflammations,  peritonitis,  or  is  a  manifestation  of  general 
anasiina.  The  walls  of  the  intestine  are  firm  and  thickened,  giving  a 
sensa.mu  to  the  fingers  resembling  that  of  wash-leather.  The  muscle 
IS  pal.-  and  gelatinous,  and  the  mucosa  is  anemic  and  swollen,  with  a 
Mu.  watery  appearance.    The  natural  folds  are  accentuated. 

Hemorrhage.— Hemorrhage  into  the  mucosa  is  a  not  uncommon 
«eM(  ^H  .ases  of  active  and  passive  congestion,  in  embolism  or  thromlxjsis 
01  III.'  mesenteric  vessels,  in  pernicious  anemia,  hemophilia,  and  the 
nem.  I. liaj,Mc diatheses. 


430 


THE  INTESTISES 


Hemorrhafte  into  the  lumen  results  from  inflammation,  ulreniliori, 
necrosis,  and  new-growths.  Dysentery,  typhoid  fever,  peptic  iihtT, 
ulcerating  carcinomas,  hemorrhoids,  are  the  most  important  causes. 
>Vhen  the  bloml  is  effuse<i  high  up  it  l)ecomes  black  and  tarr\'  as  a 
result  of  the  action  of  the  digi^stive  /  ices  and  the  sulphuretted  hvilro- 
gen  in  the  feces;  when  escaping  lower  down  it  is  usually  red.  .Severe 
bleeding  into  the  lumen  of  the  intestine  may  occur,  and  may  even  prove 
fatal  without  the  bloo«l  escaping  externally.  This  a  termed  occult  or 
concealed  hemorrhage. 

KmboUim  and  Thromboiis. — Embolism  and  thrombosis  of  the  mesen- 
teric  arteries  or  veins  lead  to  hemorrhagic  infarction  of  the  whole  area 
of  tl.e  bowel  supplied  by  the  obstructe<l  vessels.  Hemorrhage,  <»ften 
extensive,  takes  place  into  the  intestinal  wall,  which  undergoes  necrosis 
and  even  gangrene.  Peritonitis  often  supervenes,  owing  to  infection 
from  the  intestinal  contents.  The  symptoms  are  mainly  those  of  intes- 
tinal obstniction.  Melena  may  occur.  Some  of  the  orrlinar>'  eaiiMs 
of  embolism  are  present,  eiidcK-anlitis  or  arteriosclerasis.  Thr()iMlM)sis 
is  usually  the  result  of  un  infective  thniinlmphlebitis  of  the  mesenteric 
veins. 

Several  observers  recently,  notably  Ortner.  have  drawn  attention  to 
the  clinical  ini|M)rtance  of  mesenteric  arteriosclerosis.  The  <'on«lition 
gives  rise  to  colic  with  alternating  attacks  of  diarrhoea  and  consti|)ii(ion. 


nrrLAMMATIONS. 

The  inflammatory-  disturlwnces  of  the  intestines  un-,  on  the  wliole, 
strikingly  like  those  of  the  stomach,  iK)th  etioh)gically  and  anatoniiciillv. 
.\ny  differences  are  to  \ie  explain<>d  by  variations  in  function  and  ni((  luiii- 
ical  conditions.  Most  cases  of  inflammation  of  the  intestines  arc  diii-  to 
the  irritative  action  of  the  intestinal  contents,  which  may  !>e  nnsiiiliiliie, 
may  have  umlergone  abnormal  fermentation,  or,  agair  lav  inntain 
toxic  substances  of  an  animal,  vegtiable,  or  mineral  n.'itnr  -Nmic .  iises, 
also,  are  due  to  infections  or  toxic  agents  carrie<l  to  thr  .estinc  liv  the 
blcxxl-stream  or  body  juices.  These  prolxibly  act  b.  depressiu;:  the 
vitality  of  the  specific  tissue  cells,  by  modifying  secretion,  and  by  ini  rcas- 
ing  the  virulence  of  microorganisms  containecl  in  the  feces,  win'i  h,  iiiiilcr 
ordinary  circumstanct>s  are  devoid  of  pathogenic  properties. 

The  portions  of  the  intestinal  tract  most  apt  to  suffer  from  inllain- 
niatory  disturbances  arc  the  duodenum,  owing  to  its  close  as^o.  i  .tjon 
with  the  stomach,  and  the  large  bowel,  where  feces  and  other  iiiii  ling 
substances  are  liable  to  accumidate. 

Enteritis. — Inflammation  of  the  small  intestine  is  termed  enteriti«; 
of  the  large  slitis;  of  lH)th,  enterocolitii.  If  the  stomach  I)e  involved 
as  well,  wc  s,,.'iik  of  gastro-enteritia.  Any  portion  of  the  Ikjw.  i  ..y  Iw 
inflamed,  but  it  is  rare  for  it  to  lie  affected  throughout  its  wiii>lr  .tent. 
Therefore,  we  speak  of  duodenitis,  jejnnitis,  ileitis,  typhlitis,  m  cecitu, 
eolitis,  appendicitis,  sigmoiditis,  and  proctitis. 


FOLLICULAR  ENTBRITIS  431 

Atnto  eumhkl  tolwltte.— Acute  catarrhal  enteritw  is  due  to  indiwre- 
iioris  in  .liet.  i.npn.per  fo«l.  or  foo.1  containing  bacteria  of  certain  kinda 
or  Imctenal  toxins.  (  limatic  conditions  and  change  of  diet  also  seem 
I.,  have  a  considerable  effect  in  iiulucinR  the  disease.  Acute  catarrhal 
.iitentw  a.«l  gastroenteritis  is  especially  common  in  young  children,  in 
whom  It  IS  produced  by  overfeeding  and  the  use  o?  milk  laden  with 
iMicrodrganisms.  I  he  B.  dy.senteriw.  B.  enteritidis,  B.  coli,  B.  proteus 
»h.l  the  streptcKwcus  are  the  germs  usually  pment  in  these  cases! 
(  Htarrhal  enteritis  also  accompanies  or  complicates  certain  of  the  acute 
mfeitive  fevers,  such  as  typhoid  and  pneumonia.  The  Cholera  Vibrio 
produces  an  acute  .serous  enteritis. 

The  postmortem  appearances  in  acute  catarrhal  enteritis  are  not  con- 
stunt,  for  a  notable  amount  of  catarrh  may  exist  without  producing  anv 
«ross  lesions  that  are  recognizable  after  death.  In  some  ^ses  there  is  a 
imtchy  congestion  of  the  muccMa  in  the  neighborhood  of  the  h-mph-ves-scls 
mi  the  top  of  the  rugie.  and,  in  severe  cases,  of  the  sert>^.  Punctate 
hnnorrhuges  are  occasionally  to  Iw  seen.  The  mucxsa  is  often  swollen 
and  pmsents  a  dull,  cloudy,  grayish  appearance,  so  that  the  folds  art-  moi* 
11.  evulence  than  usual.  (Jenerally,  though  not  invariablv,  the  surface  is 
.•..vered  with  a  mucous  or  s,.r,)us  exudate  (sero,u  enteritis)  cntaining 
r,lu  ivelv  few  leukocytes.  In  other  ca.ses  the  white  .*|ls  are  more  abuii- 
;  ant  and  the  exudate  assumes  a  mucopurulent  or  purulent  character 
I  h.-  exudate  may  contain  also,  desquamated  epithelial  cells  in  varving 
stajres  of  degeneration.  This  may,  possiblv.  I,e  to  some  extent  due  to 
|Mtstinortem  maceration  of  the  tiii     "s. 

Microscopically,  there  can  be  -de  out  marked  hvperemiu  of  th.- 
•nii.nsa  and  submucosa.  with  some  cedema.  The  secreting  cells  of  the 
tiil.iilur  glands  show  evidences  of  increased  functional  activity  in  the 
|.r.  s,M,ce  of  great  numbers  of  goblet  cells.  Slight  erosions  of  the  mucosa 
MMv  ,KT„r  and  the  surface  is  covered  with  more  or  less  exudate.  In  the 
s.v..r.r  form.s  collections  of  leukocytes  are  to  \ye  seen  in  the  mucosa  aU.ut 
til.'  Kland-tubules  and  in  the  submucosa  around  the  blooflv^ssels  The 
••|>M.lition  of  simple  catarrh  may  pass  almast  imperceptibly  into  mtppura- 
""".  and  considerable  portions  of  the  muco.sa  may  slough  awav,  leaving 
sliarpiv  defined  ulcerB  with  infiltrated  walls.  The  submucosa  contains 
-  k.H-vtes  ,n  great  numbers.  Suppurative  enteritis  may  lead  to  a  <liffiise 
l>l<n„n,mou»  condition  or  to  the  formation  of  localized  abscesses  in  the 
sMlm,n,.„sa,  which  burst  into  the  lumen,  leaving  small  ulcere 

Desqaanative  lnteritto.-In  the  so-called  desquamative  enteritis  the 
>'u.  OS.  is  cast  off  en  mmse  in  the  form  of  a  tubular  cast.     This  occurrence 
.a^  Kcn  described  m  the  large  bowel  in  connection  with  the  summer 
in.irrtid'as  of  children. 

Poiacular  Bnteritii.-The  part  played    in   enteritis  by   the  solitair 

■III  iinninatetl  glands  is  a  varyingone.    In  many  instances  the«e  struct- 

|i.     M..,«  no  marked  changes,  but  in  others  they  are  so  greatly  affected 

"■'  ,T^\  T^  properly  be  termed  foUenlar  enteritia.'    In  this 

!    '  f  intestinal  inflammation,  the  follicles  are  swollen  and  pmject  above 

ii-rui  surface  of  the  mucosa,  where  they  are  recognizable  as  dots 


4S2 


THE  ISTS8TINES 


II 

ill 

■ii 


of  H  KntvMh  or  i;>  tyixh-white  vulor  on  a  motf  or  Icm  hyiMTrniic  l>ti<k- 
((ruiiriil.  When  the  Payer's  patches  are  affected,  owing  to  ilie  nri«-4|iiHl 
swelling;  of  thi  I  i uphold  and  connective-tissue  eleinenti,  the  siirfiMt 
liecomes  ssumevhai  reticulated  or  tr8ver»e<l  hy  shallow  grooves.  I'nl- 
licular  enteritis  i.^  not  infrequently  found  as  a  result  of  typhoidul  or 
tuberculous  inf«\ti<t;'   md  is  particularly  common  in  diphtheria. 

Histologically,  H< '  veiling  of  the  follicles  m  due  to  hypen-miii  iiml 
prolift-ration  of  i.c  1^ .'  jhoid  cells.  There  is,  in  ati<lilion,  a  prirdliiciiliir 
cellular  infiltn',!)  aiut  the  neighlxiring  lyniph-ve<<.<M>ls  are  hlle<l  \\\[h 
cells.  'ITie  fo'ld'-  iisi,  illy  pn'.sent  no  further  change,  hut  now  ami 
then  under ,<(  iit  'Lisi>  In  thi.s  way  small,  ro<m<led  altscc  ts  jirr 
fonne<l  whitli  lisdi  rg«  their  contents  and  give  rise  to  one  tonu  of 
ulcerative  entrais 

Mambnmooa  J^tc^wl>.  -Umler  the  term  niembranous  enteritis  m, 
classed  thos«  se  -  'tr  '■  nn >  *  i  ,;.;•'  ation  of  the  intestines  wlii<h  Itiul 
to  coagulati '' -II.  I'i'o.sis  w  \  ilLviaiion.  'ITiere  may  In  prrxliia-il  a 
"croupous"  ■'!•  Ii''.  inoiis  e>  in  tion  u|H»n  the  surface  of  the  mucuius  nu-in- 
brane,  which  i'  (ome;   I'  i->'*    as  it  were,  by  coagulative  dianges  into  ii 

more  or  le.ss  I nmogei ;     uia.s.s— membranous   inflammation,  or  ilit 

exu<!iite  may  W-  iKtth  im  :iii<i  within  the  .sulistance  of  the  niucosi 
diphtheroid  intiainmatioii.     It  is  impossible  always  to  sepunite  tlicv 
fonns  one  from  the  other,  sincf  they  are  onxlwefi  by  the  .same  (•allM•^, 
and  the  croupous  may  jmiss  impt-nrptibly  into  the  iliphtheroid. 

Membranous  enteritis  is  usiiiiliy  met  with  in  the  large  inlt'stinc 
(membranous  coHlin),  but  oc-i-asionally  also  in  the  ileiun.  It  pnibiililv 
liegins  as  an  ordinary  catarrh  with  ctmgestion  and  swelling'  nf  tin- 
mucosu,  which  rapidly  progn-sses  into  a  more  severe  inHammation.  'i'lic 
muco.sa  beconics  deeply  re«idened  and  a  brawny  ,"ort  of  film  of  a  '.vliii.  Ii- 
gray  color  appears  upon  the  surface,  especially  ujKin  the  top  of  tlif  ru^'.-f. 
At  first  this  membrane  can  Ik*  scrajKHl  off  wilii  flu-  knife,  l)Ut  later  tliis 
liecomes  impossible,  owing  to  the  fact  that  the  niiicosa  undcrjiiH's  a 
form  of  coagulation  necn)sis  and  the  exudate  and  mucous  nicnilinin)' 
liecome  welde<l  into  an  indistinguishable  mass.  As  the  diMNisc  |iii>- 
gresses,  the  n-dness  and  .swelling  increa.se,  the  patches  of  nu-nilii;iiic 
tend  to  coalesce,  and  the  coagulated  substance  assnniesa  dirty,  Vfll(n\i>li- 
green,  or  brown  color  through  contact  with  the  fe<es. 

In  course  of  time  jKirtions  of  the  membrane  and  necrotic  niucc- 
be  exfoliated,  giving  ri.se  to  ulcers  which  may  coalesce  and  n'aeii  .1 
.siderable  size.    They  may  extend  superficially,  or,  again,  |)<t 
deeply.     The  denuded  tissues  in  such  ca.ses  may  become  inft  i 
.septic  microorgani.sms  anrl  a  Kn-al  suppurative  <'oiHlition  or  a  lii'' 
phlegmon  may  \te  the  result.     If  the  condition  heal,  the  ulcers  1  .  . 
the  muco.sa  is  in  large  part  regeneratetl,  and  more  or  less  fibrous  tlii' 
ing  of  the  intestine  remains. 

Special  Fonns  of  Eateiitis.  Dyse&tery.  Under  the  tt  nn  >! .  < 
are  included  a  numlter  of  intestinal  inflammations,  which,  wliil' 
var\-  considerably,  have  this  in  common,  that  they  are  charaii 
clinically  by  .seven-  and  {)ersistent  diarrhfea  with  tenesnnis,     !' 


UIV 

oil 

,i(C 


EPIDEMIC  DYSENTKUY  tiVE  in  SIIIUA'S  BACILLUS         433 

loKiciilly  .^UMiking,  ihp*   uir  all  f.»mw  of  colitis.     Dysentrrv  tMiurs 
.  |)i»l  Hiifttlly.  fiMletnicnlly,  and  np«rucli«ullv.  nwrr  . ..|»«iallv  ir!  tn)i)ic-ul 
iir.-l  siihtnipHMl  iiim«t,  iMit  nlMt  wx-HHumutiv  in   teinw-roee  n-umm 
IV  .liseas*.  rimy  »•«•  acutf  or  ihronir.     'IV  diffi.iiifif«,  jn  the  whv  «)f 
miikiiiK  an  ail(>({uat(>  cla.'Mitiiiition  of  tlu-  Umns  of  .Iv-wnterv  aif  KreaJ 
ottiiiK  to  the  fa«t  that  the  etioh>Kical  faotom  are  liot  entiWlv  iimleN 
M.«»l,  nor  has  it  Ijeen  a.s  yet  powtible  to  (Wtisfactorilv  f-orrelate  olir  know- 
Inl^.-,.  of  the  tuhjert.     While  it  is  «rrtaiii  that  '  .e'niajorilv,  if  not  all 
ill.-  dysenteries  are  to  lie  attributeiJ  to  the  attivitv  of  rni('r»)dri{aniM.i,' 
It  IS  e(|ually  certain  that  a  variety  of  differing  inf«ti«)iM  pnH-.-sses  have 
Ih-.ii  xn)ii|K'd  under  the  one  hea«l.     It  is  prol.al>le  also  that  the  dvsen- 
1.T1.-.S  (x-t-urrinj?  in   different  countries  are  cbjiracterizetl   bv  siH-«ific 
ilifr»'rpii("e.s.  '      ' 

The  niiiltitudinous  investijfatioiw  which  have  IwH-n  made  into  the 
-il.je<-t  of  dysentery  .lurinK  »he  ,ia.st  few  vears  seem  to  have  determined 
iLiit  then-  are  three  main  tyf«-,s:  1)  A  form  dti^  to  irritatic.n  fn.m 
misiiit)il.le  f.KKl.  prefommJ  poisons,  t»nd  similar  causes;  (2)  a  form  due 
to  l.art,rial  activity;  an<l  (.•})  11  fonw  due  to  animal  |)aru>ites  of  the 
pn.tn/ooii  onkr.  We  know  little  as  vet  in  rejfani  f<>  the  irritafiv.  or 
<liniiicul  dvM-ntery,  and  it  secii.^  to  hi.  ■  little  f<.  .liffcrenliate  it  fi-  .11 
iithcr  forms  «)f  colitis. 

A.  iilc  dysentery  of  Ui.  Ilary  ori>cin  for  ll.c  most  |«  if  is  due  to  infection 

^iili  on.    of  i,vo  j^erms,  rlie  H.  dvscnteriH-  of  Slii>.^,   ami  the  l'seud.>- 

M-nt.Tv  Bii.illiis  of  Flexiier.     S.riie  few  cases  huv.    Ikh-ii  fomxl  to  !>.■ 

.-^.Mmtcl  wi.li  the  B.  py.K-yaneus  (('ulmette,'  UrfiL'au'),  an-1  with  u 

'inlliiiii  1 1   ■  |.,.ntc('). 

Epidemic   OyMuUij  Doe   to   Shigs'i   BwiUlM.-'rhis  disease  affw-ts 
'li.'  larp-  intestine  ami  the  lower  ,M,rlion  of  the  ileum,  thou^jh  in  some 
.as.-,  tlif-  IcMons  are  .-onfined  to  the  rectum,  si^uioid  He   nre,  and  '  .wcr 
i'-Tii,  „  of  the  <-ol„ii.     In  mild  cases  the  mm-ous  membrane  is  ini.    sejv 
<    1.;;    I'd  and  swollen  ami  the  riifrii-  are  unusiiallv  ;  rominent.     \m:.-r. 
■lis  Miiiill  hpm.,rrhaKes  may  1h-  notcl  in  the  mumsa  jin.l  t'  .■  .siirfa.e  of 
.1,.-  Im.wcI  ,s  .-ovcred  with  vis.-id.  l,/,KKl-sfained  mucus.      The   IvmpI, 
t"lli«l.-s  are  s« ,  .jlen  and  there  arc  often  sii,)erficial  erosions.      ( l„.  ,,r,>'r^ 
'Mil    .ventiially  assume  an  iih-erative  ..r  meml.ram.us  .  hai.ctc^       Tli. 
•  "!■  -Mnay  !*■  „f  a  gmyish  or  ."^-enish  ..,ior,  and  presents  l.r.,«  m>    -black 
s    .i;:l,>  or  eschars.     When  |    .-sent    r  .-  membrane  mav  U-     ,„ti„e.l  to 
"»■  "■!<-  of  the  nipe  or  may  afr.ct  larger  an-  ,  of  m   =..,a      In    he 
^»i;       vere  cases,  the  wall  of  the  intestine  is  .s«fr.  ned       .'  thic-kci.tMl 
«ini.     i„.  submumsa  is  densely  infiltrated  with  t.ns  ,•,  j'eritonitis 

•}  sii|H'rvene. 

ni''  s,H.,ific-  ca.  .e  is  tJM    H.  dy.sen.criie  of  .<?hif;    <       microorganism 
'"  ";:',!.' ';'!!;'>;/T"'''!'T  ''\^^  "^  '>'P''.«'''      '^  ,    present  in  a  large 


ill 


|.r. 


'11  of  ca-ses  of  epidemic  iiv.sentcry.  is 


■  ^-vfwrimental 


' ; '"""■'"•>^ '^"ip"'-  .lour. ,.   Kvj    r.  \ 

'   "iptps  n>n.ius,|,.  In  Soc  cle  biol.,  V.m-  IB 
■Mnm.  I.  Jlakt.,  Z.i:  mJlSm,  ibid.,  2t:  Ix-JHHIT  sT 


•<l., ;{ ;  I  sw<   -,'«. 


'tl:;. 


434 


THE  INTESTINES 


N 


U 

a 

:   1 

n 


ill 


animals,  and  is  agglutinated  by  the  serum  of  immunized  animals  or  those 
suffering  from  the  disease. 

■pidande  DyMiitoiy  Doe  to  riexner's  BmUIu  (Institutional  dysentery 
or  Pseudodysentery). — ^This  form  is  due  to  a  bacillus  first  isolated  hy 
Flexner'  from  cases  of  epidemic  dysentery  occurring  in  the  Philippine 
Islands  in  1900,  and  later  by  Kruse'  and  others  in  cases  occurring  in 
Germany.  In  America,  epidemic  dysentery  appears  to  be  more  often 
caused  by  Flexner's  bacillus  than  by  that  of  Shiga.  Flexner's  organism 
is  evidently  closely  allied  to  that  of  Shiga,  but  is  differentiated  from  it  by 
minor  cultural  peculiarities  and  by  the  fact  that  the  two  types  react 
differently  toward  immune  sera  prepared  from  the  two  strains. 

There  is  evidence,  too,  for  believing  that  there  are  a  number  of  micn)- 
organisms  differing  more  or  less  from  one  another  which  should  Ik* 
included  in  the  dysentery  group.  Park,  Collins,  and  Goodwin'  have 
drawn  attention  to  a  form  intermediate  between  the  Shiga  and  Fle.xner 
types.  Many  cases  of  summer  diarrhoea  in  children  have  been  shown 
to  be  due  to  Flexner's  organism.  Some  also  are  due  to  infection  witli 
the  B.  pyocyaneus.* 

Kndainlc  or  Amosbie  Dysenteiy. — Amoebic  dysentery  is  a  form  confined 
almost  exclusively  to  the  tropics,  due  to  the  Amoeba  coli  or  Anitrlm 
dysenterise  (Kartulis;  Losch;  Kruse  and  Pasquale;'  Councilman  and 
Lafleur^).  Small  epidemics  have  been  noted  in  New  York  and  Balti- 
more. The  lesions  are  found  usually  in  the  large  intestine,  partiodariy 
in  the  neighborhood  of  the  cecum  and  appendix,  and,  occasionally,  in 
the  lower  part  of  the  ileum.  In  the  earlier  stages  the  mucous  membrane 
is  Gedematous,  swollen,  and  hyperemic,  and  there  are  local  infiltrations 
that  manifest  themselves  as  hemispherical  elevations  above  the  general 
surface.  Later,  the  mucous  membrane  covering  these  becomes  necrotic 
and  sloughs  away,  leaving  an  ulcer  with  thickened  undermined  ed^es, 
the  base  of  which  is  formed  of  infiltrated  submucosa  of  a  grayish-viliow, 
gelatinous  apoeaiance.  It  is  this  infiltrated,  yellowish  mucosa  and  siili- 
mucosa  that  is  the  most  distinctive  gross  feature  of  this  form  .  f  colitis. 
The  amount  of  softening  in  the  submucosa  i-s  often  far  in  excess  of 
the  superficial  necrosis,  so  that  a  kind  of  abscess  communicatin;;  with 
the  lumen  of  the  bowel  by  a  small  sinus  is  produced.  In  sever'-  cu^es 
the  ulcers  may  coalesce,  forming  sinuous  tracks  bridged  by  strands  of 
comparatively  healthy  mucosa,  or  large  portions  of  the  mucosa  nmv 
disappear  leaving  only  small  islets  of  intact  membrane.  The  ulctniiion 
extends  more  or  less  deeply  and  may  eventually  reach  the  serous  mat. 
Perforation  of  the  bowel  is  rare.     As  a  rule,  in  the  advanced  cases  tin-  "all 

'  Centralbl.  f.  B:  kt.,  28: 1900;  and  Philadelphia  Medical  .lournal,  «:  liMio    111 

»  Deutsche  med.  Woch.,  26:  1!KK):  637:  ibid.,  27:  1901:  370. 

'  Jour.  Med.  ReRcarch.  ((i  N.S.):  1904:.W3. 

«  K.  Cameron,  Montrpal  Med.  Jour.,  24: 189.5-6:673. 

'  Virch.  Archiv,  66:  1875:  196. 

•  Zeitschr.  f.  Hyg.  u.  Infect.,  16:  1894: 1. 

'  Johns  Hopkins  Hosp.  Rep.,  2:  1891. 


CHOLERA  ASIATICA  435 

of  the  bowel  is  greatly  thickened.    Occasionally,  the  condition  may  be 
t-omplicated  by  a  membranous  inflammation. 

Histologically,  there  is  a  more  or  less  extensive  necrosis  of  the  cells 
bejjmmng  m  the  submucosa,  and  an  infiltration  of  the  deeper  lavere 
w.th  leukocytes  There  is  also  proliferation  of  the  connective  tissue. 
Ihe  walls  of  the  vessels  m  the  affected  area  are  infiltrated,  while  the 
vessels  themselves  are  filled  with  leukocytes  or  are  thrombosed  The 
aracebce  are  found  m  the  tissues  in  the  base  and  edges  of  the  ulcers 
but  rarely  m  parts  m  advance  of  the  active  lesions,  also  in  the  lymohatics' 
and  bloodvessels.  "^    *^ 

Plasma  celb  and  fibrin  may  be  abundant. 

The  stoob  in  amoebic  dysentery  are  frequent,  blood v,  and  mucoid, 
later  of  a  greenish-gray  color,  fluid,  and  containing  mucin.  Amoeba 
are  to  be  found  m  the  dejecta. 

Among  the  complications  are  focal  necroses  in  the  liver  and  liver 
al)scess.  Ihe  frequency  with  which  liver  abscess  occure  in  dysentery 
IS  somewhat  uncertain.  Manson,«  in  3680  cases  of  tropical  dysentery- 
fjuirul  l.ver abscess  m  21  percent.;  Hirsch.'  in  2377 autojsies  on  tropical 
dysentery  noted  the  condition  in  19.2  per  cent.  Probably  in  these 
statistics  dysenteries  of  bacterial  origin  are  included  with  the  amcebic 
fonn.  Dysenteric  abscesses  of  the  liver  may  rupture  into  the  pleural 
cavity  and  into  the  lung.  The  necrotic  substance  is  of  a  peculiar  anchovy 
saiice-like  appeara!,f»>  and  contains  the  am(pba> 

Cholera  Asiatica -Cholera  is  an  acute  infectious  disease  charac- 
teriz,Hl  bv  cramps,  diarrhwa,  vomiti  ,g,  fever,  an.l  collapse.  The  specific 
cause  IS  the  cholera  vibrio  or  comma  bacillus  discovered  by  Ko<  Ii  The 
lesi.,u,s  are  chiefly  confine<l  to  the  lower  portion  of  the  ileum.  In  genenl 
hey  are  those  characteristic  of  a  serous  enteritis.  In  the  early  stages 
tlu"  mucosa  of  the  small  intestine  is  more  or  less  congested  and  covered 
wnh  a  slight  amount  of  fibrin.  The  contents  of  the  bowel  are  tWn  a^ 
atery  cloudy,  alkaline,  and  of  a  grayish  color.  On  standing,  this 
material  deposits  a  quantity  of  small,  whitish  flakes  (rice-water  dis- 
eriiirjie),  m  which  the  specific  microorganism  may  be  detected.  The 
'"u<|ms  membrane  IS  usually  pale  and  anemic,  except  perhaps  in  the 

1  .   leNers  patches  and  the  solitary  follicles  are  swollen  and  rather 
pa  -.    I  ater,  they  shrink  somewhat  and  assume  a  reticulated  appear- 

n  1  il,..  ?v!fr  T^  ^-7".^  •**^'  **  ''yPeremia  becomes  less  maVked 
•  "i  lu"  «a  1  of  the  intestine  is  more  or  less  swollen.    The  bowel  niay 

l"-i'v' tS;     ^^*""^™"°"«  «"*«""«  "^^y  «"Pen-ene  a^  a  seconda.^ 
Hi  .ol..>:ieally,  one  sees  little  more  than  desquamation  of  the  super- 
'  l;;  .el.iim,  with  some  coagulation-necrosis  of  the  villi.    Leuko- 

'  Quoted  by  Robin«,n,  Jour.  Amer.  Med.  Amoc.,  36: 1901 :  1319. 
Handb.  Gen.  and  Hiit.  Path.,  London,  3: 1886:  412. 


fici;i 
'•Vtj, 

liic 


436 


THE  INTESTINES 


Macoos  OoUtifl.— Mucous  colitis  is  a  curious  affection  of  the  lur^e 
bowel  in  which  tubular  and  membranous  casts  are  discharged  in  the 
evacuations.  The  condition  appears  to  be  due  to  hypersecretion 
with  inspissation  of  the  mucus  and  proteids  produced.  It  is  found  must 
often  in  hysterical  women  and  is  probably  a  secretory  neurosis.  Only 
rarely  is  it  due  to  inflammation  of  the  bowel. 

Typhoid  Fevar. — Typhoid  fever  is  an  acute  infectious  disease  due 
to  the  Bacillus  typhi  abdominalLs  (Eberth-Gaffky).  Properly  speakiri};, 
it  is  a  disease  of  the  system  as  a  whole,  but  the  mast  constant  and  chanic- 
teristic  lesions  are  to  be  found  in  the  intestines.  The  portal  of  infection 
is  usually  some  part  of  the  bowel,  but  exceptional  cases  have  Ikh-u 
recortled  where  infection  has  taken  place  through  the  lungs  (Uoux, 
Sicard,  Dufaud). 

As  a  rule,  the  lesions  are  to  be  found  in  the  last  three  feet  of  the  ileu'ii 
and  in  the  first  part  of  the  colon.  In  a  few  cases  the  colon  alone  is 
affected  (Hodenpyl').  In  rare  instances  typhoid  assumes  the  character 
(»f  a  peneralize<l  septicemia,  the  characteristic  lesions  in  the  intestine 
l)eing  wholly  wanting.  Cases  of  this  kind  have  been  recordetl  in  America 
by  Fle.vner  and  Harris,'  Nicholls  and  Keenan,'  Lartigau,*  McPhedraii,' 
C)pie  and  Bassett,"  and  others. 

In  typical  cases  of  typhoid,  the  mucous  membrane  of  the  intestine  is 
swollen  and  congested,  presenting  all  the  signs  of  an  acute  catarrlial 
inflammation.  The  characteristic  lesions,  however,  are  to  l)e  found  in 
the  Fever's  patches  and  solitary  follicles.  The  lymphoid  structiins  are 
invaded  by  the'specific  microorganism,  become  inflamed,  and  proliferate 
actively.  The  Peyer's  glands,  therefore,  are  enlarge*!,  soft,  and  in- 
tensely reddeiie<l,  and  pn)ject  above  the  general  surface  as  flattcne<l 
phujiies.  The  solitary  follicles  also  may  l»e  so  much  swollen  that  they 
appear  like  liitle  polyps  on  a  slender  pedicle.  At  the  height  of  the  first 
stage  the  surface  of  the  affected  plaques  presents  a  curious  gr(Mive<l 
appearance  (plaques  h  surface  reticulile).  This  appearance  is  iliie  to 
the  unequal  swelling  of  the  i-onnective-tissue  stmma  and  the  lyni|ilM)i(l 
elements. 

Histologically,  at  this  period,  the  mucous  membrane  is  in  a  catarrhal 
condition  and  there  is  intense  congestion  of  the  vessels  both  of  the  iniicusa 
and  the  submuco.sa.  The  lymphoid  elements  show  hyperplasia,  aiul  i here 
is  a  perifollicular  infiltration  with  lymphocytes  and  leukocytes.  Leuko- 
cytes may  Im*  discoveretl  in  all  the  coa  •'of  the  lK)wel,even  in  the  sirnsa. 

.\t  the  beginning  of  the  second  week,  portions  of  the  affwted  Inllirles 
undet.;o  a  form  of  coagulation  necrosis.  The  central  parts  slotijrh  nuay, 
leaving  siqierficial  erosions,  which  often  assume  a  bn)wnish  color  from 


'  Hrit.  Med,  Jour.,  2: 1807- 18.50. 

•Johns  Hopkins  Hosp.  Hull.,  S:  l«<)7:2.5!». 

'  .Mont.  Med.  .lour..  27:  1S<W:9. 

'  .lohiiM  Hopkins  Hosp.  Hull.,  10: 1S911:  .5.'>. 

'  Phila.  Monthly.  Mod.  .Jour.,  October,  1N99. 

•  Phila.  .Med.  Jour.,  7 :  1901 :  99. 


TYPHOID  FEVER 


4.J7 


Fio.  105 


l)ile  staining.     In  the  course  of  the  next  few  days,  the  sloughing  process 

jiraiiually  extends  until  welUlefined  ulcers  are  pnxlucwl,  having  a  fairly 

smooth  base,  but  with  swollen  and  infiltrated  e<lges.     The  ulceration 

tends  to  penetrate  into  the  depths  and  usually  extends  as  far  as  the 

muscularis  mucosie,  which  may  he  recog- 
nized by  its  clean,  ribl>e<l  appearance.     The 

well-defined,  typical,  typhoid  ulcer  is  some- 
what oval,  the  long  axis  running  the  long  way 

of  the  l>oweI,  the  base  is  smooth,  the  edges 

comparatively  thin  and  undermined.    Small 

ulcers  may  be  irregular,  csjiecially  when  they 

do  not  involve  the  whole  extent  of  the  Peyer's 

patch,  or,  again,  may  lie  small  and  round, 

when   involving  a  solitary    follicle.     As  a 

rule,  the  most  advanceil  ulcers  are  to  be 

found  in  the  region  of  the  ileocecal  valve 

ami  l)ecome  less  marked  as  one  passes  up 

the  ileum.      In  very  severe  cases  the  last 

f(M)t  or  so  of  the  small  Iwwel,  together  with 

the  hea<l  of  the  cecum,  may  U-  converted 

iuti)  a  large,  gangrenous  eschar  in  which 

may  W  recognize<l   here  and   there  small 

islets  of  the  original  mucosa,  the  ulcerating 

process  having  extendefl    far  beyond   the 

limits  of  the  Peyer's  glands. 
The  process  of  healing  varies  naturally 

with    the   intensity  of    the    process.     The 

I>la(|ucs     that     are     merely     hyperplastic 

lH(,iiie  soft  again  and  hyperemic  through 

^'radual    absorption   of    the    inflammatory 

prixjucts.     Not  unconmu.  .iv,  there  is  an 

cxiravasation   of  red  corpuscles   from   the 

vessels,   so    that    hemorrhagic    infiltration 

(Mciirs.     Where    ulceration    has    occurred, 

liic  JMtrder  of  the  necrotic  areas  becomes 

less  swollen  and  again  suffused  with  blood. 

Ni't  infrequently,  there  is  hemorrhagic  infil- 
tration of  the  tissues,  a  fact  that  probably 

a(  ( ounts  for  those  cases  of  intestinal  hemor- 

rliii;,'e  which  occur  later  on  in  the  stage  of 

l'eiri?ining    convalescence.     The   glandular 

t  iiiii,  :;•<  „f  the  still  intact  mucasa  prolifer- 

:"c  iiid  graiiually  spread  over  the  denuded 

ar-M,  thus  restoring  the  original  continuity 

lit  >  iiulielium.  When  the  ulceration  has  been  very  extensive,  the  glandu- 
p-neration  ,Tiay  be  incomplete  or  absent,  so  that  the  fl(H)r  of  the 
IS  covered  by  a  layer  of  connective  ti-s-sue  containing  no  or  relatively 
in|K'rfectly-formed  glandular  elements.     Healed  ulcers  may  often 


1] 


Small  iiitetttine.  Peyer'n  platiue^t 
phowing  rumefoction  and  sui>erfiL>ial 
ulfvratittn.  Typhoid  fever.  (Fr<>m 
the  Pathological  Mu^umuf  Mr(i!M 
l'niverf"ity.) 


Ill 


;^li 


lt\ 


III 


j ' 


THE  INTESTINES 

be  recognized  as  oval  patches,  which  are  smooth,  pigmented,  and 
somewhat  depressed  below  the  general  surface  of  the  bowel.  During 
the  first  eight  or  ten  days  the  specific  bacilli  can  be  recognized  in  the 
Peyer's  patches  in  well-marked  clumps.  Coincidently  with  the  intestinal 
involvement,  the  mesenteric  glands  and  spleen  are  swollen,  hyperjjjastic, 
and  inflamed.  They  may,  as  a  consequence,  be  greatly  softened. 
Spontaneous  rupture  of  the  spleen  has  occurreiJ,  but  is  rare.  Tlic 
mesenteric  glands  may  suppurate. 

Owing  to  the  tendency  of  the  typhoidal  ulceration  to  penetrate  deef)!v, 
perforation  of  the  bowel  is  not  uncommon,  leading  usually  to  a  fatiil 
peritonitis.  Because  of  the  peculiar  ;tsthenic  type  of  the  typhoidiil 
infection  and  the  fact  that  leukocytes  are  .scanty,  the  exudate  is  pof)r  in 

Fio.  106 


Intestine  in  typhoid  fever,  siectinn  uliows  s  sinua  in  a  Peyer'.i  patch  with  the  great  |,r  iii.M- 
tion  of  the  epithelial  cells.  Zeiss  obj.  ,';,  oil  immerxiun.  ocular  No.  1.  (From  the  I'iiilinl,,Ki,:il 
Laboratory  of  McGill  University.) 

fibrin  and  adhesions  do  not  readily  form.  Only  twice  have  we  ^mi  a 
typhoidal  perforation  closed  by  adhesion  of  the  great  omentum.  1\t- 
foration  occurred  54  times  in  2036  cases  of  typhoid  treatid  ,ii  ihe 
Iloyal  Victoria  Hospital,  Montreal;  that  is,  in  2M  per  cent. 

Another  dangerous  complication  is  hemorrhage  due  to  the  erosi.-n  of 
some  vessel  in  the  ulcerated  area.  This  accident  occuired,  iiKlu.liii!: 
fatal  and  non-fatal  cases,  in  6.04  per  cent.  Other  complicjition-  -.ire 
pneumonia,  pleurisy,  nephritis, septicemia,  periostitis,  thromlw-pliM.iti  , 
thrombo-arteritis,  cholecystitis,  cholelithiasis,  endocarditis,  and  iii.nin- 
gitis.    A  general  hemorrhagic  diathesis  may  occur.' 

The  pathogenesis  of  typhoid  fever  has  been  the  subject  of  consid'  i  dile 

'  NicboUa  and  Learmonth,  Lancet,  London,  1 :  1901 :  30.5. 


-J-  -. 


TUBERCULOSIS 


439 


discussion. 


Virchow  thought  that  the  swelling  of  the  plaques  was  due 
to  oedema  and  inflammatory  exudation,  a  view  subsequently  modified 
liy  the  researches  of  Rokitansky  and  Hoffmann.  Tlie  more  recent 
studies  of  Mallory'  have  thrown  a  flood  of  light  upon  the  subject  and 
have  placed  it  on  a  more  satisfactory  footing.  According  to  Mallory, 
the  essential  feature  of  typhoid  is  a  proliferation  of  the  endothelial 
ells  throughout  the  body,  a  change  which  he  thinks  is  due  to  the  action 
of  a  diffusible  toxin  derived  from  the  bacilli.  The  lesion  in  question  is 
found  in  the  Peyer's  patches,  mesentei  ,  glands,  liver,  and  bone-marrow, 
as  well  as  in  the  lymphatics  and  blood-capillaries,  but  is  proportionately 
more  intense  the  nearer  to  the  point  at  which  the  infecting  agent  gained 
entrance.  The  endothelial  plates  attached  to  the  fibrous  meshwork  of 
the  lymphoid  follicles  and  mesenteric  glands,  as  well  as  those  lining  the 
capillaries,  proliferate,  become  fused  into  plasmodial  masses  or  giant 
cells,  and  act  as  phagocytes.  They  ingest  the  bacteria  and  slowly  eat 
up  the  lymphoid  cells,  which  thus  gradually  disappear.  A  few  leuko- 
cytes are  to  be  seen  in  the  follicles  and  within  the  crypts  of  Lieberkiihn, 
liiif  are  not  an  important  feature.  Owing  to  the  massing  of  these  endo- 
thelial cells  within  the  capillaries  and  the  consequent  obstruction  to  the 
hl(HKl  supply,  the  parts  deprived  of  their  nutrition  undergo  necrosis.  The 
focal  necroses  in  the  liver  and  spleen  are  to  lie  explained  in  the  same  way. 

Parat3rphoid  Fever. — Paratyphoid  fever  is  an  affection  that  can 
Im"  differentiated  with  difficulty  from  typhoid,  both  as  regards  its  clinical 
course  and  the  anatomical  lesions  produce<l.  The  intestinal  manifesta- 
tions vary.  As  a  rule,  they  resemble  the  lesions  of  dysentery  rather 
tliaii  typhoid.  In  some  cases  they  are  absent.  The  specific  micro- 
cirpniism  is  a  form  intermediate  in  properties  l)etween  the  B.  typhi  and 
the  B.  coli.  The  only  conclusive  point  in  the  differential  diagnosis 
iHtwcen  typhoid  and  paratyphoid  fever  is  the  agglutination  test. 

Tuberculosis. — This  is  one  of  the  most  frequent  conditions  found 
111  the  intestines.  Three  anatomical  forms  may  be  differentiated,  the 
iilirratire,  miliary,  and  the  hyperplastic.  In  the  vast  majority  of  cases 
the  condition  is  a  secondary  one,  being  due  to  the  infection  of  the  bowel 
In  bacilli  derived  from  a  more  or  less  distant  focus.  The  most  common 
event  of  this  nature  is  the  ulceration  of  the  intestines  that  accompanies 
l)tiliiionary  tuberculosis,  the  result  of  swallowing  infective  sputum. 
<)c<iisi()nally,  caseous  glands  rupture  into  t'le  oesophagus  or  intestines 
iuh!  Iiring  alwut  infection.    A  hematogenous  origin  is  certainly  rarer. 

\\  itli  regard  to  primary  tuberculosis  of  the  intestines,  statistics  are 
conlli<ting,  and  it  is  difficult  to  get  reliable  information  as  to  its  frequency. 
riic  i)rc|H)nderance  of  the  evidence  at  present  available  goes  to  show 
tiMit  the  milk  of  tuberculous  cattle  often  contains  virulent  bacilli  which 
arc  competent  to  produce  intestinal  disease  in  animals  fed  upon  the 
iiifci  tlve  material.  It  is,  therefore,  fairly  generally  held  that  tuberculous 
cattle  jire  a  grave  menace  to  the  health  of  the  community,  and  more 
csp.riiilly  to  children  in  whose  dietary  milk  forms  such  an  important 
part.  At  present  it  seems  impossible  to  decide  with  certainty  to  what 
'  Jour.  Exper.  Med.,  3:  1898:  611. 


440 


THE  INTESTISK8 


IB 


extent  pnmarj-  infection  of  the  intestine  takes  place,  though  we  nnisi 
undoubtwih-  agree  with  Koch  that  it  is  comparatively  rare.  In  1>:«I 
8Ut()p.sies  at  the  iloyal  \ictoria  Hiwpital,  Montn-al,  potentially  infwih, 
tnl)erculous  lesions  were  found  in  285  cases,  hut  onlv  two  were  nn- 
tlouhtetl  instances  of  primary  intestinal  infection,'  although  seven  otiurs 
were  prolwbly  of  this  natut.-.  During  five  yeaw  at  the  Charity  Hospital 
at  Herlin,  Koch  only  met  with  ten  examples.  Kawel,'  in  286  i-onsecutiv.- 
autopsies  on  chil.lren,  of  whom  22  had  died  of  tuberculosis,  in  only 
one  found  the  affection  confiiml  to  the  intestinal  tract.  Hunter"  iii 
5142  autopsies  in  Thiiia  found  only  five  instances.  On  the  other  hund 
Spengler  refers  to  02  cases  of  tuln-rculosis,  in  4  of  which  the  intestinni 
tract  was  alone  affected.  Still,'  in  209  autopsies  on  cases  of  tulwrcuK.sis 
in  ciildren  under  twelve,  found  that  where  the  course  of  infection  ct)Ml.l 
Ik?  determined  with  some  certainty  the  lungs  wei«  attacked  primariiv 
in  10a  cases,  the  intestines  in  53,  the  ear  in  9,  the  Iwnes  and  joints  in  ,i 
Miennon  in  355  cases  of  tuberculosis  in  children  found  the  primary 
seat  of  infection  to  l)e  intestinal  in  28.1  per  cent.  Apparently  primarv 
intestinal  infeciion  is  more  common  in  Englaml  and  France' than  it  is 
in  America  and  (Jermany.' 

Ill  typical  cases  of  tulierculosis  of  the  intestines  resulting  from  infection 
of  tlie  alimentary  ty,K>.  the  process  begins  in  the  Pever's  phKiues  and 
solitan'  follicles  in  the  form  of  small  nodular  elevations  l)eneatli  the 
muc-ous  membrane.  These  are  tiil)ercles  or  specific  granulomata.  In 
a  short  time  the  central  pmion  changes  to  a  vellowish-white  color 
an  evideiR-e  of  central  necn)sis  and  caseation.  Later,  this  softens  and 
IS  discharged,  so  that  a  small  ulc-er  with  infiltrated  Iwrders  is  prcHlMccd 
in  the  neighlx)rh(KMl  of  which  other  minute  caseous  foci  appear  Tlicse 
ultimately  cH)alesce,  forming  a  larger  ulcer.  A  typical  tul)ercuIous  nlcr 
of  the  intestine  has  the  following  peculiarities:   the  edges  are  irn-^iiliir 

mhltrated,  but  not  usually  undermined;  the  I)ase  is  uneven,  r d 

and  necrotic,  and  in  it  can  often  l)e.seen  small,  yellowish,  rounded  nias>.s. 
which  are  caseous  tul)ercles;  the  ulcers  tend  to  encircle  the  Iwwei.  ovvinj; 
to  the  fact  that  extension  of  the  infection  takes  place  along  \\w  <'omm- 
of  the  lymphatics;  the  ulcers  do  not  tend  to  perforate;  small  isolated 
tiil)ercles  can  often  \w  seen  upon  the  serous  surface  of  the  Ih)wiI  the 
mesenteric  lymph  nodes  are  often  caseous.  The  tissues  alniut  tli.'  ul,  .r 
usually  show  little  disturbance,  but  there  may  Ix-,  in  addition,  a  catiinhnl 
enteritis.  Certain  catarrhal  and  ulcerative  proces.ses  in  the  howtl  ^mii 
even  meinbranous  and  gangrenous  enteritis  have  also  lieen  aftril.ntfd 
to  the  action  of  the  tul)ercle  bacillus,  but  it  is  uncertain  in  how  far  ih.  se 
mav  i)e  due  to  associatejl  microorganisms.  We  have  met  with  om(  (  um- 
of  fo  h.ular  enteritis  in  which  the  puriform  material  from  the  intl.uii.Ml 
follicles  contained  tiil»ercle  bacilli. 

'  Nichi)lls.  Mont.  MchI.  .lour,  .31 :  1902:.327.  »  Zeit.  f.  Hvg.,  12:  .■.(!. 

'  Hrit.  Mwl.  Jour.  1 :  1904: 112(5.  t  Zeit  f  Hys    1.3-  IS'i:!  .    ■, 

'  Urit.  .Me<l.  .I,,ur.  2:  lS!t!t:4.W.  •  VAm.  Hosp.Hrp.,  1!»«. 

'  A  useful  rpsumC"  of  rcc-iit  work  on  this  controverted  Rubjocf  will  be  imm        ■  lii- 
British  .Mfijical  Journal,  1:  1!H)<):  epitome,  7. 


TUBERCULOSIS 


441 


Fio.  107 


Ihe  tuljenulous  process  usually  extends  into  the  muscular  coats  and 
.ven  into  the  serous  membrane,  infection  taking  place  along  the  course 
..f  the  lymphatics.  Thus,  we  may  Knd  a  small  crop  of  tubercles  on 
the  serous  surface,  surrounded  by  congestecl  and  newlv-formed  capil- 
laries. Not  infrequently,  there  can  be  seen  also  u>H)ut  these  a  little  knot 
(.f  dilated  lymph-channels  fiil«l  with  clear  fluid  or  cellular  and  caseous 
iiiuterial,  vessels  which  have  liecome 
l)l(K'ked  from  the  tulierculous  infiltra- 
lioii.  In  the  neighUirhiNKl  of  these 
siii)sert)us  tubercles  there  is  often  a  local 
peritonitis,  evidenced  by  a  slight  dulling 
of  the  peritoneal  membrane  and  possibly 
a  deposit  of  delicate  fibrin.  As  the  ulcers 
coalesce  and  enlarge,  they  tend  to  extend 
transversely  around  the'lwwel,  forming 
a  girdle-shaped  area  of  erosion.  In 
cases  where  the  Peyer's  patches  are 
involved,  especially  where  the  process 
lias  not  had  time  to  progress  very  far, 
the  ulc-ers  may  resemble  the  typhoidal 
form,  in  that  they  are  oval  or  rounded, 
their  long  axes  running  the  long  way  of 
liif  lK)wel. 

Histologically,  the  structures  at  the 
ffl^'fs  and  base  of  the  ulcers  present  the 
orilinary  features  of  granulation  tissue. 
Ill  this  can  l)e  made  out  a  varying 
iiiiiiiIkt  of  tubercles,  composed  of  the 
usual  leukocytes,  epithelioid  and  giant 
•tils,  with  a  certain  amount  of  central 
<a^t'ation.  In  the  more  advanced  cases 
similar  tul)ercles  can  l)e  found  l)etween 
the  iiiiiscie  bundles  and  along  the  course 
III  ilif  lymphatics  in  the  serous  coat. 
<iriiit  iiuml)ers  of  "Mast-zellen"  are 
Ills.)  to  Ite  seen  in  the  submucosa  and 
iiiiisi  iilaris.  The  muscular  coat  shows  a  certain  amount  of  fattv 
'l'';:.iitration.  By  appropriate  methods  tubercle  bacilli  can  l)e  demon- 
sinitnj  in  the  granulomatous  areas. 

All  interesting  and  imp»)rtant  form,  that  has  of  late  lieen  attracting 
soiiM'  little  attention,  is  the  .so-called  chronic  productive  or  hypcrplaMic 
•"'•'•'■'•iil'isis  of  the  intestines.  In  this  tyjje  tissue  destruction  is  trifling, 
« liil.'  .ell  proliferation  is  in  excess.  The  condition  mav  involve  the  peri- 
•""  'I  membrane  as  well,  either  wholly  or  in  part,  or,  again,  mav  lie  one 
iii^i' it.-iaiion  of  a  widespread  tul)erculosis  of  all  the  serous  sacs."'    When 


Tulierculoua  uli'eralion  nf  llie  bowel. 
(From  the  Pathological  Museum  uf 
McGill  I'niversity.) 


^'  li'ills,  Some  IJare  Forms  of  Peritonitis  .Aiwocialed  with  Productive  Fibromg 
'  Mime  Degeneration,  .lour.  .\mer.  .Med.  .As.soc.,  40:  l«J03:69fi. 


442 


THE  INTESTIIfES 


localized,  the  lesions  are  generally  found  in  the  cecum  and  appendix 
or  in  that  neighborhood.  Occasionally,  certain  coils  of  the  large  or  siniill 
intestine  are  matted  together,  thickened,  and  rolled  up  into  a  ball,  owin^r 
to  sclerotic  induration  and  retraction  of  the  mesenterv,  and  the  omentum 
may  be  converted  into  a  thick  conl.  The  wall  of  the  affected  bowel  is 
enormously  thickened,  sometimes  measuring  as  much  as  1  cm.  The 
infiltration  may  in  fact  be  so  great  that  a  tumor-like  mass  is  formed 
which  can  be  felt  through  the  abdominal  wall.  This  has  been  mistaken 
for  a  carcinoma.  The  infiltrated  bowel  may  be  surrounded  by  dense 
fibroid  adhesions,  which  may  anchor  it  to  the  parietes.  If  caseation  be  at 
all  active  in  such  cases,  fistulous  communications  may  be  formed  with  tlii' 


Fill.  KM 


h 

lip 


Intestine  shnwing  two  miiuU  cowouh  foci  of  tubercle  ia  the  submucoKH.     Zei^'*  o>>J.  I)l>, 
ocular  No.  1.     (Fn>m  the  Pathological  Laboratory,  McGiil  Lnivernity.) 

exterior  of  the  body  and  iH-tween  the  l(M>ps  of  (he  gut.  The  lumen  of  the 
intestine  is  sometimes  narrowed  to  such  an  extent  as  to  cause  obstrnciiiui, 
but  there  is  rarely  ulcenition  of  the  nnicosa.  Histologically,  tin  iiniin 
feature  is  extensive  hyperplasia  of  the  connective  tissue  in  which  typit  iil 
tubercles  are  scanty  or  even  absent.  Cuseation  is  rarely  extensive,  mid 
the  specific  bacilli  may  be  hard  to  demonstrate.  A  striking  feiitiiic  in 
.some  cases  is  a  hyaline  degeneration  of  the  exudate  and  of  ?!  >  wlv- 
fornied  connective-tissue  fibrils.' 

'  The  foUov  lag  papers  may  be  consulted  on  this  subject:  Lartigau:  .(  'H'  "f 
Exper.  Med.,  6:"  1901^:  23;  Koerte:  Deut.  Zeit.  f.  Chir.,  1894  to  1895;  lii':  .'ta; 
Coquet:  Thdse  de  Paris,  Ue  la  vari^t^  chir.  de  Turaeiirs  cecales  tuber,  !^''':  ^"»; 
[ti6:  Th^se  de  Montpellier,  I)e  la  tuber,  intest.  d  fomie  hyper.,  1898: 12. 


i  I 


DUODENITIS 


443 


SyphiUl. — Syphilis  of  the  intestines  may  be  hereditary  or  acquired. 
Ill  the  hereditary  form,  the  small  intestine  is  perhaps  the  part  most 
frtH|uendy  involved,  and,  moreover,  unlike  what  occurs  in  other  infectious 
diseases,  it  is  the  upper  portion,  usually  the  jejunum,  that  is  affected. 
Cellular  infiltrations  and  gummata  have  been  observed,  which  lead 
tu  ulceration. 

The  lesions  of  acquired  syphilis  are  most  frequently  localized  in  the 
rectum,  rarely  in  the  colon  and  small  intestine.  The  chancre  has  under 
certain  circumstances  been  found  in  the  rectum,  as  well  as  specific 
condylomas  and  papules.  The  common  lesion  is,  however,  the  gumma. 
Here  the  inflammatory  process  begins  in  the  submucosa  and  leads  to 
extensive  ulceration.  In  severe  cases  the  mucosa  for  a  distance  of  10 
to  12  cm.  above  the  anus  may  be  almost  completely  destroyed,  only  a 
few  shreds  being  left.  In  recent  cases  the  ulcerated  surface  exudes 
pu.s.  Later,  extensive  fibrous  proliferation  takes  place,  which  eventually 
leads  to  marked  stricture  of  the  rectum,  with  all  its  attendant  disorders 
of  olistruction,  dilatation,  hypertrophy,  and  ulceration.  Ciunimas  may 
also  develop  in  the  perirectal  cellular  tissue  and  lead  to  the  formation 
of  external  or  internal  fistule.  About  half  the  cases  of  stricture  of  the 
rectum  .re  said  to  be  of  syphilitic  origin.  The  condition  is  twice  as 
common  in  women  &s  in  men. 

ActinomycoaiB.' — Actinomycosis  of  the  intestines  in  aliout  UO  per 
(Tilt,  of  cases  is  to  be  found  in  the  neighborhood  of  the  appendix  and 
ceciiin.  In  many  cases  of  abdominal  actinomycosis  with  external 
sinuses  and  peritoneal  adhesions  it  is  impossible  to  determine  the  exact 
starting  |)oint  of  the  process.  Hinglais'  has  collected  120  cases  of  actino- 
mycosis of  ihe  appendix  and  cecal  region.  In  such  cases  the  affection 
U'ljins  with  symptoms  of  appendicitis,  but  subsequently  large  rectoce<'Hl 
al)scesses  or  external  fistulie  have  develope<l.  Actinomycosis  of  the 
intestines  begins  by  the  formation  of  whitish  patches  in  the  mucosa 
with  pniliferation  of  the  submucosa.  As  the  disease  progresses,  ulcera- 
tion takes  place,  with  not  infrequently  the  formation  of  external  fistula>, 
in  the  discharge  from  which  the  characteristic  "sulphur  grains"  or 
aciinomyces  can  usually  be  demonstrated.'  In  other  cases,  instead  of 
sn|)|)nrution  or  ulceration,  hard,  tumor-like  masses,  sometimes  peduncu- 
latt'cl,  may  be  produced. 

Tlic  iiifef  lion  is  supposed  to  be  due  to  the  use  of  contaminated  water 
or  M'i;<'(ahles. 


Inflammation  of  Special  Begions. 

Duodenitis. — Inflammation  of  the  duodenum — duodenitis — is  nearly 
aln  jys  associated  with  gastritis.  In  this  affection,  infective  agents  may 
tr.ivil  up  the  common  bile  duct  and  the  pancreatic  duct.  In  this 
way  a  catarrhal  or  suppurative  cholangitis  or  sialodochitis  may  he  pro- 


'  Icith,  Edin.  Hoep.  Rep.,  2: 1894: 128. 
Kr.isnol>BJew,  Arch.  f.  Kinderbeilk.,  23: 1  to  3. 


'  ThJse  de  Lyon,  1897. 


444 


run  llfTESTINtS 


n 
t  ■ 

i 
I  i 


1  r 


'lie 


WM 


tluced.  Duodenitiit  not  infrequently  lead.<<  to  acute  interstitial  lie|)Hli(i.s 
and  occa.sionally  to  acute  suppurative  pancreatitis  (q.  v.).  Catarrh  of 
the  ducts  in  question'  predisposes  to  the  fomiation  of  calculi  also.  ( 'uttir- 
rhal  jaundice  is  due  to  a  plug  of  mucus  in  the  ampulla  of  Vatcr  iinil 
probably  is  attributable  always  to  «  preexisting  ga.stroduodeiiiti.s. 

IlaitiB. — Ileitis  is  practically  the  same  thing  as  the  enteritis  HlmidN 
described,  the  inflammation  lieing  commonly  localized  to  this  portioii 
of  the  intestinal  tract. 

OoUtil. — Colitis,  or  inflammatiim  of  the  colon,  is  a  comparutivciv 
frequent  condition,  lieing  a  notable  feature  in  cases  of  dysentery.  The 
colon  may  lie  alone  involved  or  in  association  with  other  portions 
of  the  bowel.  Ileocolitis  is  the  ordinary  lesion  of  the  so-calle<l  chcihra 
infantum.  Many  cases  of  colitis  are  associated  with  the  infectiun.s 
and  various  forms  of  intoxication.  Colitis  is  not  uncommon  in  udvuncttl 
Bright's  disease.  Anatomically,  we  may  recognize  catarrhal,  follicular, 
membranous,  hemorrhagic,  mucous,  ulcerative,  and  gangrenous  forms. 
The  rea.son  why  colitis  is  so  common  is  perhap.s  not  far  to  seek,  when  we 
consider  the  opportunities  afforded  for  traumatism  and  infection.  Tiie 
feces  tend  to  accumulate  in  the  large  bowel,  they  are  harder  there  than 
elsewhere,  and  their  progre.ss  is  slower,  and  the  antibacterial  action  of 
the  digestive  ferments  is  much  lessene<l.  A  frequent  cause,  therefor*', 
of  colitis  is  the  presence  of  dense,  scybalous  masses,  the  accumulation  of 
which  leads  to  dilatation  of  the  intestine,  with  possibly  the  formation  of 
diverticula.  Hani,  fecal  masses  are  retained  in  the  little  pockets  thus 
formed,  and  lead  to  ulceration  through  pressure  necrosis. 

Typhlitis. — Typhlitis  is  inflammation  of  the  cecum.  When  the  nlhilar 
ti.ssue  about  the  cecum  is  involved  as  wtll,  die  condition  is  termed 
perityphlitU.  When  the  inflammation  "is  extraperitoneal  and  behind  the 
cecum,  it  is  spoken  of  as  paratyphlitU.  Typhlitis  may  occasionally 
l>e  due  to  the  presence  of  hardened  feces  in  the  cecum,  but  apart  from 
this,  the  three  conditions  are  nearly  always  the  concomitants  of  inflam- 
mation of  the  appendix  vemiiformis.  We  have  met  with  a  membranous 
typhlitis  in  the  case  of  a  cerebral  lesion,  however,  where  the  patient  had 
Ijeen  unconscious  for  some  days  before  death.  It  is  also  met  with  in 
mercurial  poisoning  and  uremia. 

Appendicitis. — Not  many  years  ago  the  terms  typhlitis,  ptritvph- 
litis,  paratyphhtis,  and  the  still  vaguer  appellation,  "inflammation  of  the 
bowels,"  were  employetl  to  designate  almost  all  affections  of  an  inHam- 
matory  character  occurring  in  the  right  iliac  fossa.  We  owe  to  I'itz's 
classical  monograph  the  recognition  of  the  fact  that  the  va.st  nuijority 
of  these  cases  have  their  origin  in  a  diseased  appendix  vemiiformis, 
from  which  naturally  followed  the  adoption  of  more  rational  nw  a>iirt's 
of  treatment. 

Inflammatioti  of  the  appendix — appendidtit — is  much  more  .•.iiunon 
in  males  than  in  females.  Most  ca.ses  come  to  operation  Intwi .  ii  the 
ages  of  twenty  and  thirty.  Where  previous  attacks  have  l)eeii  n n'rcied 
in  the  histories  they  have  occurred  in  the  .second  decade  of  life. 

We  .shall  perhaps  \w  lietter  prepared  to  understand  the  elicl  cy  of 


^ 


APPBSDICniS 


44S 


iiiflainirati(.ii  of  thr  append!:   7  we  consider  the  anatomical  stnifture 
and  the  situation  of  the  orgun  tunc-enied. 

'i'he  appendix  in  .tituuted  at  the  head  of  the  L-eruni;  its  cavity  is 
(iintiiiuoua  with  that  of  the  large  bowel,  lieing  divided  fmni  it  by 
a  in(»re  or  less  inconstant  fold  of  mucous  membrane,  the  valve  of 
(ierlach.  It  U  long  and  narrow  and  apt  to  be  somewhat  cur\-ed 
ii|Min  itself.  'I1ie  appendix  appears  to  be  the  relic  of  a  large  cecal 
|MiiU'h,  such  as  is  still  to  l>e  found  in  the  ruminants  an<l  others  of 
thf  lower  animals,  and  considerable  evidence  has  been  adduced  to  show 
tliiit  it  is  gradually  involuting.  Hibbert,  in  a  study  of  4U0  appentlices 
rciiioved  at  post  mortems,  fouml  retrograde  and  atrophic  changes  in 
ulMitit  23  per  cent,  in  the  absence  of  any  indications  of  previous  in- 
fluiniiiatory  change.  A.  O.  J.  Kelly'  has  found  more  or  less  obliteration 
i»f  the  lumen  in  about  on«'-quarter  of  the  cases.  Being  an  organ,  there- 
fore, that  is  disappearing  one  nee<l  not  be  surprised  that  the  appendix  is 
a  common  seat  of  disease.  In  view  of  its  situation,  moreover,  it  is  apt 
to  l>e  a  depository  for  foreign  Ixxlies  or  inflammatory  exudates,  whicn, 
owing  to  its  dependent  position  and  narrow  lumen,  are  almost  certair; 
to  \w  retained  within  it.  A  slight  inflammation  or  kinking  at  the  nee  ( 
will  also  favor  the  retention  of  its  contents.  Thus,  the  appendix  pra  • 
tKiilly  l)ecomes  at  times  a  culture  tube  for  various  microorganisms, 
and  the  subject  of  traumatic  and  chemical  irritation.  Considerable 
'tr«'ss  uswl  to  l)e  laid  upon  vascular  disturltances  as  a  cause  of  appendi- 
citii,  but  the  importance  of  these  has  undoubtedly  been  overestimated. 
'riiroinlKksis  and  embolism  might  conceivably  bring  about  anemic  ne<<ro- 
sis  of  the  organ,  which  would  thereupon  become  an  easy  prey  to  putho- 
jrenic  microorganisms,  but  this  appears  to  l»e  a  verj*  rare  occurrence. 
Bri  iicr  has  shown  that  the  arter}'  of  the  appendix  is  not  an  end-arterj-, 
and  that,  c-ontrary  to  the  usual  opinion,  there  is  a  fairly  eflfective  anasto- 
mosis in  the  various  <t>ats  of  the  organ.  Again,  the  endarteritis  and 
(XTJarteritis  held  by  some  to  be  a  chief  cause  in  bringing  about  necrosis 
liavf  not  been  found  constantly  or  even  frequently  present.  In  anv  case, 
to  l)ring  alwut  the  condition  in  tjiifstion,  oKstniction  of  the  vessels  wouhl 
have  to  lie  somewhat  widespread.  The  vascular  changes  are  more 
rcasiitiahly  to  be  interpreted  as  the  result  rather  than  the  cause  of  the 
intlaniniation.  Possibly,  however,  kinks  or  other  constrictions  of  the 
ai>i>(iidix  at  its  orifice,  by  interfering  with  the  free  outflow  of  1)1o<kI, 
niiiy  in  some  few  cases  play  a  leading  role. 

At  one  time  it  was  almost  imiversally  hel«l  that  foreign  Unlies  or 
fp'  ;i|  conciTtions  within  the  appendix  were  the  important  factor.  Apart 
from  fecal  concretions,  foreign  bodies  are  quite  rare  in  the  appendix, 
anil  when  present  are  to  be  clas.se(l  as  accidental  occurrences  rather 
tlian  ( aiisative  agents.  James  Bell,'  in  lietween  900  and  1000  cases  of 
■I !>l"n. Ileitis  operated  upon,  found  foreign  bwlies  within  the  appendix 
in  rinly  7,  and  thinks  that  this  is  probably  more  than  the  usual  pro- 
poiiKin.    Foreign  bodies  have  also  been  met  with  in  appendices  that 

'  I'liila.  Med.  Jour.,  4: 1899  .-928,983: 1032.  » Mont.  Med.  Jour.,  31:  1902:  765. 


446 


THE  ISTESTINSS 


1 


3  : 


iil 


Hi 

Is 
1 3 


prpsriitftl  no  obvious  «p{)roniiK«9  of  diaeBiir.  Anions  the  .iulMtunct-H 
fuuml  limy  be  mentioned  apple-pips,  gnpe-see«lr .  hair,  bits  ot  bone,  [>iii<<, 
hit!)  of  ^lafls,  f^lUtones,  wood-iiber,  segments  of  '  tia,  thread  wnnii.<t, 
and  round  wonat.  In  the  Pathological  Miitteum  -t  MHiill  Univertiiy 
ii  an  ap|)endix  containing  a  large  nuiid>er  of  shot,  <l.e  owner  of  which 
nfver  suffered  from  appendicitis.  Sharp  subatanves,  such  as  pins 
or  glass,  might,  ho^vever,  be  expected  to  ipve  trouble.  Pecal  roiun- 
tiori.i  coasist  of  fecal  material,  deaquamateil  relb,  and  letdcocytes,  in.s|.i%. 
sated  in  a  muft>id  matrix,  and  sometimes  inhltrMtni  with  calcium  suh-*. 
They  are  found  in  nonnal  appendices,  aiui  in  theiii.selve.s  appear  to  In> 
comparatively  unimportant.  It  is  quite  likely,  however,  in  appt'iuiiii's 
that  are  intlained  and  swollen,  concretions  may  bp  about  necrosis 
through  pre.'wure  and,  as  a  matter  or  fact  they  are  ...  -^  n<niien>iis  in 
api>endiciti.<i  of  the  ulcerative  and  gangrenoas  type  t  s\.  Vn-hibulil,' 
in  his  analysis  of  8J)  cases,  found  concretions  ir-  i  >ul  of  '.iS  imui- 
perforative  cases,  while  in  41  perforative  cnses  c  .  ms  were  foiiiKJ 
in  22.     It  should  be  pointed  out  that  concrelion*i  .n  expression  of  a 

previous  or  co-t.dstent  inflammatory  proce.ss  ramer  than  the  extitiiiK 
cau.se  of  inflammation.  As  in  the  case  of  biliary  or  urinary  ctilciili, 
there  must  have  been  a  preSxi.sting  catarrh  of  the  mucosa  pnMliicin^' 
an  excess  of  mucus  with  exuilation  and  (les(|iiamation  uf  cells  tii  pro- 
vide a  nidus  in  which  the  salts  may  be  dcpo.site<l.  Once  foriiifd,  of 
course,  the  concretion  might  l)e  expected  to  perpetuate  or  uggni\iitp 
the  condition.  As  a  rule,  however,  it  is  only  the  larger  concn'tions 
which,  by  pre.s.sure  upon  th«-  mucosa  and  obstructing  the  free  disciiarjre 
of  retained  secretions,  lead  to  trouble. 

.\nother  point  of  etiological  moment  is  the  fact  that  the  lyiii|»lii>i(| 
elements  of  the  appendix  undergo  involution  along  with  the  otlicr 
structures.  The  appendix,  at  first,  is  much  more  rich  in  lyniphoiil  < ii- 
ments  than  the  rest  of  the  intestine,  the  cells  in  question  being  dilfuMil 
throughout  the  muco.sa  or  aggregated  into  follicles.  Thes*'  tlciiicnis 
are  pmlutbly  concerned  in  the  manufacture  ot  sub.stanc-es  that  iinniiiniice 
the  iKxIy  against  bacterial  infection  from  the  lumen  of  the  Uiwcls. 
Ribbert  and  Kelynack  liave  pointed  out  that  this  lymphoiii  tisMic  is 
most  marked  in  childhiHMl  and  atrophies  after  the  thirtieth  ytari>riii 
exceptional  ca.ses  lis  early  as  the  twentieth.  The  fact,  therefon'.  rliat 
the  defen.sive  powers  of  the  appendix  against  infection  uikIit  tlu^e 
(•ircum.stances  are  lieginning  to  wane  will  explain  the  greater  pn"  .iIimicp 
of  appendicitis  after  early  adult  life. 

The  mo.st  inijiortant  .single  cause  of  appendicitis  is  infection,  the 
activity  of  the  microorganisms  being  aided  by  the  anatotnicnl  p>riiii.iniifs 
just  detailed.  Aschoff,  the  mo.st  recent  investigator  of  the  siihjfft,  i.olds 
that  the  di.sease  In-gins  as  an  enterogenous  infj-ction,  lK>giniiiiiir  ;ii  t!ic 
bottom  of  the  crvpts.  To  prndnre  this  result  only  the  .slightest  iii)ra-i'>n 
of  the  epithelium  is  neces.sary.  Of  the  bacteria  at  fault,  the  ino>t  im- 
portant are  the  B.  coli  communior(in  Montreal),  Staphylococcus  pvi.^fiips 

*  Mont.  Med.  Jour.,  29:1000:81. 


JL 


iCVTK  DIFFUSE  APPKS  Hcni. 


4f7 


rtllms  and  aun  ^  Sti^plocotiu-  pytiKem  DipimiM  ms  pnriimunia-. 
utxl  ».  pyocyaikeus.  li.  Keller's  400  owiw  the  B,  col  vas  pr«)«it  in 
!t2  [ler  cent. 

'I'avel  and  Lani,  Bamacfi,  anil  Welch  have  pointed  out  the  frequeix-y 
i>f  mix»^  infection.  Ppobal  <1  y  the  vast  majority  »f  iit>pendicitia  c-asr^  are 
(lii»'  to  mixed  infection,  and  'lie  reason  that  thw'is  not  -f  *»erally  reali/.«l  i?, 
to  Ik-  looked  for  in  faulty  l>tt»terioloj{i«al  techfiique.  The  B.  coli  r*-udily 
ovtrtfTows  and  destroys  |«^■^  vJKonHis  jrtrras  Therefore,  plate  cultures 
should  be  matle  at  i ..  time  of  ojieration  in  onler  thiit  the  various  fonns 
may  Ik-  pniitt-riy  isolateil.  Cuhiires  sIk.iiI.1  also  Im-  made  under  anaero- 
bi<-  oindition-i.  It  is  likely.  iLso,  that  -lurini'  life  the  same  destruMion 
of  the  weaker  organisms  hy  the  B.  roli  takes  j,|a«<»,  so  that  'lie  eultur** 
tiieihiMls  may  reveal  only  a  .siiiKl"'  s.-enn  when  the  'lisease  has  really  bt-f-ii 
hn.iijtht  alxnit  hy  several.  It  i»a..  be  sho^.i  that  mifroscop  sections. .f 
the  ,i(»}»endix.  api^mpriately  si.iiiied  to  aho  '  Iwi  *na,  oft.  i,  reveal  the 
pr»vtwT  of  mimj6rganisms  within  the  lum.  .1  wlii.-h  liave  failed  to  de- 
velop  in  the  cultures  taken.  Wht  t-e  mixed  iiifeetion  can  be  ncojrnized. 
the  H.  coli  and  the  Staphylococ-*  us  are  usually  d^Mrid  topet  er  In  a 
few  eases,  the  Staphylixttccus,  I';i.  iimii(i..fMi>,"<>r  B.  pvnev:..,,us  have 
lieeii  found  alone. 

In  irparil  to  the  extent  of  the  ni'liiiiiniii.  )  pr-  0  it-M-lf,  .In-  whole 
a|.'..ti(lix  may  be  inv<»|v«l  or  only  a  porti  n  of  it.  i.suallv  the  listal 
piirt.  It  is  difficult  to  give  an  aeeurafe  f  la-itieatioii  01  the  forms, 
inii.mueli  11.S  the  tyiK's  nK-t  with  iiii|MTeeptil.|\  pass  one  into  the  f-ther' 
Tl"'  folhmiiig  ma    lie  sufyjested  n.<*  a  (t)ii\eni(iii  irroiipitpj;: 


Acut€ 


I  linmic 


I'nhirrh.il. 

Ihffii^,  mppiimh ,-,,  ,.r  jJilegmntmun. 

Vice,     :nq  '  ''rf"'^t'-f-   ^   , 

(lanf/rtnous. 

Sprrijir  (r.  q.,  lyphmil). 

Caliirrlinl 

Sprriiir        '  'i'»''"<^'>l">"- 
■     I  Artinnmijrulir, 


Acute  CaUrrhal  AppendicitU.- Catarrhal  ii[)i>en.lioitis  mav  be  acute  or 

•  liri.Mic.  In  the  acute  form  the  apf¥>n(lix  is  swollen,  the  external  venules 
ar<-  (oiipsted,  and  the  orpan  is  often  kinke.l  or  twisted.  The  mucous 
iixnihrane  is  swollen,  succulent,  onpeste.l.  with  possibly  minute  hemor- 
rlwL'es,  iHHJ  there  may  l)e  even  slight  roughening  of  its  surface      The 

•  iiMiv  contains  thin  mums  with  a  few  leukocytes,  and  there  mav  l>e  con- 
(•nimns.    ( )ccasionally.  there  are  a  few  old  adhesions  alwut  the  appendix 
Un  l,isf,,i,  j;,ea:  examinati<.n,  the  mucosa  is  er.ngested,  a-dematoiis   and 
«"•■•  I'll!,  hum  '3  in  a  state  of  catarrh.     Tl.»  Kniphoid  folHcles  .-.re 
|.p.lii. Til.    ..J  „|„,  the  subniucosa  is  also  fedematnn. 

Acute  hiSuM  Appendicitis.— This  form  is  .nore  ..  >  .,v.  The  apiien.lix 
i^  pv'll.n  m  all  its  thickne.s.s  and  may  be  o.veiv,!  with  fibrinous  Ivniph 
eM'  1  :  Illy.    All  til.  features  of  the  acute  catarrhal  form  are  present,  but 


s     I 


44S 


T//fc'  IXTESTISKS 


in  ud«iition  there  is  a  tlitTuiM-  iiifiltnttiun  of  leukoi-ytes  in  all  the  cotiis, 
whieh,  therefore  are  greatly  thickenetl  uiui  (i><len)utun.s.  The  lyniphniil 
elements  are  also  actively  pniliferating.  Here  and  there  there  may  In- 
small  superficial  erosions  of  the  mucosa.  The  cavity  may  contain 
mucopus.     The  meso-appenilix  is  often  involved  a.s  well. 

Aent*  meanting  Appendidtii.-In  the  iuute  ulcerative  type  there  i> 
at  some  point  or  other  an  area  of  necrosis,  usually  correspon«lin<»  to  tlic 
situation  of  a  fe<-al  concretion.  This  ulceration  may  he  of  varying  (ie|)tli, 
an<l  not  infre(|uently  {lerforates.  The  appendix  is  often  discolored  at  llit' 
|M>int  of  necrosis  and  is  liathe<l  externally  in  pus. 

Otngnnoui  Appandidtia. — (iangrenous  apfiendicitis  is  a'l  extreme 
and  fulminating  variety,  in  which  the  whole  appendix  or  some  jMirt  of 

it  rapidly  necnxses  and  is  convcrlid 
into  a  lilackish,  sloughy  mass.  This 
form  may  l)e  primary  or  may  In-  tii- 
gnifted  upon  other  ty|)es  of  apiMii- 
dicitis.  It  is  due  to  a  particiihirlv 
virulent  form  of  infection  or  to  vascu- 
lar obstruction. 

Typhoidal  nlearation  of  the  appcniiix 
n'semhles  typhoidal  ulcenition  cNi'- 
when'.  It  may  lead  to  iMTfonitinti 
and  {Hiitonitis. 

Chronic  Appandidtis. — Chronir  ii|>- 
|M>ndicitis  may  Ix*  insidious  in  its  unset 
or  result  from  an  acute  or  .siiluiriitc 
attack.  In  not  a  few  of  the  cnsrs  «»• 
find  a  succession  of  attacks  of  irmn' 
or  less  acute  inflammation,  in  .my  of 
wliitli  ulcerative  and  gaiu;r<'iioii>  jiro- 
cesses  may  su[)ervene,  pliiciiiL'  ili'' 
patient's  life  in  jeopardy.  Hoih  ilic 
(•hn)'iic  and  the  relapsing  ciisc^  Irjul 
to  proliferation  of  conii('cliv<'  ii->ii('. 
wher«'l>y  the  api>en(li\  Ih-i-oiik'^ 
rated  ari<l  the  lumen  in  soinr 
entirely  ol)literated,  so  that  tin 
organ  is  converted  into  a  lit  iron 
isrlrroning  appendlritin).  \\i\- 
there  colleclions  of  n)un<l  cclU  n 
seen  in  the  various  coats,  rrli. 
inor«'  active  stage  of  iiiHiinn 
Obliteration  of  the  proxiniiil  |' 
may  lead  to  the  retention  of  -i 
and  inflammatory  pnMlucts,  soi ' 
n-inainder  of  the  ap|M'iiilix  I 
dilated  into  the  form  of  a  cyst  of  cylindrical  or  globular  shiij  • 
c"ontents  of  the  cyst  are  either  serous,  mucous,  or  purulent,  :> 


Ai-iite  ii|t|M>iMlii'iti>,  with  i*xl(*nMivf' 
riniiH!-«'"Mfsl  infiltmtidii  of  nil  nf  (h,.  rnur.. 
of  rlie  apitpDilix.     (Srettir**).) 


inilii- 

I    ilM'S 

.'hnlc 

ninl 

:illil 

^   Ik' 

„r  :i 

tiiili. 

■  linn 

'  tinli 

I  llli' 

■.UK'S 

I'lir 

lllilV 


CHRONIC  APPENDICITIS 


449 


U-cc)me  inspissated.  In  all  chronic  and  relapsing  cases  fibrous  adhesions 
form  in  the  neighborhood  of  the  appendix.  By  obliteration  of  the  lumen 
.s|H»ntaneous  cure  may  result.    This,  however,  is  not  to  be  expected. 

'I'he  danger  from  appendicitis  is  largely  dependent  on  perforation, 
which  tK-curs  sooner  or  later  in  a  large  proportion  of  acute  cases.  If 
ihc  inflammation  l)e  a  fulminating  one  and  adhesions  have  not  forme<l, 
a  septic  peritonitis  supervenes,  which,  in  the  vast  majority  of  cases  is 
fatal.  A  general  peritonitis  due  to  the  B.  coli,  or  in  which  the  cultures 
arc  sterile,  appears  to  l)e  less  virulent  and  some  few  ca.ses  get  well  after 
appropriate  surgical  treatment.     Where  fibrinous  adhesions  have  forme<l. 


Km.  im 


.  iilciTulive  a|>|>rinliritN.     Thi.  Kwlion  l•how^c  ^linht 


■  nnv  .n.rranve  a|>|K-inliriti,..  ri,e  w,i„„  „1,„»,,  ,|i,|„  en„i„„  ..f  ,(,,  „„„•.,,«  wilh  .ainrrh  nf 
'I..  .,.;.l-  »t,<l  hyiK-rplaMu  ..f  th»  lympll.ii.l  elriiie,,!,  „f  |he  IVyfr'.-  |.atilir».  /,,(<»  ,.l)j  \ 
*" "  "'"lar.     (Kn.iii  the  Pat liuliviral  Ulxiralury  uf  .Mr(;ill  IniviTMIy.) 

|Mitoii,ii;,ii  „f  tlie  app«>n(lix  leads  to  the  formation  of  a  ItMalizcd  abscess 
III  wli'  h  concretions  or  |H)rtions  of  the  apix-ndix  mav  lie  founti.  The 
|Mii.  1,1  will  frc(|uently  recover  in  such  cases  if  the  aUscrss  \te  promptiv 
'v.M  i.it.-d  and  (Irair.-d.  More  favorable  still  are  those  cases  in  which 
'I'll  '  'iliroiis  adhesions  wall  off  thediseasetl  appendix  from  the  general 
:'l-l  -'iiiiial  cavity.  The  ap[)eiulix  may  lie  In-hintl  the  <vcimi,  |M>inting 
ii||'ir.|.  and  lead  to  the  formaticm  of  an  abscess  in  the  n-gion  of  the 
li^'  III  other  cases  the  organ  lies  in  a  little  |MK'ket  of  |)eritoiieiim  or 
<■■■•■•■  'iitirely  lM>hiiid  the  peritoneum.  Such  cases  ar<'  relativelv  favor- 
■>i'  l'<Tiap|K'ndicular  abscesws  may  burst  into  the  lM)wer.  giving 
n  '      '  r.cal  fistuhe,  or  may  evacuate  themselves  externallv.     Septic 

-hi  *  ' 


n 


450 


THE  INTESTINES 


thrombosis  of  the  mesenteric  and  omental  veins  is  a  common  accomnuni- 
ment,  as  are  also  septic  portal  pylephlebitis  and  abscesses  in  the  liver. 
Empyema  of  the  right  pleural  cavity  is  occasionally  met  with. 

TabOTCalosil. — ^'ruberculosis  of  the  appendix  is  found  in  association 
with  tuberculosis  of  other  parts  of  the  intestinal  tract,  and  does  not 
differ  in  any  way  from  it.  Here  also  the  hyperplastic  form  has  \m-n 
observed. 


Fra.  Ill 


Gangrene  of  the  appendix  verraifnrrai:*  in  acute  appendicitis;  coucretiun. 
Museum,  McGill  University.) 


(l'atl»<l.'i:iiJl 


Proctitis. — Proctitis,  or  infianiniation  of  the  rectum,  is  con 
brought  al)out  by  traumatism,  .such  us  may  be  cau.sed  by  impaci"! 
fruii-stones,  fish-bones,  or  foreign  bodies  intnxluc-eti  into  tlif  f 
Dilated  hemorrhoidal  veuis  may  also  Ijecome  thrombo-setl  and  in 
thus  leading  to  inflammation.     Proctitis  is  also  cau.sed  by  goii' 
syphilis,  tulK>rcul(>.sis,  and  certain  mitienil  substancrs  snili  a>  . 
and  mercury.     Ulceration  is  a  common  feature,  but  is  of  ciiro; 
and  leads  to  thickening  of  the  wall,  polypoid  outgrowths,  ,11  ' 
or  less  atresia.    The  ulcers  may  penetrate  deeply  and  give  li 
scesses  alxjut  the  rectum  (periproctal  abscesses),  which  niiiy  K 


lllolliv 

I.  CCS. 
.■IMIl). 
,,!,■<!. 

v-iiiic 
more 
:  into 


'M 


;!L 


TUMORS 


451 


the  bladder  or  vagina  (redovetical  and  rectovaginal  /utula).  or  mak« 
their  way  to  the  external  surface  (comjdete  or  external  fistula).  Wliere 
the  abscess  communicates  only  with  the  lumen  of  the  bowel  and  has  no 
.xteniai  opening,  the  condition  is  termed  by  surgeons  blind  or  internal 

tiMuta. 

UTBOOaBSaiVI  mbtamokphoui. 

Atrophy.-Atrophy  cf  the  intestines  is  not  uncommon.    It  may 
atfect  the  mucosa  only  or  the  whole  thickness  of  the  Ijowel 

Dejrener»tion.-ntt7  digtiwntton   and   hyaUiw   d«g«M„tioii   are 
otcasionally  met  with  in  the  muscular  coat 

Amyloid    IiilUt«tion.-Amyloid    infiltration    is    not    uncommon    in 
a.lvance<l  cases  of  amyloid  disease.     It  aflfects  the  walls  of  the  smaller 
hl.)(j<lve.s.sels,  principally  of  the  mucosa  and  submucosa. 
•  Enterolithiaita.— The  curious  condition,  known  as  entonUthiMii    in- 
<Im(I."s  the  formation  of  large  concretions  within  the  cavity  of  the  bowel 
arirl  of  tine  granular  particles,  or  intestinal  sand 

/»/,  ,//W  .a»rf  is  «.mp<xse<l  of  a  large  proportion  of  o^janic  matter 
Mth  aU.ut  33  per  cent,  of  (^Icium  salts.  Myer  and  Cook'  have  shown 
tliat  .1.  some  cases  at  least,  certain  articles  of  diet,  notablv  bananas 
may  U-  responsible  for  the  c-on.lition.  A  vegetable  resin  toother  with 
tannic  at.d  is  found  in  this  fruit  and  under  the  influence  of  digestion 
ail  insoluble  tannate  is  produced  which  appears  in  the  feces 

Conrrrtwns  or  rnterMh>,  are  usually  found  in  the  appendi.xordiver- 
!!ll'  \1:  Jf  i""''*)"*'  "";'  ""it'  ?'  inspis.sat«l  fe«s  and  .iesquamate,! 
<^'K.  «hich  have  forme,!  a  nidus  for  the  deposition  of  calcam,us  salts. 

Necrow,  ulMration.  and  gangreiw  are  not  uncommon  in  the  intestine, 
•n.l  result  from  inflammation,  pressure,  and  cirtiulatoiy  disturbances. 

PKOORUUIIVI  MITAMOBPH08B8. 

Hypertrophy.-IIypertrophy  of  the   intestinal   wall  occur  as  the 

n'Milt  of  chronic  okstruction. 

inlTul^rThTf  *"'"'""""'.  poniparatively  ra,^  and  of  no  great 
mlT  :  '^^\^"""''  "i*"'  ^'th  are  the  adenoau,  flbronu,  liMins 
myom..  o.teom.,  henungiom,  lymphtnglom..  and  ehybnciom  The 
■;;-"' t.ve-t.s.s,ie  tumors  usually  spring  fmm  the  subm3a  and  pn^ 
-H.  ward  into  the  peritoneal  cavity.  Polypoid  or  pedi.nci.irte.1 
n  1  ."°  '"f'r')"^"*'y  ?»«♦''«■«'.  which  mav  bi^ak  l^se.  forming 
<"•    n„l,.fe  intti.s.siisception  and  intestinal  obstniction. 

"  enterocyitom.  is  a  curious  cystic  growth  insulting  from  a  develop- 
;;;;;'  1  anomaly  in  the  form  of  partial  persistence  of  the  omphalomese!!: 

M.bstance  of  the  intestinal  wall,  or  forming  a  small  n<>dular  ma.s.s 
'  Amcr.  Jour.  Med.  Sci.,  137: 1909:383. 


i  1 


452 


THE  ISTESTIXES 


Fio.  112 


pn>jectinj5  on  the  .serous  aspect.  Such  tumors  are  the  result  of  ilevel- 
opinental  errors,  and  are  usually  found  in  the  upper  alimentary  trad, 
duiMlenuu)  or  jejunum.  When  in  the  jejunum  they  may  l)e  situati-d 
at  the  tip  of  a  diverticulum.' 

Polypoid  ontgrowthi,  often  pedunculateti,  and  having  the  genenil 
.structure  of  an  adenoma,  are  not  uncommon  in  the  intestine,  especially 
in  the  <lu(Mlenum  and  in  the  large  bowel  near  the  ileocecal  valve  or  in 
the  rectum.  They  are  found  especially  at  the  mar^irins  of  chronic  u!c«ts 
and    in    conne<-tion    with    lonf;-.standing  enteritis.     It    is   (lUcsiionuMc 

whether  they  are  ever  true 
tumors,  and  they  should  certainly 
lie  clas.sed  with  the  inflammatory 
hyperplasias. 

The  malignant  growths  arc  B«r- 
eoBu,  IjmidioMrcoiiu,  endotbeli- 
osu,  ami  eareinonuk.  Sarcomas 
are  round,  spimlle-<Tlled,  alvn>- 
lar,  and  melanotic.  The  roiiiid- 
celle«l  fcHTO  is  the  commoiit'st  of 
the  primarj-  sarcomas,  l>ut  i>  si  ill 
rare.  It  usually  (K-ciirs  iK'twt'cii 
the  apes  of  forty  and  fifty.  V..  \. 
Rol)ert.son'  has  recorded  a  cusc 
in  a  child  of  four.  The  ;.Tn»ili 
wa.s  situated  in  the  neij;iilM)rliiirK| 
of  the  ilecK-ecal  valve.  Mcljiiiniic 
.sarcomas  are  single  or  iiiiiliipir, 
and  are  found  studding  the  sen  ms 
surface.  They  an'  .sccHMidiiry  in 
melanotic  .sarcomas  of  the  skin  nr 
choroid  of  the  eye. 

Lymphosarcoma    may    l»'   pri- 
mary or  .secondary.      It   h^ikiIIv 
.starts  in  the  lynipli-follitlt-.  \>\\\ 
may  l>egin  independently  <>f  ilnin. 
.ScMHier  or  later   lln'  iu'"-l'I'i'"'Ii 
extends  lieyoiid  the  liniii>  nt'  ilir 
follicles  and  invades  the  iinM'^ii 
an<l  other  coats  of  the  iiiir  •  uf. 
The  l)<)wel  may  also  Im-  iiu  'inl 
.secmidarily     fn)ni     siircDin  '  u^ 
mesenteric  glands. 
Carcinoma.- -My  far  the  comnMXH'st   new-growth  \tf  the  iiiii-i'       i- 
the  can-iiioina.     In  the  large  majority  of  casf-s  it  is  found  in  il"       "-'' 
intestine,  and  iismdlv  in  the  rectum.     It  is  occasionallv  met  wiiii       'HI 


rlin>ni<'  colitis  with  (Hilypoid  outitriiwlht*. 
(Kriiiii  lilt*  PufluiUmirul  Mui«futu  uf  .Hdiill 
rnJMTsity.) 


'  Nioholls,  A  ('ii.st'oi  .\cp('s.s<ir\   I'liiicrcii.'*,  Vliinl    Moil.  .Imir  ,  211:  I'.KNI 
'  Mont.  .Med.  .lour.,  27 :  ISlts :  ;tl . 


PLATE   V 


Acle 


noma  (Papilloniaioiis)  of  the  Co! 


Cnrpinomatoiis  Chanq 


on   with    Early 


f.      'NirhoMs. 


11 


1 


1  ! 


31 


i- 1 1    i  1 


CARCINOMA 


453 


the  ileocecal  valve,  the  iliac,  splenic,  and  hepatic  flexures,  and  the 
cecum.  Of  late  yeafs  a  considerable  number  of  caaes  of  primary 
carcinoma  of  the  appendix  have  been  recorded.'  They  are  curious  in 
that  they  do  not  tend  to  form  ilistant  metastases.  Primary,  round- 
celled  sarcoma  of  this  structure  has  also  l)een  described.'  When  in  the 
small  intestine,  a  rare  occurrence  comparatively,  the  site  of  election  is 
in  the  neighborhood  of  the  bile  papilla.  A  note-  worthy  fact  is  the 
relative  frequency  with  which  intestinal  carcinomas  are  met  with  in 
voung  people.  This  perhaps  is  to  l)e  explained  in  connection  with  the 
common  occurrence  of  mucous  polyps  of  the  intestines  in  children. 


mi 


Tm.  US 


( ■■ir.in..nia  of  the  m-tum.     Zei.s  nbj.  A.  without  .n-ukr.     Sew  formatinn  of  tiibulen  i» 
well  lieliiw  the  museulariii  mucoMp.     (From  the  .•olleriioii  of  Dr.  A.  «.  Nicholl».) 


'1 

Clllll 


lit'  carcinomas  of  the  intestine  arc  of  the  medullary,  .irir 
III  type.     Histologically,  with  the  exception  of  the  s(|iianu 


rrhou,t,  or 
exception  of  the  s<|uanious-celle(l 
form  starting  at  the  anus  and  that  originating  in  the  Bnmner's  glands. 
lilt  V  an-  cylindrical-celled  and  of  glandular  appearance. 

I  111-  ncw-gn)wth  forms  n  solitarj',  localized,  sharply  <lefined,  fungating 
iiiM-s,  or,  again,  may  invv>lie  a  cnnsi(lend>le  area  of  the  Iwwel.  The 
Mill,  r  (•aiicprs  have  little  tendency  to  obstruct  the  lumen.  In  stnnc  cases, 
til'  infiltration  is  more  restricted,  but  forms  a  ring-like  mass  encircling 
ill'  l".\vcl.  The  muscular  wall  is  infiltrated  and  hardened,  so  that  the 
I'll'  line  is  convertwl   into  a  stiff,   tmcollapsible  tiil)e.     The  surface 

I  iiiiig.  Annuls  of  Snrg-rv,  .'JT:  1903:549;  also,  Harto.  .\iinnU  of  Siirgcn-.  .lime: 
1'"'"    iii'l  HiillcHton,  Uncpt,  Lond.,  2:1900:11. 
i'orsun,  Practitioner,  70:  1903:515. 


4M 


THB  llfTESriNBa 


1     i:i 


generally  ulcerates,  producing  a  shallow  erosion,  the  edges  and  base  of 
which  are  densely  fibrous,  leading  to  a  cicatricial  constriction  of  (lie 
bowel.  The  affected  part  may  become  adherent  to  neighboring  structures, 
or  the  ulcer  may  perforate,  leading  to  peritonitis.  Metastases  in  tli<- 
liver  (through  the  portal  system),  lymph-nodes,  and  peritoneum  iire 
common.  Secondary  carcinomas  are  as  rare  as  the  primaiy  are  common. 
They  are  metastatic  or  arise  by  impUntation  of  carcmomas  of  the 
pancreas,  stomach,  uterus,  and  vagina. 


Ill 


CHAPTER   XXI. 

THE  LIVER. 
AMOMALIII. 

Oongenital  AnonuUei .— The  liver  may  be  completely  ftkMBt,  or  may 
deviate  considerably  from  the  normal  in  form  and  size.  The  organ 
is  occasionally  thin  and  flat,  or  the  shape  of  a  short  truncated  pyramid. 
A  Nuinewhat  common  anomaly  is  for  the  left  lobe  to  be  prolonged  back- 
wunl  and  downward  in  the  form  of  a  Uncnla.  The  lolit-s  may  be  increased 
in  number  and  abwrant  lobw  attached  by  a  narrow  pedicle  have  Iteeri 
found  in  hernial  sacs  at  the  umbilicus,  where  they  have  been  mistaken 
for  tumors.  AcMiaoty  Uvan  are  occasionally  met  with,  situated  in  the 
suspensory  ligament.  The  liver  may  be  rtvtrMd  and  situated  on  the 
left  .side  of  the  abdomen  in  the  condition  of  transposition  of  the  viscera. 
It  inayalsobe  diiloe«t«d  in  various  forms  of  congenital  hernias. 

The  gall-bladder  may  lie  aUsent  or  buried  in  the  liver  substance,  or, 
apiin,  directed  Iwckward.  The  biliarj-  ducts  may  be  absent,  abnormally 
dilated,  or  occluded  at  .some  point.  The  ductus  communis  choled<>- 
olius  may  be  reduplicated  and  the  single  or  double  duct  may  discharge 
into  the  stomach  or  at  some  unusual  situation  in  the  bowel. 

Acqiiired  Abnoniudities  of  81i»p«  and  Positioii.— Of  acquired 
deformities  the  most  common  is  the  so-called  "tediic-lobe."  The  prc.s.s- 
un-  of  a  tight  corset  forces  in  the  lower  portion  of  the  thoracic  wall,  so 
tliiit  u  transverse  fissure  is  produced,  which  divides  the  right  lobe  into 
an  upper  and  a  lower  portion.  The  Glisson's  capsule  over  the  fissure 
IS  thickened  and  of  a  pearly  white  color,  while  the  subjacent  acini  are 
atrophic.  A  portion  of  the  liver  may  be  almast  if  not  quite  separated 
from  the  main  mass,  being  connected  merely  by  a  fibrous  band.  The 
la(inK-lol)e  is  generally  seen  in  persons  having  a  short  thorax,  ti^rlit  lacing 
111  timse  with  long  waisU  being  more  likely  to  produce  a  movable  ki<lney. 

riie  so-called  Uebemaiiter  groovei  are  ^-ommon  also,  occurring  m 
"tir  .'X|)erience  in  7.26  per  cent,  of  all  autopsies.  These  cfuisist  in  a 
viii i.il)!..  number  of  parallel  grooves  on  the  outer  convexitv  of  the  right 
lolx',  which  are  directed  forward.  They  do  not  correspond  in  direction 
«itii  the  rilw.  Several  explanations  have  been  offered  f  -r  their  occur- 
Tvnn:  I.iel)ermeister  thought  they  were  due  to  pressure  from  difllrult 
n-.pir,it.)i V-  movements,  while  Zahn  attributed  them  to  the  action  of  a 
hv|,,riropiiied  diaphragm.  la  some  cases  the  depres-sions  can  lie 
;'linwi.  I-,  correspond  with  thickened  bands  of  muscle.  VossMy  a  few 
instances  are  congenital. 

<  Hvm^  to  a  laxness  of  the  suspensory  ligament  the  liver  may  be  more 

''  -s  remote  from  its  natural  position  (Iwpatoptoaii;  ttobila  or  floating 


or  Ic-^s 


THK  LIVER 


1  I 


Um,  The  organ  may  lie  aiitevcn d,  its  anterior  Umler  passiiiK 
ilownwani  and  forward,  the  |M)8terior  border  remaining  prHciicallv 
unaffected.  The  HUplacement  may  abo  be  oblitjue,  the  left  lolie  d«'. 
BcendiiiK,  or,  apiin,  the  whole  arjpin  may  b«'  affected.  The  con«lition 
of  disliM-atcd  liver  i.s  (Himmonly  assoc-iuted  witli  gustruptoHia  or  enti'n>- 

ptOHU). 

The  liver  may  lie  pu  lied  downward  liy  the  pressure  of  pleural  exu- 
dates or  effusions,  intnithoracic  growtlus,  or  emphy.sema.     It  may  In- 
foreecl  upward  in  easen  of  a-scites,  ititra-abdommal  cysL<i,  or  tunioi 
The  traction  of  iiitra-alMiomiiuil  udhcsiunii  also  may  pull  the  orcaii  oui 


of  its  natural  position. 


OOtOULATOBT  DISTDKBAMOIS. 

Antmia.— Anemia  of  the  liver  is  eilhcr  a  manifestation  of  a  genenil- 
ize<l  or  systemic  anemia,  or  is  due  to  s«)nie  IcM-al  di.stiirliance,  such  us 
pres.sure  u|i<in  the  organ  or  swelling  of  the  parenchymu. 

BypMrMDia-— Activa  H]rp«rainia.— .\ctive  hyperemin  is  met  with  us 
a  physiological  coiidiiion  after  a  meal.  and.  pathologicully,  in  the  early 
stages  of  acute  inflammations  of  the  liver,  and  in  all  cases  «»f  congestioti 
of  the  gastro-intestinal  vascular  .syst<'m. 

PuiiT*  BTpanmia.— Passive  hyperemia  i.s  brought  aliout  by  any  cauM- 
that  raises  the  bliMxl  pressure  within  the  hepatic  vein  and  inferior  \<im 
cava.  Among  the  important  conditions  that  sh«iul«l  lie  mention- . I  in 
this  connection  are  stenosis  or  insufficiency  of  the  mitral  or  tri(ij-|)<l 
valves,  canliao  weakness,  emphysema  of  the  lungs,  indurative  pneumonia, 
right-sidefl  pleural  effusions,  aneurisms,  tumors,  or  enlarged  jjImmiIs 
pressing  up<in  the  inferior  vena  cava. 

In  the  early  stages  the  liver  is  enlarged,  often  attaining  a  considrrahli' 
size,  soft,  and  full  of  bloo<l,  which  drips  out  of  it  on  section.  In  mlor 
it  is  dark.  purplish-re«l.  After  the  blood  has  been  draine«l  out  the  ..i;;an 
will  lie  found  t<i  lie  somewhat  shrunken  (red  atrophy).  loiter,  tin  !i^<r 
is  more  or  less  diminished  in  .size,  firm,  with  a  finely  granular  snrt;i<e. 
On  section,  the  appearance  is  like  that  of  a  nutmeg,  whence  the  u  nn 

"iiiitiny-llrer."    This  is  due  to  the  fact  that  the  central  jiorti I  ilie 

lobule  is  «ingeste<l  and  .somewhat  depre.s.se«l  lielow  the  general  sMir;iir, 
while  the  jieriphery  is  pale  yellow  or  ycllowish-lmiwn,  and  sw.  il.ri. 
owing  t<i  the  pre.sence  <if  fat  within  the  .secreting  cells,  llcr'  hikI 
tiiere  redder  patches  are  to  lie  seen  which  are  regenerate*!  lobiili 
the  most  advanced  stage  the  liver  is  small  and  hard,  owing  to  ll 
duction  of  filmin.s  ti.ssue  (cyanotic  induration).  In  this  way  a  l( 
cirrhosis  may  lie  prtxluced— the  "cirrho.se  canliaqiie"  of  the  I 
writers.     In  ,!ur  exjierience  this  affection  is  rare. 

On  histological  examination,  the  main  changes  are  at  first  to  1" 
in  the  central  p<irtion  of  the  !<tlinles.     The  centriloliular  veins  wi;! 
capillaries  are  distended  with  blood,  and  the  <Tilunins  of  liver  c 
tween  are  coniprt<s.se(i.     The  .secreting  cells,  therefore,  l.oisifne  a: 


In 

!"■"- 
.,  of 
tii'll 

iiud 

'icir 

U- 

>liir, 


LBUKEMIA 


457 


>°i(i.   114 


ami  cimtoin  yellowi»h4.nwn  Rniniilf^i>r  \»^wn{,  ti^thor  with  minute 

|;l(>l)iil«*  of  fat.     ly  drKenerutiiMi  Is.  a.n  <.i.r  ii.iKht  exiiwt.  inoNt  niarM 

III  the  central  ami  intermediHte  zones 

iif  the  lohules.  Here  and  there gmiipti 

of  (rlU  are  seen,  mueh  bujjrr  than  the 

onlinary  parenvhytn8touscelU,havinK 

also  lar^e  nuclei,  which  take  an  in- 

fiiise  Mtain.  Thes*'  imlicate  an  attempt 

at  rcjp-neration.  In  theinoreadvanced 

fiiriiw  practically  all  the  capillarieit  of 

ihc  lohule  are  cunffested  and  the  ^mit 

Itiilk  of  the  liver  <-elb  disappear,  beinjf 

rrpresented  only  by  fragmented  nuclei 

and  iiiiis.se.s  of  pi);inciit.     In  certain 

cases,  where  the  con(>e^4tion  is  gratliial 

ill  its  «)n.set,  concomitant    with   the 

<i«>,'eneration  there  is  pnJiferation  of 

(•(mnective  tissue,  leading  to  inilura- 

ti<>ii(repla<'ementfil>rosis),a  condition 

foiiiMl  iisiiully  alM>ut  the  radicles  of 

ilu'  hepatic  vein,  but  to  some  extent 

also  in   the  periportal  districts.      The   portal    sheaths   mav   present 

•  vulenccs  of  a  round-ceiled  infiltration.  " 

Leukemto.— In  ienlcemia  the  capillaries  evervwhen"  are  filled  with 
Inik.K  vfes.  and  pjirticiilariy  iarjte  ucciimiilatioiis  nmv  U  noted  in  the 


NulnifK  livfr  (Krim  ilir  rallinlii(i<-al 
DapMimviit  .if  (Ik  ||,,yal  Viiluria  \\,m. 
pilall 


'Hi 


Km.  IIS 


.k.n,ia  nl  ,l,e  liver.      Tl*  r.„ilUrie.  «„  lille.1  will.  Ie«k.«-y„..     Z,i„  „bJ    *    willu.at 


MKROCOrv   MSOWTION   TBT   CHART 

(ANSI  and  ISO  TEST  CHART  No  2) 


A 


.>^PPLIED  IM/IGE    Inc 

1653   Eosl   Moil    Stree' 

Rochester.    Ne«   York         U609        USA 

(716)   *82  -  0300  -  Pfiofie 

(716)   288-  5989  -  Fo. 


458 


THE  LIVER 


portal  districts.  There  has  been  a  debate  whether  these  represent 
a  hyperplasia  of  lymphoid  tissue  normally  present  there  or  a  multiplica- 
tion of  leukocytes  that  have  migrated  there. 

(Edema. — (Edema  of  the  liver  is  met  with  occasionally  and  leads 
to  enlargement  of  the  oi^an.  The  condition  has  not  attracted  much 
attention,  but  is  more  common  tiian  has  usually  been  thought.  The 
liver  substance  is  more  succulent  than  usual,  and  on  section  has  a  pale, 
dull,  shiny  appearance.  Microscopically,  one  can  see  clear  spaces  be- 
tween the  capillaries  and  the  parenchymatous  cells  of  the  liver.  The 
condition  can  l)e  reproduced  experimentally  by  stimulation  of  the  liver, 
and  apparently  may  be  readily  brought  about.  Birch-Hirschfeld  attrib- 
uted icterus  neonatorum  to  compression  of  the  bile  ducts  by  cedematous 
connective  tissue. 

Hemorrhage. — Hemorrhage  into  the  substance  of  the  liver  nia\ 
occur  from  traumatism,  the  hemorrhagic  diathesis,  infarction,  acute 
yellow  atrophy,  and  various  infections. 

Embolism  and  Thrombosis. — Embolism  or  thrombosis  of  the  hepatic 
artery  or  its  branches,  especially  when  associated  with  cardiac  weakness, 
leads  to  the  formation  of  an  infarct  (Chiari).  The  infarction  is  rarely 
typical,  for  the  reason  that  the  liver  is  well  supplied  with  blood  also  froiii 
the  portal  vein. 

Tkroml)o.iin  of  the  portal  vein  is  a  not  uncommon  condition.  In  the 
majority  of  instances  it  is  really  a  thrombophlebitis.  The  main  trunk  of 
the  vessel  or  any  of  its  branches  may  be  affected.  Infective  processes 
occurring  in  the  organs  or  structures  included  in  the  portal  system,  as, 
for  example,  the  spleen,  intestines,  stomach,  or  mesentery,  particular! v 
when  septic  in  character,  may  lead  to  it.  It  is  especially  common  in 
connection  with  appendicitis.  Inflammations,  too,  about  the  bile  ducts, 
or  in  the  retroperitoneal  tissues  in  that  neighborhood,  may  extend  to  the 
portal  vein  and  induce  thrombosis.  If  septic,  the  thrombus  may  break 
down  and  lead  to  the  formation  of  an  abscess,  and  minute  particles  of 
infected  material  may  be  carried  as  emboli  into  the  liver.  Or,  a^ain, 
if  non-infective,  the  thrombus  may  gradually  soften  .-.;id  d.^appear,  or 
may  organi  2.  In  one  case  which  we  observed,  following  typhoid  tV\or, 
the  main  trunk  of  the  portal  vein  was  completely  occluded,  and  here  jind 
there  in  the  smaller  branches  strands  and  tags  of  fibrous  tissue  dMild 
be  detected,  the  remains  of  the  previously  existing  thrombus. 

Thrombosis  is  also  occasionally  observed  in  cases  of  portal  cir 
and  where  pressure  is  exerted  upon  the  portal  vein  by  tumors  exu 
from  the  biliary  passages,  pancreas,  stomach,  or  intestines. 

Where  the  ol)struction  to  the  circulation  is  complete,  ascites  con 
rapidly  and  may  be  intense.     Important  structural  changes  in  tli' 
do  not  usually  occur  '"n  the  liver  itself,  since  it  is  supplied  with 
from  the  hepatic  ar»  ry. 

Infarcts. — Infarcts  of  the  liver  of  the  same  type  as  those  o((  1 
in  other  organs  are  rare.  They  may  be  produced  by  embolism,  t! 
bosis,  or  other  caiises  leading  to  occlusion  of  the  portal  vein,  ^ 
artery,  or  hepatic  vein.    The  condition  seems  to  be  more  coniinf ' 


Ik  ISIS, 


ilig 


iiii^  on 
liver 
lood 


iiTing 
irom- 
j.atic 
after 


ACUTE  PARENCHYMATOUS  HEPATITIS  459 

occlusion  of  the  artery  than^of  the  vein,  and  in  this  case  is  of  the  anemic 
variety.  Hemorrhagic  infarction,  so-called,  is  believed  to  be  more  fre- 
(juent  y  due  to  portal  embolism,  though  it  may  also  result  from  obstruc- 
tion of  the  hepatic  artery,  The  condition  is  not  a  true  infarction,  however 
inasmuch  as  the  liver  cells  still  retain  their  ataining  properties.  More 
properly  it  is  an  intense  capillary  congestion.  When  the  obstruction 
involves  the  vessels  in  the  intermediate  portion  of  the  lobules,  formed  by 
the  union  of  the  capillaries  of  the  portal  vein  and  hepatic  artery  it 
leads  to  the  production  of  one  variety  of  focal  necrosis.  Schmorl  and 
Frutz  have  described  this  condition  in  connection  with  eclampsia  Such 
necrotic  areas  are  usually  demarcated  by  a  zone  of  reactive  inflammation, 
if  the  part  be  infected,  abscess  formation  will  follow,  but  if  not  and  the 
patient  survive,  the  degenerated  cells  are  absorbed  and  replaced  by  con- 
nective tissue.  •' 


INFL1BIMATI0N8. 

Hepatitis.— The  subject  of  hepatitis,  or  inflammation  of  the  liver 
is  one  of  the  most  difficult  in  the  domain  of  special  pathology  This' 
in  part,  arises  from  the  fact  that  we  are  still  to  some  extent  ignorant  of 
the  etiology  of  many  of  the  diseases  coming  under  this  category,  and  in 
part,  from  the  circumstance  that  the  terminology  has  been  and  still  is 
greatly  confused.  It  is  impossible,  therefore,  to  establish  a  classifica- 
tion that  IS  entirely  satisfactory,  and  any  that  may  be  proposed  must 
be  largely  tentative.  '^    "^ 

Fi-orn  the  standpoint  of  the  morbid  histologist,  we  may  divide  hepatitis 
into  the  acute  parenchymatous,  the  acute  interstitial,  and  the  chronic 
mterstitul  an  arrangement  that  is,  perhaps,  as  little  open  to  cavil  as 
any.  It  should  be  remarked,  however,  that  these  types  are  not  alwavs 
sliarply  defined  one  from  the  other,  and  that  various  combined  or  mix^ 
forms  occur. 

Acute  Pwenchym^us  Hei>atitis.-Acute  parenchymatous  hepatitis, 
an  affection  with  difficulty  distinguishable  from  cloudy  swelling,  is  a 
airlv  frequent  occurrence  in  the  course  of  the  infective  fevers,  particu- 
larly typhoid,  tuberculosis,  pneumonia,  and  septicemia.  The  liver  is 
Slightly  enlarged,  and  on  section  is  pale,  grayish,  and  friable.  Micro- 
sc..i.icailv,  the  parenchymatous  cells  are  swollen  and  granular,  while 
n,' V'l"  r  T  '''^^^'^  obscured.  Not  infrequently,  one  can  see  in  the 
portal  sheaths  small  collections  of  leukocytes,  which  may  even  extend 
tor  some  little  distance  between  the  columns  of  liver  cells.  At  the  height 
0  M„.  process  the  parenchymatous  cells  become  fatty,  hyaline,  and 
oft.M,  vacuola  ed.  While  certain  of  them  necrose  and  disappear,  others 
seen,  ,,,  proliferate,  as  there  is  an  increase  in  the  number  of  the  nuclei 
^ul  also  m  their  size.  The  condition  approximates  to  the  type  of 
lie  inflammatory  necroses  accompanied  by  a  reactive  and  reparative 
mtiuniniation.  *^ 

Alli<.,|  to  this  affection  is  the  rarer  condition  in  which  necrosis  and 
■«rn|,i,v  are  the  prominent  features,  the  regenerative  processes  being 


460 


THE  LIVER 


for  a  time  at  least  in  the  background.  Wasting  is  marked  and  tlie 
shrinkage  of  the  liver  can  be  watched  clinically  tlay  by  day.  Of  this  the 
type  is  the  so-called  acitte  yellow  atrophy  of  the  liver.  This  disease  l>egiiis 
with  all  the  .signs  of  a  severe  systemic  intoxication — high  fever,  deliriiiin, 
a  quickly-developing  jaundice,  multiple  hemorrhages,  and  finally,  con- 
vulsions and  coma.  A  fatal  termination  generally  takes  place.  In  the 
early  stages  the  liver  is  usually  enlarged,  but  quickly  diminishes  in  sizi-. 
The  liver  may  lie  reduced  to  one-half  its  natural  size,  its  consistency 
is  increased,  and  the  capsule  is  thrown  into  folds,  owing  to  the  .shrinkii^'e 
of  the  parc'uchyma.  On  .section,  the  surface  is  of  a  bright,  leniim- 
yellow  color,  with  numerous  patches  of  a  darker  brownish-red.    The 


Fio.  lis 


'!  i 


Acute  yellow  atrophy  of  the  liver.  Section  show:*  atmphy  of  parenehymatoun  cells,  fr;t4.'mpnt- 
ation  of  iiuclt-t.  and  i>!«etulohile  ducts.  Zeiss  uhj,  .\.  without  ocular.  (Front  llie  cull«'iti>)n  of 
the  Royal  Victoria  rifispital.) 


reddish  color  usually  pi-edominates  in  the  left  lobe.     The  yellow 
are  .soft  and  .somewhat  sv.ollen,  while  the  red  are  firmer  ami  i 
of  a  leathery  consistency.     Small  hemorrhages  are  common  thmii; 
the  substatice.     The  vessels  ct>ntain  thin  bltMxl  and  the  bile  ciiii'l 
thin  bile. 

Histologically,  the  parenchymatous  cells  in  the  yellow  pat(Ii<' 
extensive  fatty  changes,  together  with  an  aociimulatitm  of  bile  p'l: 
and  crystals  of  bilirubin.     The  fatty  droplets  can  Iw  foimd  ii'i 
within  the  cytoplasm,  but  also  within  the  nucleus.     The  redtii^': 
are  compo.sed  mainlv  of  a  network  of  capillaries,  in  the  meshe.'^  ni 
run  be  .seen  isolat'       legcncrating  liver  cells,  and  a  detritti.s  of  ' 
down  cells,  fragmt      d  nuclei,  masses  of  pigment,  chromatin,  am' 


.irea.s 
atluT 
jhoiit 
hirie.s 

-liow 
nient 
only 
im'iis 
.hirh 
rken- 
I(HkI. 


SUPPURATIVE  HEPATITIS  OF  ARTERIAL  ORIGIN  4^i\ 

Where  death  has  l)een  more  than  usually  delayed,  some  evidences  of 
rej;eneration  can  be  made  out.  Small  nodes  of  newly-formed  liver 
ttlls  may  be  found  here  and  there,  recognizable  by  the  fact  that  they  are 
iarjier  than  normal,  stain  more  intensely,  and  have  large,  deeply-staining 
nuclei,  some  of  them  exhibiting  mitosis.  A  round-celled  infiltration 
can  l)e  made  out  in  the  portal  sheaths  together  with  some  proliferation 
of  the  connective  tissue.  Pseudobile  capillaries  may  also  be  present  in 
considerable  numbers,  giving  the  section  somewhat  the  appearanc-e  of 
a  cirrhftsis. 

.\ciite  yellow  atrophy,  in  most  cases,  is  almost  certainlv  an  acute 
(iefjeneration,  the  result  of  a  circulating  toxin.  From  the  fact  that  cases 
sometimes  cwcur  in  epidemic  form,  though  rarely,  this  toxin  is,  probably, 
in  some  instances,  bacterial  in  origin.  The  disea.se  is  most  common 
iHtween  the  ages  of  twenty  and  thirty,  and  is  usually  found  in  women 
(hiring  the  puerperium.  Very  similar  forms  of  acute  degeneration 
and  necrosis  of  the  liver  parenchyma  wcur  in  connection  with  poisoning 
In  phosphorus,  arsenic,  and  chloroform.  Several  ca.ses  have  been  re- 
ported lately  resulting  from  chloroform  anesthesia.  Thev  usually  are  met 
with  in  children,  the  subjects  of  long-standing  and  debili'tating  disease. 

Acute  IntentitiAl  Hepatitis.— Acute  interstitial  hepatitis  may  be  simple, 
but  is  more  often  suppurative.  It  is  due  to  infection  of  the  liver  by 
mil  n)6rganisms  that  gain  entrance  to  it  through  the  general  blood  stream, 
the  portal  vein,  or  the  bile  passages.  In  newlwrn  children  infection 
throu>;h  the  un-bilicn!  cord  is  an  occasional  cause.  In  rare  cases  a  retro- 
grade meta,it:isi  ■  of  Ivctciial  agents  may  take  place  from  the  superior 
vena  cava. 

Simple  infer.itltial  hepaiitix  is  occasionally  seen  in  the  livers  of  persons 
(ivmj;  from  infectious  disease,  notably  typhoid  and  tuberculosis.  Besides 
cloudy  s.velliiig  of  the  parenchyma,  small  collections  of  inflammatory 
round  cells,  of  greater  or  less  extent,  are  to  be  found  in  the  portal  sheaths. 
N)nie  authorities  are  inclinetl  to  attribute  some  importance  to  this 
manitestation  of  infectious  disea.se  in  the  etiology  of  cirrho.sis. 

Acute  suppurative  interstitial  hepatitis  may  be  primarv  or  secondary. 

I  he  pnmary  form  is  rather  rare  in  temperate  regions  but  is  more  common 
III  the  tropics,  where  it  is  known  under  the  name  of  tropical  abscess. 

llie  cases  occurring  in  this  country  are  almost  invariablv  due  to  trauma. 
sii.Ii  as  severe  crushing  injuries  to  the  liver,  or  are  examples  of  wound 
intect  i,m.  The  vast  majority  of  cases,  as  we  meet  them  here,  are  second- 
ary (,,  infection  elsewhere,  and  are  either  metastatic  in  nature  or  arise 
In  .  M<ct  extensum.  In  the  metastatic  forms  the  infective  agents  reach 
the  hver  l,y  way  of  the  hepatic  artery,  the  portal  vein,  or  the  bile  ducts. 

II  n.  4  autopsies  of  which  we  have  notes,  performed  at  the  Montreal 

<nn.  ral  and   Royal  Victoria  Hospitals,  there  were  4(1  cases  of  liver 

ahs, , ,.;  22  were  due  to  portal  infection,  S  were  biliarv,  .J  gave  a  historv 

'  ntery,  .i  ca.ses  were  arterial,  7  occurre*!  from  extension,  and  1  was 
I'litly  primarv. 

Suiipurative  Hepatitis  of  Arterial  Origin.-  -This  form  is  usuallv  but 
""'      111  infestation  of  a  generalized  septicemia,  the  infective  agents 


al)s 
of,l 


3 


1-^ 


462 


THE  LIVER 


reaching  the  liver  by  way  of  the  hepatic  artery.  The  etiology  of  this 
form  in  tiiat  of  septicemia  in  general.  The  disease  may,  therefore,  com- 
plicate all  kinds  of  wound  infection,  ulcerative  endocarditis  and  aortitis, 
osteitis,  osteomyelitis,  putrid  bronchitis,  gangrene  of  the  lung,  infection 
of  the  puerperal  uterus,  and  suppurative  lesi.ns  about  the  bladdtr, 
prostate,  and  urethra.  It  has  been  known  to  follow  carbuncle  and 
whitlow.  The  infective  agents  usually  at  work  are  the  Streptococcus 
pyogenes  and  the  Staphylococcus  albus  and  aureus. 

Snppuntiva  Bepatitia  of  PorUl  Origin. — Here  th<'  infective  agents  come 
from  any  part  of  the  district  drained  by  the  pirtal  system.    Septic 
processes  in  the  appendix,  cecum,  small  intestine,  stomach,  pancnas, 
and  spleen  are  important  in  this  connection.    The  most  frequent  siujik 
cause  is  appendicitis  (perityphlitis).    Combining  the  statistics  of  Arm- 
strong,' Einhom,  Langheld,  «<nd  Fitz  in  546  cases  of  appendicitis  that 
were  examined  post  mortem,  pylephlebitis  and  abscess  of  the  liver  w»'re 
found  in  28,  or  rather  more  than  5  per  cent.     Exceptionally,  in  cases  of 
cholecystitis  and  pericholecystitis,  extension  of  the  process  to  the  jiortal 
vein  may  result  in  an  embolic  infection  of  the  liver.    The  lesion  is  in 
many  instances  essentially  an  acute  thrombophlebitis  of  the  portal  vein 
or  a  purulent  infiltration  of  the  vessel  wall  and  adjacent  parts — suppura- 
tive portal  pyelephlebitis.    In  a  typical  case  of  septic  portal  infection 
the  liver  contains  a  number  of  abscesses  of  varying  size.    These  are 
grouped  about  the  branches  of  the  portal  vein,  after  the  fashion  of 
currants  upon  a  stem.    The  larger  abscesses  are  often  irrej^uiar  or 
lobular  in  appearance,  owing  to  the  fact  that  they  result  from  the  con- 
fluence of  smaller  foci.    Small,  isolated  abscesses  are  often  to  l)e  foinid 
grouped  about  the  larger  ones,  but  separated  from  them  by  a  small  amount 
of  comparatively  unaltered  liver  tissue.     The  abscesses  are  filled  with 
yellowish-green,  viscid  pus,  often  mixed  with  blood,  having  a  foul  odor, 
and  sometimes  containing  sequestra  of  liver  substance.    Round  about  the 
abscesses  is  a  narrow  zone  of  a  yellowish-white  color,  or,  in  casts  of 
a  gangrenous  type,  of  a  dirty  green  appearance.     The  portal  vein  iiiid 
its  branches  within  the  liver  usually  contain  more  or  less  dirtv-iookinj; 
septic  clot.    The  abscesses  are  chiefly  to  be  found  in  the  rijilit  InUe. 
Where  the  infection  has  taken  place  through  the  hi>patic  artery  the  tod  of 
suppuration  are  usually  smaller  and  more  widely  and  evenly  distritintcd. 

Histologically,  in  the  more  receov  lesions,  the  smaller  branches  ut  the 
portal  vein  or  the  arterial  capillaries,  as  the  case  may  be,  are  pnkid 
with  microorganisms.  Round  about  are  extensive  accumuiatiui.  of 
inflammatory  leukocytes,  tending  to  stain  badly  towanl  the  ccTitn  Ir. 
the  larger  abscesses  the  central  portion  has  broken  down  and  tli'  "Us 
composing  it  are  in  various  stages  of  necrosis  and  disiiitegratim  At 
the  periphery  of  the  abscess  the  leukocytes  gradually  lose  iIkim  !ves 
between  the  liver  cells.  The  parenchyma  of  the  liver  in  theiieighi'  ■! 'mhI 
presents  the  appearance  of  coagulation  necrosis.  The  specific  (>  '  :ire 
swollen,  hyaline,  or  compressed,  containing  nuclei  that  stai"   i    'Hy. 


Brit.  Med.  Jour.,  2:1897:945. 


SUPPURATIVE  HEPATITIS  ARISING  PER  EXTENSIONEM       46;j 

^^J.!"  !**?  "t"***'*?  T.."?*""  *•'«  «'"'«<*•  the  Glis.son'3  cafxsule  is  often 
inhUrated,  the  endothelial  cells  are  in  process  of  desquamation,  and 
there  may  be  a  deposit  of  fibrinopurulent  exudate  (perihepatitis)  The 
hver,  as  a  whole,  is  congeste<l  and  more  or  less  swollen  and  cloudv  The 
rases  are  usually  fatal,  but  instances  are  on  record  where  the  abscesses 
have  ruptured  mto  the  lung  or  intestine  with  spontaneous  cure.  Healing 
may  take  place  with  the  evacuation  or  absorption  of  the  pus  and  the  for- 
mation of  nbrous  scars. 

Fio.  117 


Mul,i„le  ab«e.,«!»  „f  the  liver.      Zn-«  „l,j.  m>.  wiUu.ut  ocular. 
<'f  I>r.  .\.  (i.  .\icholl3.) 


(Kriim  the  colleitirui 


Suppurative  Hepatitis  of  Biliary  Oiigln.-Here  infection  takes  pla«> 

y\  »..sociated  cholangitis;  in  o-her  ca.ses  the  infection  results  upon 
ol.stru.t.on  of  the  bile  duct  from  tumors  or  cvst.s.  The  bile  nass S-s 
mav  occasionally  be  infected  from  the  intestine,  as  !n  dy^nt'en  S 
.  .    Lannois'  has  recorded  a  ca.se  of  liver  abscess  occurring  in 

here   .7^'  ^"T^"'  Ti    r^*^  '^'  ^"^'"^   "'"'"»""■«  and, 

ll-  description  of  the  variou.s  abscesses  giver,  nbove  hol.ls  fairlv 
'"I'l  in.i.\  contam  gritty  matter  or  concretions 

fonnTl'n.°T"-  ^"f'*'  «xf  n,ionem.-This  is  a  fairlv  common 
■'"  "f  suppuration  m  the  In.r.     The  pnucs  i.s  u....„!ly  .\ii,erficial, 


'  Revue  de  M^decine,  15: 1.S9."):<)09. 


/■^ 


TW 


4(>4 


THK  L> 


I'. 


affecting  the  tapsule  uiitl  that  ptirtion  of  the  liver  immeiliately  beneutli 
it.  Diaphrapnatie  and  sulxliaphragmatic  abseesses,  empyema,  suppu- 
rative choletv.stiti.s  ami  choleilochitis,  perinephric  absc-ess,  alwoess  of  tli.- 
head  of  the  pancreas,  perforating  ulcers  of  the  stomach  and  duodeiiiini 
invade  the  liver.  ForeiRii  bodies,  such  as  fish-bones,  needles,  or  otlur 
sharp-pointed  articles,  may  pass  through  the  stomach  or  intestines  and 
be<-omc  loilged  in  the  liver,  where  they  may  set  up  suppurative  inHam- 

mation.  .     ,  ,       .     .         .•        t 

TropiMl  Abicew.— This  variety  is  characterized  by  the  formation  of 
one  «)r  more  foci  of  necrasis  and  softening  in  the  liver,  either  with  or 
without  a  relation  to  dvsentery.  Unlike  the  forms  of  abscess  we  have 
i)een  describing,  the  riile  here  is  for  one  large  or  at  most  but  a  f«w 
abscesses  to  lie  developed. 

The  cases  are  met  with  usually  in  tn)pical  and  subtropical  countries, 
whence  the  name.  The  etiological  factors  are  as  yet  but  imperfectly 
understo<Kl.  Some  few  cases  appear  to  l)e  due  to  dietetic  errors;  fne 
living,  the  excessive  use  of  animal  food,  and  particulariy  excess  in  alco- 
hol, are  thought  bv  some  to  »)e  particularly  jM>tent  causes.  We  nuisl, 
ill  these  cases,  assume  that  there  is  some  previous  deterioration  of  the 
resisting  power  of  the  liver  that  renders  it  a  more  ea.sy  prey  to  toxins  aiu 
invading  microorganisms.  The  great  majority  of  ca.ses  are  associated 
with  tropical  dysentery.  In  this  connection  Kartulis*  states  that  in 
.500  cases  of  liver  abscess  coining  under  his  notice,  from  50  to  fiO  per  cent. 
gave  a  history  of  dvsenter>-.  There  must  lie  something  peculiar  al.ont 
the  condition,  for  in  the  catarrhal  an«l  ulcerative  dysenteries  foiin<l  in 
temperate  c'=mes  liver  abscess  is  excessively  rare.  The  studies  of  Kartii- 
lis,  Losch.'Knise  and  Pas(|uale,' Councilman  and  Lafleur,*have  sliown 
that  a  fairiv  large  projK)rtion  of  cases  of  dysenteric  origin  are  due  t«. 
the  ama-ba'coli.  What  this  proportion  is  is  uncertain.  Flexiier  is  of 
the  opinion  that  the  great  majority  of  tlysenteric  cases  are  of  aiiuiljir 
origin.  In  a  large  experience  he  did  not  fintl  a  single  case  due  to  tlie 
Shiga  bacillus.  A  few  writers,  however,  refer  to  the  discovery  i.f  a 
typhoid-like  bacillus  which  pos.sibly  was  this  organism,  and  Pansiin  an<l 
Babes  seem  to  have  obtained  it  or  a  similar  germ  in  several  cases  of 

liver  abscess.  . 

The  amn-bic  abscess  in  about  75  per  cent,  of  the  cases  is  solitary, 
and  in  about  the  same  proportion  is  situated  in  the  right  lobe,  usimilv  in 
the  dome  or  under  surfac-e  near  the  hepatic  flexure  of  the  colon.  In 
eariy  ca.ses  the  necrotic  area  may  be  scarcely  liquefied,  and  is  liypcn  inir, 
.spongy,  and  infiltrated  with  a  glairv  tenacious  material.  Later,  .i  ripi- 
iar  ab.sc-e.ss  is  formed,  its  walls  formed  of  necrotic  liver  substan  <■  ami 
shreddy,  connective  tissue.  The  contents  of  the  abscess  vary  nnich. 
In  .s<mie  few  ca.ses  the  fluid  is  .serous,  but  in  mast  there  is  a  niiM  i.e  of 
pus  and  necrotic  material.     The  pus  is  .somewhat  glairy  and  traii  hu^-nt 

1  Centralh.  f.  Hikfpr..  2:1887:  Virch.  .\rcliiv.  118:1889. 

'  Virch.  .Xrcliiv.,  O.'i:  187.">.  '  Zeil.schr.  f.  Hyg.  u.  Infectionskrankli     "'1 

•  Johns  Hopkins  Hosp.  Rop.,  2: 1891. 


CIRRHOSIS 


•iaj 


III  »«>ine  cases,  in  others,  gra.vish  or  brownish-red,  so  t'.at  its  appearanee 
has  lK*n  compared  to  anchovy  sauce.  The  quan'.ity  varies  from  a  few 
oumes  to  many  pints.  Practically  the  whole  of  the  right  lobe  of  the  liver 
1ms  l,een  found  in  some  cases  to  be  occupied  by  a  huge  absc-ess  enclosed 
m  u  thin  shell  of  liver  substance.  In  long-standing  cases,  the  abscess 
Mcomes  walled  off  by  pyogenic  membrane  or  a  fibrous  capsule  The 
hv..r  substance  in  the  neighborhood  is  generally  congested,  softened 
( ioiidv,  and  fnable,  and  shows  other  signs  of  degeneration,  but  in  some 
cases  has  tjeen  found  to  lie  practically  normal. 

Histologically,  the  contents  of  the  abscess  are  a  finely  granular  detritus 
l.n.ken-down  iver  cells,  red  and  white  blood-corpuscles,  and  hematoidin' 
J ii.re  IS  usually  a  more  or  less  widespread  necrosis  of  the  liver  paren- 
cliviim.  Ihe  amwbK  are  found  chiefly  at  the  {.eripherv  of  the  abscess 
HI  the  capillaries,  and  about  the  portal  sheaths.  They  ai^  moi*  numerous 
in  the  smaller  foci.  An  important  point  is  that  leukocytes  are  scantv  in 
th.-  toiitents  of  the  abscess  and  in  the  wall,  except  in  eases  where  second- 
ary infection  has  taken  place,  showing  that  the  lesion  is  essentiallv  a 
II  i-suppurative  one.  In  many  cases  bacteria  are  found  in  the  abscesses 
imial.ly  staphylococci  and  streptococci.  The  eariier  obsen.ers  wer^ 
of  tlie  opinion  that  the  necrosis  was  due  to  the  pvogenic  cocci,  while 
some  others  held  that  the  amoebae  acted  as  carriers  for  the  germs  and  bv 
their  jrrowth  and  movement,  which  rupturetl  the  capillaries,  paved  the 
«  a,v  f.,r  bacterial  infection.  The  preponderance  of  evidence  at  the  present 
.lay  however,  is  in  favor  of  the  view  that  the  amo-bie  are  the  direct  cause 
of  the  lisions. 

Most  cases  end  fatally,  but  if  death  do  not  take  place  soon  or  if 
ti"'  <on.iiti.>n  l,e  not  relieved  by  operative  interference,  the  abscess  mav 
rupii.r."  and  give  rise  to  further  serious  consequences.  The  most  fre'- 
jimnt  event  ir.  for  the  rupture  to  take  place  into  the  right  pleura  or 
hin^.  the  fluid  subsequently  being  discharged  through  a  bronchus;  next 
"'  tliat.  ir'.  ^     -.oneal  cavity.     More  rarely,  the  abscess  may  dis- 

<  lar^'..  in»  ardium.  sudden  death  being  the  result.    Again 

•  "■  'ii'-j'-^       ^  -ut  externally  or  empty  into  the  transveree  colon' 

',;""•','  •'";  '■"^y  "'«■•>•.  into  the  bile  passages,  the  hepatic 

^•■"■thevf  a,  or  t;.    pelvis  of  the  right  kidnevT  ^ 

III  .x.rptionnl  cases  t.R  process  becomes  latent'or  comes  to  an  end 
N.iijll  to,.,  of  suppuration  may  be  absorbed  with  the  formation  of  a  scar' 

ili.-  'ase  of  larger  ones,  the  fluid  part  of  the  contents  is  absorbed,  an.l 
fil,.,l'.l?i""  i  ^'»^'tyj^«»«d  in  by  a  connective-tissue  capsule  and 
I '  ,il.  !„id  '''  ■''"^'**"'*  '"  ""'^'""^  ""1^  '^"'t^  may  subsequently 

Cirrhosi8.-Under  the  terms  cirrhoms,  chrouic  inlerMitial  hepatUh, 
"  '"  hejmUUs,  are  included  a  variety  of  morbid  conditions,  which. 
.    "?'  K         '"  "^K^ll  *?  "^^i"-  ^t'o'W  and  the  minuter  details  of 

.        :  ive'^""^'    rt*-"  •"  'T™''"'  *•'«*  '^^"^  '■"  «  hyperplasia  of 

l\^  ":'"*'•  ^■'"^'i';"  t""^-  becomes  sufficient  to  markediv  intcr- 

M^.e  functions  of  the  organ.     Much  confusion  of  mind  has'exist«l 

"  ^.irrl  to  these  conditions,  owing  to  the  difficulty  of  bringing  clinical 


ff    .if 

■  % 


mi' 


;i  - 


466 


THE  LIVER 


.symptunu  into  harmony  with  the  anatomical  appearances  found  /kw< 
mortem,  but  perhaptt  even  more  from  the  lax  use  of  terms.  Parti*!!- 
larly  unfortunate  are  tlu-  terms  "hypertrophic"  and  "atrophic"  iis 
applied  to  cirrhosis,  for  at  best  they  are  merely  relative,  and,  moreover, 
have  been  used  in  an  erroneous  manner  as  synonymous  with  enlargemt-nt 
or  diminution  in  size. 

All  the  evidence  at  our  disposal,  whether  clinical  or  experimentui, 
clearly  indicates  that  cirrhosis  or  fibrosis  of  the  liver  is  in  most  cases  tli*- 
result' of  the  irritation  of  some  toxin,  bacterial  or  otherwise,  which  nmy 
reach  the  liver  in  one  or  other  of  three  ways,  i.  e.,  through  the  he|mtic 
artery,  through  the  portal  vein,  or  thniugh  the  bile  passages.  'I'lie 
occurrence  of  cirrhosis  as  a  result  of  infection  or  intoxication  openitiiij; 
through  the  hepatic  arterj-,  while  theoretically  possible,  is  not  estabiislifd 
by  positive  evidence.  The  cirrhosis  resulting  from  the  action  of  ctwl 
dust — drrhoili  uithraeotieft — may  perhaps  be  of  this  uatun-  It  is  beyoml 
question,  however,  that  irritants  may  reach  the  liver  through  the  {M)rlul 
vein  and  the  bile  ducts,  so  that  we  can  at  once  recognize  two  important 
classes  of  ca.ses — porUl  dirhosii  and  biUuy  dnhoiit.  A  fourth  form, 
one  that  Is  included  with  doubtful  propriety  among  the  cirrhascs,  is 
calletl  caprolar  cirrhoiU  or  ^rUwp«titli  with  ciirhoiU,  in  which  the  irri- 
tants affect  prii.iarily  the  capsule.  A  few  <  ses  also  i.re  met  with  of 
fibrosis  of  the  liver  that  are  more  akin  to  degeneration  than  ti>  iiifliim- 
mation,  of  which  the  cirrh(xsis  following  chronic  passive  congestion 
is  the  mast  important  form.  The  following  cla.ssification,  bas'd  mainly 
upon  anatomical  and  histological  gn)uii<ls,  will  be  found  iiseful,  ami 
has  at  least  the  merit  that  it  fits  in  fairly  well  with  clinical  observations; 
I.  Portal  cirrhosis  with  enlargement. 
II.  Portal  cirrhasis  with  contraction  (Laennec's  cirrhosis;  \wh- 
nailed  liver,  gin-<lrinker's  liver). 

III.  True  biliary  cirrhosis  (Hanot's  form) 

IV.  Obstructive  biliary  cirrhosis  with  enlargement. 
V.  Obstructive  biliary  cirrhosis  with  c-ontraction. 

VI.  Pericellular  or  «liffuse  cirrhosis. 
VII.  Capsular  cirrhosis  (perihepatitis  witli  cirrhosis). 

VIII.  Senile  atrophy  and  arteriasclerosis. 
IX.  Cirrhasis  from  passive  congestion. 

PorUl  Oiirhosis  with  Enlargement. — The  first  form  mentioned  is  in 
many  cases,  in  our  opinion,  simply  an  early  stage  of  Laennec's  ciri  liosis. 
We  have  met  with  one  or  two  instances  in  which  the  liver  was  :ii  tirst 
greatly  enlarged,  and  at  death,  many  months  later,  the  ordinary,  -inall, 
hob-nailed  liver  was  discovereid.  This  preliminar}'  enlargement  i^  not 
likely  to  be  due  to  hypertrophy,  but  rather  to  acute  congestinn  ami 
inflammatory  infiltration.  Hvpertrophy  and  hyperplasia  of  lii'  liver 
cells  proper  undoubtedly  occurs  in  the  various  forms  of  cirrhosi-  Imt  is 
particularly  marked  in  the  contracte<l  or  hob-nailed  liver,  cal 
properly  the  liver  of  "atrophic"  cirrhosis.  Such  hyperplasia  occi 1 1 
what  late  in  the  disease  and  always  falls  .short  of  the  amount  w 
to  restore  the  perfect  function  of  the  organ.     Conversely,  liyi' 


1111- 
iime- 
vsar}' 
lasia 


LAEiWEC'S  CIRRHOSIS 


467 


r  i".r  .  '*■?!  ""T  '."  'T^  «'  ""h--  with  enlaiyement.  sometimes 
ralU-l  hypertrophu-  nrrhosis.  A.s  a  nmtter  of  fact,  h vperp  a.!,.  ofT 
hver  iMjrenchyma  and  of  -ourse.  of  the  mnneetive  tissue  ^  pn^sent  in 
a  vanable  degive  m  all  forms  of  .irrhmi,,  so  that  it  woul.l  conduce  o 
rlearness  ,f  the  terms  "atrophic"  and  "hypertrophic  "  wen-  disc^ntrued 
in  connection  with  this  subject.  ^^^mmueu 

A  second  and  important  form  of  p  rt,I  cirrhosis  with  enlarRcment 
.stheso^alledtottTCfathori..     Hen-,  in    ddi^ion  to  the  ordinary  aS 
K-«  chanRes  characteristic  of  portal  cirrh,«i.s.  there  is  moi*  or  less  extreme 
tally  innhration.  raireiiie 

Flo.  118 


^f*;. 
^^i 


"liKliI  I  irrlii,>i. 


..f  tl,e  liver  fa„y  iafiltra.ion.     Zei„  .,bj    A,  without  ocular.     (Frnm 

the  colleftion  of  Dr.  A.  O.  NiiholU.) 


or  no"  ';ir"'  r  ?  r"""''!;''^*'  ™^^'  ''  """•'^  ^"'«'->f^«'.  with  a  smooth 

•     '-.  a  shghdy  granular  surface      Theed^es  L  ^oundedaTthe 

.  f    'ir     •     ,«         «PIf«rance  is  that  of  the  fattilv  infihrated  liver 

U    "'  '''^'■"'/>''  r'"^.'*'  '*""  "^^^^  «f  «*"^"«  "•^^"e  that  is  p«.sent 

.1..        ;  tX  .?■•  ''^U  .  "  T'^^^  "  ""^""**'  «—»  «f  cirrfoZ  of 
.         >  t^  ch^scnbe,    under  the  next  head,  but  the  rein.u-ning  liver 

'I'  n"  sle^in:''''  ^^-  '^'  ^"^  '"'"^'  «"^^'  -i»h  '»»•«-  f«»N 

Tl>-    „M    n  rrlT    l''''^"*^*«  '  »*'^  -^^v  l>e  HO  normal  liver  cells  left" 

=      'l'      :..   h  sol       '  "^^y  ^y  '^'''  '-"'K  f«"nd  accidentallv     t 

r,„ .'.      '•7''"  ""'''*■""-!•     This  form  of  1    er  is  met  with  usuallv  in 

^        -!i  ^^  ith  pronounced  alcoholism. 

as  l!:l  u  ;?dr"rir*?'  Contniction.-Thi.s  is  the  form  variouslv  designated 
"<  <  >  cirrhosis,  atrophic  cirrhosis,  hob-nailed  liver.  gin-drSker's 


4((K 


THK  LIVKH 


liver,  coiitractetl  liver.  While  alnthol  lm.i  Ixrii  cmliteil  wilh  'iein>{  \\\v 
etinln|{irHl  fiictor  in  about  fA)  |ierfent.  of  «'iw«'.s,ex|K'riniental  iiivesti^jialioris 
do  not  lieur  this  out.  Fn)l>ubly  alc«ihol  t«-M  not  directly  but  iridin-c tly, 
like  a  variety  of  other  gulwtances,  in  brinKUift  about  cirrhosi.s.  AIcdIkiI 
prtxluces  gastro-intestinal  catarrh,  this  leads  to  abnonnal  fernientativr 
prcM-esM's  and  the  elaboration  of  toxins,  which  toxins,  in  turn,  act  iijton 
the  liver.  The  finer  details  of  the  pnM-ess  have  le<l  to  mu«'h  diseii.Hsioi,, 
but  it  is  prolwble  that  the  toxins  lead  primarily  to  ilejfi'neraiive  ••Imii^.ts 
in  the  |>arenrhyinatous  cells,  which  necr«)>(e  an<l  are  rcphut-d  by  m-w 


Fio.  IIS 


if 


LMnmr'a  iiiTho«i»,  portal  cirrhosis,  hobnailfd  liver,  gin-drinker'a  liver.  A  lruii.i\<  i-c  seclinc 
is  made  through  the  organ  and  the  upper  portion  is  turned  upward.  (From  the  I'liholiijiol 
Museum  of  McGill  University.) 

connective  ti.s.sue.     It  is  not  in<pas.sible,  however,  that  a  vi(i<'ii>  cinlc 
is  produced  and  that  irrita  \  the  blood  act  throufth  the  vcsm  l>  upon 

the  fibrous  structure  of  ihe  portal  sheath.s,  stimulating  it  directly  t..  l]y[)er- 

plasia  (cf.  p.  377  et  .seq.).  

To  pross  appearance  the  liver  i.s  more  or  less  diminished  i:  -ize,  in 
advanced  cases  perhaps  not  weighing  more  than  half  the  noriii:i!  amount. 
The  organ  is  deformed  and  the  surface  warty,  being  covered  \  iili  frra"- 
Illations  or  nodules,  ranging  in  .'ize  froir.  that  of  a  pin-hejtd  '  •  :•.  Ii*"!!" 
The  color  is  yellowish,  orange,  or  yellowish-green,  whenct  !ie  terni 
"cirrhasis,"  according  to  the  amount  of  bile  .staining  that  hit-    tcnnw. 


LAKSS.     S  ClkKHOSIS 


469 


I'll.-  Kniniilutiuii  is  often  nimt  niurkiHi  in  tlit-  |,.ft  |»Ih.  an<I  on  the  anterior 
lM.r.l.r.  Tlie  -aiwule  is  usimllv  ihi.kenwl,  un<i  there  ar-  rommonlv 
a.lh.sions  lietween  tlie  liver  ami  the  tliaphranni.  Tli.  j{n!H>lmliler 
i>  >;.neralK  clinunishetj  in  size.  < )n  settion,  the  or>{an  tuts  firmlv  with 
a  nsislant  feel,  anil  it  ciui  then  lie  seen  that  the  (lepre.s.sioi..s  on  the 
siirfac«-  are  a.s.s<K-iateil  with  Immls  of  iiUnms  tissue  which  form  a  net- 
w-.rk  ihrouKhout  the  liver,  ilividinx  the  jwreiuhvma  into  a  ^reat  nuniln-r 
..f  sharply  defined  islets.  The  film.us  Iwnds  are*  of  a  whitish  or  pinkish- 
ffniy  i-olor,  slightly  transhu-ent  in  ap|)earance,  and  project  alniv  the 
it.ii.nd  level,  thus  jrivinjc  the  cut  surface  an  irregular,  Kranular  •     lear- 

UIIC.'. 

Histologically,  the  niost  striking  feature  is  the  enormous  pro""     ation 
..f  th,-  connective  ti.ssue  whi.h  forms  a  series  of  «-onnected  l>an<ls  endasinir 
th.-   ..Iiules.     ihese  twnds  may  U-  disfrihutetl  so  as  to  enclose  several 
li.l.iil.s   (p..lylol>ular   cirriiosis)   or   to   isolate   each    lobule   separatelv 
I  rnon..l.,hular  cirrhosis).     Both  cinditions  are  usuallv  to  be  made  ou't 
Ml  cases  ,,f  I^ennecVs  cirrh..sis.  an.l  v...  ■  Ik-  includecj  under  the  terms 
•[..riiobular   or "  interlobular" «irrho.sis.    In  advanml  cases,  the  fibrous 
lissiif  may  uisnmate  itself  In-tween  the  individual  columns  of  liver  cells 
,iiitral..l)ular  .irrhosis);  but  this  is  never  a  marked  feature.  althouRh  it 
IS  not  at  all  uncommo..  in  the  biliary  forms.     Where  the  inflammatorv 
prmrss  IS  rett-nt  or  active,  the  jK.rtal  sheaths  are  more  or  less  densel'v 
inhltratcd  with  clusters  of  nxm.l  cells,  in  part,  til.mblasts.  and,  prt)bablv 
i>i  part  leukocytes.     In  the  older  porti.ms  or  where  the  di.sease  has  alwiit 
rmi  Its  .oiirse  the  roun.l  cells  are  scanty,  an.l  we  find  dense  Un.ls  of 
ht.mi..  tissue  having  the  characteristic  fibrillati.in  .)f  the  adult  tissue 
with  nlatively  few  el-)iigate.l  nuclei.     In  the  bHuds  of  fibro-is  tissue  an 
f.mml  KH'iips  of  c-ells  arraiige.1  in  parallel  n>ws  closelv  re-semblinc  bile 
<"'|)illaries.     Iheir  origin  is  somewl  at  debatal)!e.     The     are  generallv 
ni..r..  a  ,. Ill,  ant  m  the  parts  where  cellular  infiltration  is  c  .n.s;>icuou.s 
f..r,  as  tlu-  hbrous  tissue  is  formed  it  .seems  to  crush  them  out  of  existence 
1  iHs..  api.  irent  bile  capillaries  may  l)e  fairiv  numerous,  but  in  so.iu  oas^ , 
.U'aiM.  are  scanty  or  even  ab.sent.     Three  moiles  of  origin  are  5.    sihle- 
""?   Miay  Ik.  new  ducts  .lerive.1  by  prolife.-ation  of  the  origi-    !  bile 
<;apillar...s;  they  may  l,e  bile  capillaries  that  have  pt ;    .,-m1  after  il  ., , uc- 
t  -M  '.t  the  lobules  to  which  they  bel.mge.!;  or  thev  indicate  mer- 

^iri  ''*'«*'"*'r""°"  «^  «'•*■  'iver  cells.     0„  ,.„,vful  examination,  one 
"  'I  utt.n  see  that  these  apparently  newly-forme.1  capillaries  do  rot  re- 
;   'j''l"  'apil  aries  .so  much  as  they  do  columns  of  liver  cells  that  have 
|"<I<  tr......  atr(.phy,  for  the  protoplasm  of  their  component  cells  strikes 

i.,"',"l  '"       'i!:'"«['«>''"-«'«''i   •similar  to   that  ..f   the   normd  liver 
Pr,.hy,„„.     Further   certain  of  them  will  l,e  fouiul  to  Ix-  in  .lirect 

,,,„.„  with  the  cells  of  the  periphen-  of  the  liver  lobules.     Such 

"■'I»illaries,  therefore,  probably  represent  columns  of  liver  c*lls 
iii,|t   ,  ,w.  reverted  to  a  more  primitive  condition. 

'-  -  ...tmn,  blmrdvessels  can  be  ma.Ie  out  in  the  fibrous  septa,  which 

a       ..„„,p„„,  ,„r^,^         ,    ,^;,,_^.^„^j      The.se  can  Ik.  injected  fKrough 

r'^'Hc-  artery.     The  l^-anches  of  the  portal  vein,  on  the  oth  r  hand, 


I  ■■ 
I 


I    k 


470 


THK  LIVER 


either  from  external  pressure  or  changes  in  the  intimu,  are  more  or  Ifss 
otrluded,  thus  accounting  for  the  portal  obstruction  that  sooner  or  later 
becomes  so  marke<l  a  feature  in  this  form  of  cirrhosis.  The  liver  ceils 
themselves  often  present  little  alteration,  but  at  the  periphery  of  the  loli- 
ules  many  of  them  present  atrophic  changes,  l)eing  fattily  degenerated  or 
reduced  to  flattened  plates,  or,  perhaps,  little  more  than  nuclei.  The 
atrophy  is  to  some  extent  due  to  the  encroachment  of  the  fibrous  tissue, 
but  also,  no  doubt,  to  the  influence  of  circulating  toxins  and  impiiiwi 
nutrition.  Occasionally,  there  is  marked  fatty  infiltration,  as  in  the 
fatty  cirrhosis  above  described.  Here  and  there  attempts  at  comj)eiisa- 
tion  can  be  made  out,  for  masses  of  liver  cells,  more  or  less  perfeeliv 
reproducing  the  lobules,  can  be  seen,  composed  of  newly-formed  cells, 
which  are  large,  stain  deeply,  and  show  nuclei  in  various  stages  of 
mitosis.  Pigment  granules  of  a  yellowish-brown  or  yellowish-green  color 
are  also  to  l)e  seen  within  the  specific  cells,  in  the  interstices  of  the 
connective  tissue,  and  in  the  endothelial  cells  lining  the  vessels.  Some 
of  these  may  lie  biliary  pigment,  but  not  infretjuently  they  can  be  shown 
to  contain  iron,  p'obably,  therefore,  l)eing  hemosiderin  derived  from 
broken-ilown  red  bloo<l  corpuscles.  Cases  are  on  record  where  sufficient 
of  this  iron-containing  pigment  has  l)een  pnxluced  to  stain  most  of 
the  tissues  of  the  Ixnly,  including  the  skin,  a  bluish-gray  or  leaden  color. 
This  is  the  condition  known  as  hemochiomktosis  (see  p.  481). 

In  well-marked  cases  of  Laennec's  cirrhosis  the  portal  vein  and  its 
branches  are  dilated.  Dilated  veins  may  often,  also,  be  sten  in  the 
skin,  especially  o.i  the  sides  of  the  alnlomen  and  thorax  and  around  the 
umbilicus  (caput  Medusa).  The  n-sophageal,  gastric,  and  lieinor- 
rhuidul  veins  are  usually  dilated  and  may  be  varicosed.  Rupture  of 
the  (esophageal  vessels  may  give  rise  to  fatal  hemorrhage.  The  spleen 
is  moderately  enlarge*!,  its  capsule  thickened,  and  it  is  sometimes 
embedded  in  adhesions.  Not  infre()uently  the  pancreas  is  c-irrlv/tie  as 
well.  The  gastro-intestinal  mucosa  is  in  a  state  of  passive  c()M};(stion. 
Ascites  is  present  in  about  half  the  cases.  Jaundice  occurs  in  iilMMit 
27  per  cent.,  and  is  usually  slight.  A  not  unusual  complieation  is 
tuberculous  peritonitis. 

Hanot's  Ciirhosis. — Hanot's  cirrhosis,  sometimes  called,  thou^'li  erro- 
neously, hypertrophic  cirrhosis,  and  sometimes  "true"  biliary  ciirhosis, 
is  a  Hire  form  in  this  country.  In  fact,  it  seems  to  be  unconnnon  outside 
of  France.  The  di.sease  is  characterized  by  enlargement  of  the  liver 
and  jaundice,  which  persists  for  months  or  even  years.  The  j;nin<lice 
is  often  inten.se,  as  in  the  obstructive  form,  l)Ut  the  stools  are  usiiiilh 
colored.  In  .some  cases  the  jaundi'-e  comes  on  acutely  and  the  . Iisea.se 
runs  a  course  like  that  of  acute  febrile  icterus,  or,  again,  of  aciili  yellow 
atmphy. 

The  liver  is  greatly  enlarged,  weighing  from  2  to  4  kg.  Th'  -iirfare 
is  smooth,  or  at  most  covered  with  flat  prominences.  On  seiiiMii,  the 
organ  is  firm  and  grates  under  the  knife.  The  cut  surface  is  \.  ilowisli 
or  yellowish-green,  owing  to  bile  staining,  and  has  a  finely  i;r  milated 
appearance  resembling  shagreen  leather. 


PERICELLULAR  CIRRHOSIS 


471 


Histologically,  there  is  an  overgrowth  of  connective  tissue,  often 
rather  poor  in  nuclei,  which  is  diffuse  in  character,  tending  to  invade 
the  lobules  (intralobular  cirrhosis)  or  isolate  small  groups  of  liver  cells. 
Tiie  islets  of  parenchyma  remaining  are  small,  and  single  cells  or  small 
groups  of  celb  are  seen  separated  one  from  the  other  by  delicate  strands 
of  connective  tissue.  'J'here  is  usually  a  considerable  production  of 
pseudobile  capillaries.  The  cells  contain  bile  pigment.  The  process 
seems  to  be  essentially  due  to  a  catarrh  of  the  finer  bile  capillaries  and 
the  portal  system  appears  to  be  free.  An  infective  origin  is  probable, 
liiit  the  etiology  has  not  yet  been  thoroughly  worked  out. 

Obstructive  Biliary  Oirrhosia.— This  form  is  due  to  some  gross  obstruc- 
tion to  the  free  outflow  of  l>ile,  either  within  the  ducts,  as  from  a  calculus, 
carcinoma,  or  a  fibrous  stricture;  or  from  without,  as  from  a  new-growth 
ill  the  head  of  the  pancreas  or  in  the  periportal  lymph-nodes.  Obstruc- 
tion alone  does  not  appear  to  be  an  adequate  cause,  for  complete  occlusion 
of  the  (lucts  may  occur  without  the  production  of  cirrhosis.  Another 
factor  is  nec^sarv,  and  this  is  apparently  inflammation  in  the  form 
of  a  cholangitis.  This  is  ea.sily  accounted  for,  since  bacteria  are  invari- 
ably to  be  found  in  the  bile  passages  in  such  cases,  a  catarrhal  inflam- 
mation, originally  dependent  on  microbic  infection,  being  the  cause  of 
the  {aUulus  formation  in  the  first  place. 

In  the  earlier  stages  of  the  disease  the  liver  is  much  enlarged,  closely 
resemhhng  the  liver  in  Hanot's  cirrhosis.  In  one  of  our  cases,  in  which 
a  stone  was  found  in  the  hep^atic  duct,  the  organ  weighed  4850  grams. 
To  gross  appearance,  the  liver  is  enlarged,  smooth,  and  bile-stained. 
It  cuts  firmly,  the  cut  surface  being  finely  granulated  and  of  a  yellowish- 
grt-en  color.  The  bile  ducts  can  be  seen  to  be  dilated  and  their  walls 
tlnikened. 

Microscopically,  the  newly-formed  connective  tissue  is  both  inter- 
lolmlar  and  intralobular  in  its  distribution  and  is  rather  dense.  It  is 
c  utracterized  by  the  presence  of  central  dilated  bile  ducLs  surrounded  by 
c  lapk-ts  of  pseudobile  ducts  which  are  conspicuous  by  their  numbers. 
l)ef;.iierative  changes  can  l)e  made  out  in  the  parenchymatous  cells, 
l-oca  iiecrf)ses  may  be  found.  Ascites  is  rare,  and  the  spleen  is  not 
frnatly  enlarged.  The  portal  circulation  appears  to  be  not  notably 
int.rf.'red  with.  Pyogenic  infection  of  the  bile  passages  mav  occur 
with  tlic  production  of  a  suppurative  cholangitis  and  the  formation  of 
siiiiill  al)s<f'sses  along  the  course  of  the  infected  ducts.' 

In  anotlier  type  of  the  affection,  probablv  a  later  stage  of  that  just 
<l<'^'  II  K-,|,  the  hver  is  contracted,  bile-stained,  and  has  a  fairly  diffuse 
firaimlation,  the  granulations  being  of  medium  size  and  rather  even  in 
cliiiractcr. 

PericeUular  Oiirhoais.— In  this  form  of  cirrhcxsis  there  is  a  singularlv 
I'll  " '•  liyperplasia  of  connective  ti.ssue,  which  tends  to  surround  and 
iM.in,.  very  small  groups  of  liver  cells  or  even  in.lividual  cells.     The 

;  1  ■'  ..  useful  consideration  of  this  form  of  cirrhosis,  see  Ford,  Amer.  Joum.  Med. 
^'1        l:l!H)l:GO. 


!iF"' 


I;: 


mi 


t-mu  I 


i 
i 


472 


THE  LIVLR 


fibruus  Ivssae  is  curiously  transparent  and  almost  hyaline  l(M>kinK,  witli 
but  little  fibrillation  and  relatively  few  nuclei.  Degenerative  chaiips 
in  the  parenchyma,  save  atrophy,  are  not  pronounced. 

Pericellular  cirrhosis  is  met  with  occasionally  in  .syphilis  and  tulxT- 
culosis  of  the  liver  (q.  v.),  and  is  also  well  exemplified  in  a  curious  affec- 
tion of  cattle,  studied  by  Osier,  Wyatt  Johnston,  and  Atlami,'  known  as 
"Pictou  Cattle  Disease."  This  disease  is  restricte<l  to  a  particular 
district  of  Pictou  County,  Nova  Scotia,  anil  ap{)ears  to  l)e  infectious. 
In  .some  particulars  it  is  not  unlike  Laennec's  cirrhosis  in  human  l)eiiif.'s. 
There  is  a  mcNlerate  ascites,  a  right-sided  pleural  effusion,  without 


Fio.  120 


Pericellular  cirrhosis  of  the  liver  fnim  a  case  of  Pictou  cattle  disease.  Note  the  Kreat  r>  ;.iti^f 
isolation  of  the  liver  cells  and  the  delicate  connective  tissue  with  scanty  nuclei,  lieiclurt  l.I.j. 
7a,  without  ocular.     (From  the  collection  of  Dr.  J.  G.  Adami.) 

jaundice,  and  the  abdominal  and  periportal  lymph-nodes  are  enhir^rtii 
and  succulent.  There  is  a  curious  gelatinous  oedema  of  the  nie.^t'iitfn 
and  the  intestinal  walls.  The  liver  is  moderately  enlarged,  villi  a 
smooth,  or  occasionally  a  slightly  granular  surface.  Recent  and  In  iling 
ulcers  are  found  in  the  fourth  stomach. 

Capsular  Oiirhosis  (Perihepatitis;  Pseudociirhosis;  "Zuckergusse)  ^r"; 
Olissonitis). — This  is  a  somewhat  rare  affection  of  the  liver,  in  '  iicli 
the  surface  !s  more  or  less  completely  covered  with  a  thick,  ti'ntu- 
investment,  of  pearly  white,  cartilaginous  appearance,  and  liKiline 
stnicture.  The  liver  is  at  first  enlarged,  but  subsequently  umii  rjnes 
marked  contraction.    In  the  majority  of  instanc-es  the  affect  it  »n  i-    upH 

'  Montreal  Med.  Journ.,  31 :  1902: 105. 


.t.jif!    • 


mMk 


SEMLE  ATROPHY  OF  TH  El  LIVER 


473 


a  peculiar  form  of  perihepatitis,  and  is  asually  associated  with  a  similar 
transformation  of  the  capsule  of  the  spleen,  the  peritoneum,  and  the 
other  serous  men-branes.  In  fact,  the  condition  is  often  part  and  parcel 
.,f  a  chronic  progressive  multiserositis,  or,  as  one  of  us  (A.  G.  X.)  has 
(ailed  it,  "hyaiosenxsitis."  The  relationship  of  cirrhasis  of  the  liver  to 
tills  form  of  capsulitis  or  perihepatitis  is  still  somewhat  obscure.  It  is 
rair  to  find  a  true  cirrhosis  associated  with  the  condition.  The  liver, 
rather,  shows  brown  atrophy  and  passive  congestion.  At  most,  there 
may  l)e  a  slight  invasion  of  the  liver  substance  bv  small  fibrous  bands 
pa-sing  down  from  and  in  connection  with  the  capsule.    \Mien  cirrhasis 


:iHi]R 


Fio.  121 


<l,r..„..'    „fr.l,e,mt,ti,    w.th    hyaline    tninsfnnnati.,,,    of    the    exuda.e    (hyaloserositi.)      The 
I.I.-  n  -  cap,ule  i»  thr3wn  into  folds  from  atrophy  of  the  liver  parenchyma.     Lein  obi    No    7 
ut  neular.     Urom  the  collection  of  Dr.  A.  G.  Nicholls.)  '     ' 


Wlliii 


'>  I'v.  sent  in  these  cases,  as  it  undoubtedlv  mav  be,  it  is  more  probal)Iv 
'  ii"  ic.  passive  congestion,  or  at  all  events  is  "to  be  regarded  as  a  con- 
dition (|uite  distinct  from  the  perihepatitis.' 

Senile  Atrophy  of  the  Liver.— Here  the  liver  is  small  and  shrunken, 
t  !<■  <apsule  thrown  into  folds,  and  the  whole  organ  is  firm.  It  is  often 
al^o  .„„re  deeply  pigmented  than  normal.  Micro.scopicallv,  the  con- 
'I'-iiM-  ti.ssue  is  increased.  It  is  questionable  whether  this  is  not  an 
apl'.i.-.  lit  increase  due  to  the  paucity  of  liver  cells,  rather  than  a  true 
'M"ii'lasia.  It  IS  not  to  be  denied,  however,  that  the  disappearance  of 
""■  livf-r  parenchyma   may  be  acconipanie<I  by  a  compensatory  new- 

l:i'  relation.ship  of  perihepatiti.s  to  cirrhosis  is  (li.scus.sed  at  some  length  bv 
'^      .-.  >tuihes  from  the  Royal  Victoria  Hospital,  Montreal.  1:3: 1902: 60. 


474 


THE  LIVER 


I    i: 

i    .i' 


In 


It 

»  t 

■  t 

t         t 


growth  of  connective  tissue,  an  example  of  what  one  of  us  (J.  G.  A.) 
has  elsewhere  termed  " replac-ement  fibnisis."  If  this  be  true,  the 
condition  might  he  termed  an  interstitial  fibrosis  or  cirrhosis,  though  it 
should  lie  rememl)ered  that  it  is  primarily  of  a  degenerative  rather 
than  an  inflammatory  origin.  The  atrophy  in  such  cases  may  possii)ly 
l)e  referred  to  lack  of  nutrition,  due  to  thickening  of  the  branches  of  tin- 
hepatic  artery.  It  must  be  admitted,  however,  that  we  have  practically 
no  anatomical  evidence  in  favor  of  an  arteriasclerotic  cirrhosis  of  tlie 
liver  per  se. 

Oirrhosis  from  Puiiva  Oongeation  (Oiirhose  Oardiaque). — This  is  a  form 
of  cirrhosis  descrilied  mainly  by  the  French  school  of  pathologists. 
The  Germans  in  general  are  disposed  to  deny  its  existence.  It  is  a 
fact,  however,  that  in  motlerately  advanced  and  long-continued  cases 
of  passive  congestion  of  the  liver,  associated  more  especially  with  cardiac 
weakness,  there  may  l)e  a  certain  amount  of  fibrosis  in  the  neighlrarhiMxl 
of  the  centrilobular  vein,  following  a  preliminary  atrophy  of  the  liver 
parenchyma  of  these  parts.  This  is,  in  our  experience,  a  rare  occiir- 
rence,  but  imcjiicstionably  does  occur.  It  may  well  lie  doubted,  however, 
whether  such  ii  fibrosis  is  ever  sufficiently  extensive  to  give  rise  to  clinical 
.symptoms. 

Tuberculosis. — The  occurrence  of  primary  tuberculosis  of  the  liver 
is  doubtful.  Ca.ses  of  this  disease  can  usually  be  traced  to  foci  of  infec- 
tion in  some  other  r^<»ion  of  the  ImmIv.  The  path  of  infection  may  !« 
through  the  hepatic  artery,  the  portal  vein,  the  lymphatics,  or  by  con- 
tiguity. 

Anatomically,  three  forms  can  l)e  recognized — disseminated  miimry 
iuherculos'is,  solitary  fubcrcidomas,  and  chronic  tuberculous  srtrrosing 
hi/Httitis.  If  the  liver  be  fatty,  as  it  so  often  is  in  cases  of  advanced 
tulKTCulosis,  miliary  tul»ercles  may  readily  be  overlooked.  When 
visible,  they  are  present  as  minute,  gray,  or  yellowish  dots,  often  slij;litl\- 
bile-stained.  The  milia  are  situated  for  the  most  part  in  the  periportal 
connective  ti.ssue  and  may  encroach  to  some  extent  upon  the  lolmie. 
Exceptionally,  they  are  found  within  the  lobules.  The  foci  have  ti .' 
appearance  of  lymphoid  nodules  with  epithelioid  cells  and  possibly  jjiant 
cells.  Caseation  is  not  uncommon.  In  the  centre  of  the  tubenlc  the 
liver  cells  are  destroyed,  while  those  at  the  periphery  show  fatty  cliaiijres 
and  atrophy.  Care  should  l)e  taken  not  to  mistake  collapsed  bile  diuts 
for  giant  cells  in  cases  where  they  have  liecome  included  within  the 
granuloma,  for  there  is  a  superficial  resemblance  between  the  two  ^tnie- 
fures.  In  some  cases,  the  tubercles  are  not  fully  formed,  and  am'  find 
merely  a  round-celleil  infiltration  in  the  periportal  .sheaths  with  -onie 
'•irrhosis  and  the  formation  of  p.seudobile  capillaries.  The  cirihosis 
is  often  of  the  pericellular  type. 

Solitary  tubercles,  usually  few  in  numlier,  are  occasionally  ol>- 
but  are  rare.  Thev  niav  he  of  considerable  size,  are  ca.seoiis  in  tl f  i 
and  are  enclo.sed  in  a  more  or  less  dense  fibrous  capsule.  Occas:' 
they  soften  or  liecome  secondarily  infected,  giving  rise  to  abscess 

In  the  third  form,  the  liver  is  the  seat  of  a  diffuse  and  exteiisi  ■ 


Tveil, 

■  litre, 

lallv. 


-  Is-' 

•j{"i'5:  ' 


SYPHILIS 


475 


fjrowth  of  connective  tissue,  in  which  can  lie  seen,  here  and  there,  gray 
or  grayish-yellow  tubercles. 

Syphilis.— Both  congenital  and  acquired  syphilis  may  affect  the  liver. 
The  lesions  of  congenital  syphilis  in  the  main  are  comparable  with  those 
of  tul)erculosis.  We  can  differentiate  anatomically,  disseminated  miliary 
ijummas,  large,  well-formed  gummas,  and  syphilitic  cirrhosis. 

In  the  form  with  numerous  miliary  gummas  th--  liver  is  often  enlarged. 
The  lesions  affect  either  the  whole  organ  or  circumscribed  areas  of 
it.  The  milia,  histologically,  are  identical  with  the  milia  of  tuberci  Osis. 
The  absence  of  the  tuliercle  bacillus  in  the  former  is  practically  the 
(Hily  way  to  differentiate  between  them.  There  i.s  usually  marked 
filirttsis  in  the  neighborhoo<l  of  miliary  gummas  al.so.    Large  gummas 

Fia.  122 


llnrmnn  nf  the  liver.     Zeiw  o'.y.  A.  wi,i,„ut  ocular.      The  gumma  is  Ilie  darlt  mass  to  the 
nghi.     (From  the  colleft'on  of  the  Montreal  General  Hospital.) 


arc  occasionally  met  with  in  congenital  syphilis,  but  are  more  common 
Ml  the  ac(|uned  disease.  They  are  of  nKnlerpte  size,  as  a  rule,  easilv 
viMl.lc  to  the  i.aked  eyt,  and  .nre  scattered  irregjlarlv  through  the  o  -gan. 
Ilic.v  also  present  a  yellowish  appearance,  v  ith  broken-down  centres, 
iMi.illy  surrounded  by  den.se,  often  radiating  scars.  In  a(iv,.t,ced  cases 
til'  .ivcr  13  greatly  deformed  and  divided  into  numerous  lobules  of 
I  HMnjr  size  by  deep  fissures,  which  represent  contracting  fibrous  cica- 
tn..>.  the  .sole  remains  of  the  previon.slv  .existing  gummRS.  Thi.s  gives 
n  ;  to  the  .so-called  hepar  lobatum.  The  comparativelv  unaltered  liver 
-ni  ti.ncc  IS  often  of  a  dark  brown  c-olor. 
Ili-tologically,  gummas   closely  resemble   tuberculous  granulomas, 


'if  •? 


476 


THE  LIVER 


■I 
I 


i 
If    I 


having  a  necrotic  centre,  a  i-ellniar  periphen-  with  giant  cells,  iml 
being  enclosed  in  a  fibrous  capsule.  'I'he  capsule  is  somewhat  irregj.liir, 
sending  out  processes  into  the  liver  substance  in  the  neighlM)rho*i<l,  tind 
contains  collections  of  small,  n)und  cells,  and,  often,  numerous  psendu- 
bile  capillaries.  The  liver  cells  projier  usually  show  brown  atrophy, 
and  there  may  be  evidences  of  amyloid  transformation.  In  advanit'il 
cases  nothing  but  the  scar  is  visible,  the  necrotic  material  having  \wft] 
completely  absorbetl. 

In  infants  a  ditfiise  cirrhosis  is  the  common  lesion  of  hepatic  syphilis, 
and  is  of  the  pericellular  an<l  intra-acinous  type.  In  he  early  stages,  fliere 
is  a  cellular  infiltration  of  the  interlobular  and  intn.iobular  connective 
tissue.  This  may  l>e  observwl  throughout  the  organ  a.«  a  whole,  or, 
again,  may  be  restricted  to  .vcatterrtl  areas..  The  liver  is  somewliat 
enlarged,  hard,  and  the  capsule  is  smooth  or,  exceptionally,  fi .  !y 
granular.  On  section,  the  color  is  yellow,  yellowish  or  reddish-lirowri, 
somewhat  recalling  the  appearance  of  flint.  The  lobules  are  not  reiidilv 
recognized.  Histologically,  there  is  a  periportal  proliferation  of  emi- 
nective  tissue,  which  tends  to  invade  the  lobules,  des^>  ying  their  snl)- 
stance,  and  containing  numerous  foci  of  nnmd  cells  w!'')  psemlolnle 
capillaries.  The  newly-formed  connective  tissue  is  deli(ate  and  tratis- 
lucent,  containing  relatively  few  nuclei,  and  is  laid  down  diffusely,  insinu- 
ating its  way  between  the  liver  cells,  so  that  they  are  found  isolated  'ue 
from  the  other,  or  in  little  groups  of  twos  and  threes.  There  is,  appan'ntly, 
not  much  tendeney  to  contrac»ion  in  this  form.  Hoffmann  and  others 
have  demonstrated  the  presence  of  the  spin>cheta  pallida  in  the  livers 
of  children  dying  of  congenital  syphilis. 

The  manifestations  of  acquired  syphilis  in  the  liver  differ  but  little. 
on  the  whole,  from  those  of  the  congenital  form.  Any  difl^erences  are 
probably  to  l)e  explained  on  the  basis  of  time  and  the  difference  in  the 
reactive  powers  of  the  liver  at  the  different  life  periods. 

The  amdition  of  the  liver  in  the  secondary  stage  is,  of  course,  diflic  iilt 
to  ascertain.  The  occurrence  of  jaundice  and  hepatic  enlarfreiiieiit 
at  this  perioti  suggests  the  presence  of  an  acute  interstitial  hepatitis, 
perhaps  associated  with  a  cholangitis,  or  wen  a  more  severe  afl'ei  lion, 
an  acute  parenchymatous  hepatitis,  closely  resembling  acute  yt How 
atrophy. 

The  common  tyjM-  !n  the  tertiary  stage  is  the  multiple  guniiiia  « ith 
cirrhosis.  This  is  often  associated  with  jaundice  and  gives  ris'  to  a 
nmlular  or  fissured,  contracted  liver,  which  may  lie  bile-staitied.  '  •>  <  a- 
sionally,  the  gummas  are  so  large  iis  to  be'mistaken  for  niali-naiit 
growths.  In  such  cases  there  is  a  <lense  mass  of  fibrous  tissue.  \»ith 
more  or  less  gininny  degeneration,  surnnuided  by  an  outer  h 
liver  tissue,  which  is  infiltrated  with  round  cells.  These  seem 
rierived  from  isolated  gummas,  presenting  a  reactive  new-foriiiai 
liver  substance  at  the  periphery,  which  is  dotte<l  with  numerous  . 
gummas  and  eventually  destroyed  and  replaced  by  fibrous  tissue 
Actinomycosis. — Actinomycosis  of  the  liver  may  l)e  prim 
secorulary.     There  are  but  few  undoubted  ca.ses  of  the  primtiry 


■  T    of 

;..  l.e 

■H    of 

•liarx- 


or 
'■ase 


PARASITES 


4n 


Fio.  12.'? 


1.11  record.'    The  infectiim  is  j^nerallv  thmijrht  to  be  from  the  intestine 
thmugh  the  portal  system.     I^-.,.-*  often  it  is  from  tlie  kichiev  or  lunj;. 

The  lesion  takes  the  form  of  more  or  less  numerous  abseesses,  which 
ift-  n  fjecome  agjiregated  into  lobular  area.s,  owinp  to  the  coalescence  of 
"inaller  foci.  With  this  there  is  a  proliferation  of  connective  tissue. 
iriviiig  the  larger  abscesses  a  curious  un«l  characteristic  appearance. 
.\fter  the  ,. -erotic  material  is  Wiusheil  out.  the  larger  cavities  can  be  seen 
to  l)e  traverse«l  in  all  ilirectiuns 
l>v  rather  coarse  communicatii  g 
liaruis  of  connective  tissue,  so  that 
an  appearance  rather  like  that  of 
;  loofah  sponge  is  pnxlucetl.  The 
sjHTific  ray-fungus  can  lie  recog- 
nized in  the  tissues  and  in  the 
necrotic  and  liquefied  material. 
The  liver  l)ecomes  adlu-rent  to  the 
iliaphrjgm,  ab<loniinal  wall,  or  a 
neighlM>ring  viscus,  and  fistulous 
c'liiuniinications  may  l)e  opened 
with  tiie  exterior  or  some  organ, 
discharge  of  the  abscesses  into 
the  lung  is  perhaps  the  ;nost  fre- 
<|iient  occurrence.  TIm  infection 
in  some  cases  bectmies  fal'l  •  gen- 
eralized. In  one  ca.se  wnich  we 
had  the  opportunity  of  .sectioning, 
the  liver  was  adherent  to  the  dia- 
plirajmi  and  the  right  lolje  was 
occupied  by  a  very  large  trabecular 
aliseess  of  the  type  ju.st  descril)ed. 
Multiple  small  ab.sces.ses,  resem- 
liliiij:  those  found  in  pyemia,  were 
foiMul  in  the  Itmgs  and  kidneys,  in 
whidi  the  specific  organism  was 
detected. 

Parasites. — The  most  ini(K>rt- 
ant  are  the  Echinococcun,  the  Pni- 
Uixliimum  drvticiilatum,  and  the 
Ihstoma  hcpaticum.  Echinocincus 
•  Incase  is  not  .so  frequently  met  with  in  America  as  in  Europe.  It  is  occa- 
M.iiiMJiy  foimd,  however,  among  the  Mennonites  of  Manitoba  and  the 
Xoitliwest.  Echinococcus  cysts  are  unilwular  or  muh-!ocular,  and  are 
'" "Milled  by  a  laminated  connective-tissue  capsule  The  liver  cells  in 
the  iniinetliate  neighborhood  of  the  cysts  art  ilattened  from  pressure. 
^^'iiiri  the  fibmus  capsule  is  the  gelatinous,  transparent,  echinococcus 

'  -( e  Moser.  New  York  Med.  Jonrn.,  tiO:  1894:  17(i,  .intl  .\uvmy.  Rev.  ile  Chir., 


Eohinopoccus  cysts  of  the  liver  in  a  hog. 
(From  the  Pathological  Muaeum  of  Mi-Gill 
Univenity.) 


478 


THE  LIVER 


membrane,  which,  under  the  niirrosc-ope  is  of  hyaline  appearance,  witli 
a  characteristic  concentric  lamination.  'I'he  containetl  fluid  is  c  iir, 
watery,  or  lightly  tinte<l.  It  may  contain  numerous  small  blad<Jer<  or 
dauj?hter-cysts.  ( )winx  to  absorption  of  the  fluid  and  inspissation  of  tin- 
contents,  the  cysts  may  contain  a  caseous,  gritty  substance,  resembling' 
mortar. 

RITROOKI88IVI  MITAMOKPH08I8. 

Simple  Atrophy. — Simple  atrophy  of  the  liver,  the  result  of  nial- 
nutrition,  is  met  with  in  marasmus,  old  age,  and  cachexia.  The  form 
due  to  pressure  has  already  been  referred  to.  Carcinoma  of  the  u'sophii- 
gus  and  stomach,  by  inducing  star\-ation,  has  a  spt>cial  tendency  to 
cause  atrophy  of  the  liver.  In  such  ca.ses  the  diminution  in  size  niiiv 
lie  very  marked,  the  organ  in  some  instances  l)eing  only  one-third  of  ilic 
normal  weight.  The  atrophy  affects  the  organ  as  a  whole,  but  the  untf- 
rior  Iwrder  suffers  mast.  The  liver,  therefore,  is  small,  the  edges  jm- 
sharp,  and  the  capsule  wrinkled.  The  gall-bladder  sometimes  projects 
considerably  beyond  the  liver  margin.  In  advanc°tl  cases,  little  niitv 
be  left  at  the  Ixinlers  but  the  connective-tissue  capsule,  which  is  reciij;- 
nizable  as  a  thin,  semitransparent  membntne  containing  blooilvesstiv 
The  liver-substanc-e  remaining  may  lie  firmer  than  normal,  owing  to  the 
relative  increase  of  the  connective  tissue. 

Histologically,  the  parenchymatous  cells  are  shrunken,  stain  nitlier 
badly,  and  are  .somewhat  pigmented  (brown  atrophy).  The  fibrous  tissue 
appears  to  be  increa.sed,  but  this  appearance  is  largely  due  to  the  dis- 
appearance of  the  liver  cells  pn)per.  Frerichs  has  called  attentici)  tn  a 
form  of  atrophy— meUnemie  atrophy— lielieved  to  lie  due  to  blockini:  of 
the  capillaries  with  black  pigment.  Atrophy  of  the  liver  is  a  niarked 
feature  in  the  disease  known  as  acute  yellow  atrophy  (q.  v.). 

Oloady  Swelling. — Cloudy  swelling,  a  condition  hanlly  distinf:iiidi- 
al)le  from  acute  parenchymatous  hepatitis,  is  a  common  occurreiut-  in 
the  course  of  the  infective  fevers,  particularly  typhoid  and  scarlntiiia. 
It  may  also  be  due  to  the  action  of  toxins,  apart  from  elevation  of  i-  iii- 
perature.  A  liver  so  affected  is  .somewhat  moist  on  section  ami  ilie 
lobules  are  no  longer  distinguishable,  the  cut  surface  having  a  [xdiliiir 
glassy  appearance,  as  if  smeared  with  thin  glue.  It  is  siir|iriMnj:. 
however,  how  little  change  can  lie  recognized  microscopically,  the  cells 
lieing  at  most  a  little  .swollen  and  rounded,  while  the  nuclei  t«  i  1  to 
stain  badly. 

Fatty  Liyer. — Fatty  degeneration  of  the  liver  is  a  common  .  mel 
of  cloudy  swelling  and  occurs  in  the  course  of  severe  anemias,  >\\<-h  as 
pernicious  anemia,  in  acute  yellow  atrophy  of  the  liver,  from  coiil'<  :ion. 
and  from  the  action  of  various  toxic  substances,  notably  phosp'  ni>. 
In  .-idvanced  cases  the  liver  h  diminished  in  size,  it  feels  (loiif.'!i  iT 
the  fingers,  and  the  capsule  is  thrown  into  folds.  The  color  i~  ii'ht 
yellow  or  yellowish-bmwn.  On  section,  the  tissue  is  .soft  ai>(l  •  Me. 
and  fat  droplets  can  be  scraped  off  the  surface  with  the  knife 


id. 


AUrWID  OR  LARDACEOUS  TRASSFORMATlnS  479 

Histologicall V.  the  liver  cells,  particulariy  those  of  the  centre  and  rni.i.ile 
zoneof  thelobules.contain  a  variahlenumberof  small  clear  vesicles  which 
represent  the  spaces  occupied  by  the  fat  when  the  ti.s.sue  was  in  th^  fresh 
>tate.  Material  haitiened  it.  formalin  and  cut  on  the  freezing  micrr,tome 
may  be  stamed  by  .>,udan  III,  a  selective  stain  for  fat.  'ITie  parenchv. 
n.atoas  cells  appear  then  to  be  filled  with  globules  of  a  carmin,.re.J  .'.r 
y,|low  color.  In  the  most  advanced  condition,  it  mav  l,e  har.1  to  rer^- 
nize  any  normal  liver  substance  e.xc-ept  the  portal  sheath.s.  Slight  grades 
of  fatty  degeneration  can  I*  seen  in  the  centre  of  the  lobules  in  cases  of 
jmssive  congestion  of  the  liver,  and  in  the  neighborhood  of  inflammatory 
f<Ki  and  new-growths. 

-Not  unlike  fatty  degeneration  in  many  wavs  is  fatty  infihiation.  'ITie 
liver  IS  normally  a  storehouse  for  fat.  esp^^-ially  that  taken  into  the 
«..nomv  in  the  way  of  food  or  elaborate,!  from  oth^r  nutritive  substands 
A  certain  amount  of  fat,  therefore,  can  onJinarilv  I*  obser^e.^  in  even- 
liver  section,  even  under  normal  conditions,  and.  indeed,  after  a  meal  th^ 
amount  mav  be  quite  noteworthy.  An  e.xc*..sive  amount  of  fat  mav 
however  be  deposited  in  the  liver  cells  in  cases  where  an  excesTof 
fat  or  of  Its  precursor^has  been  inge.ste,l.  or  where  there  is  a  lessene.1 
ox,,  ation  of  the  fat  ordinarily  supplier!.  The  latter  .Krurrence  is  s^n 
.  ioHK-standing  and  wasting  di.sea.se.s.  such  as  tuberculosis,  anem^^ 
t^ZT^^    Theuseofal«,holisespeciallypn>netoind.::; 

Matroscopicalh-,  the  liver  is  enlarge<l  and  its  weight  increased  Its 
^,H..-.hc  gravity  however,  is  diminishe<l,  an.l  mav  be  reduced^,' such 
a.,  ex  en,  that  the  organ  will  float  in  water.  The  tdges  are"^,.  «1  he 
.ap,uie  smjjoth  and  tense,  and  the  surface  can  readilfbe  indent«l  The 
ir  "^r;:^  ofst""  "i;  '"^^'^  •^^""^;  ^^^^^^^  ^°  ^^e  amoun  ,. 
!inHl"2tuou'      "^'""'  ''"  "'^""  '^  f"*'--  >-^""^-  ^'-^'--  -d  «i- 

Ili.tologicallv,  the  appeara.if^s  are  much  the  same  as  in  fattv  .le- 
|.'H,eranon.  and  in  fact,  in  advance.!  ca.s.s  one  condition  "an  Ti-.r.k 
«•  .lH„ngu,she,!  from  the  other.     In  fatty  .legeneration    he  tendencv  ^ 

r  Mnali  droplets  o    fat  to  form,  which  ultimatelv  coale.c^  ami  incre-.se 
n  ^i/e  until  they  fill  the  c^H.     I„  fa„v  infiltration  the  glol.u  is  "re  am 

of  tl  ,■  lobules.     Ihe  nucleus  is  pushed  to  one  side  so  that   he  H TTJh 
'-;volve.l  .s  swollen.  rounde<l.  an,!  presents  a     gneling  linnet 


tivciv 
whil. 

el:;, 


'""•liLliseaseelseuwTf,^  r  •     ^^^  """^  circumstances  as 


4§0 


Tim  LIVER 


l-l 


1 


11:1 


'Hie  orpiii  is  enlurjjwl,  iia  wl}^  are  ruundeil,  uiid  its  c-onsisteiicf  is 
iiiiTfased,  so  that  it  h»»  a  somewhat  elastic  or  rubbery  feel.  It  does  not 
lie  flat  on  the  table  and  looks  as  if  forced  into  a  capsule  that  whs  itMt 
small  for  it.  Onsec-tion,  the  cut  surface,  if  the  amyloid  chnii)^-  !»«■ 
extensive,  looks  as  if  it  were  covere«l  with  a  thin  layer  of  jfelatin, 
and  the  e«lj<es  are  translucent  when  held  up  to  tlie  light.  The  aniyinicl 
masses  can  be  recognized  by  their  semitranslucent  glue-like  appearaiur. 
The  remaining  liver  siiUstance  varies  in  appearance  according  to  ilie 
amount  of  fat  present  mid  the  degree  of  congestion.  The  gall-biaddi-r 
usually  contains  clear,  thin  bile. 

Microscopically,  in  a  moderately  advanced  case,  the  amyloid  mntcriiil 
is  found  to  occupy  by  preferenc-e  the  intermediate  zone  of  the  iobiilis, 
the  centre  and  wriph-.y  being  free.  The  .substance  appears  to  lie  of 
the  nature  of  a  dt-pasit  and  is  laid  down  in  glistening  scales  in  the  wtills 
of  the  capillaries  beneath  the  endothelium.  In  advanced  ca.ses  the  liir>fcr 
arterioles  of  the  portal  districts  are  affected,  particidarly  in  their  niiddle 
coats.  The  parenchymatous  cells,  lying  between  the'  thickened  oipij. 
luries,  present  various  stages  of  fatty  degeneration  and  atrophy. 

Pigmentary  Zllfiltration. — When  we  examine  sections  of  liver  iiiulcr 
a  high  jjower,  we  fintl  normally  a  certain  amount  of  gohlen-vfliow 
pigment  in  the  fonn  of  granules  within  the  set-reting  cells.  This  inav 
be  the  natural  coloring  matter  of  the  liver  cells,  bile  pigment,  or,  iis  one 
of  us  (.1.  (i.  A.')  has  suggeste<l,  bacteria  in  a  deail  or  «lying  condition  u  liidi 
have  Ijecome  bile-staine<l. 

Under  pathological  ctmditions,  the  pigment  of  the  liver  nuiy  lie 
much  increase<l  and  may  l)e  of  verj-  varying  nature.  In  irlrriix  or 
jaundice  the  liver  may  Ih-  stained  a  bright  yellow  or  green.  This 
coloration  is  due  to  the  retention  of  bile  and  its  pa.ssage  out  of  the 
bile  capillaries,  owing  to  some  ol>struction  to  the  free  di.scharge  of  the 
secretion.  Cholelithiasis,  cholangitis,  tumors,  and  aneurisms  pro-injr 
upon  the  bile  ducts  are  among  the  main  conditions  to  lie  nienliomil  in 
this  cuiinection.  Icterus  (f  the  liver  al.so  (Mc-iirs  in  some  forms  of  <iiTlio>is, 
in  severe  blood  destruction,  and  in  acute  yellow  atrophy  of  the  liver. 
In  a  well-marked  case  of  icterus,  the  finer  bije  ducts  on  section  arc  U>»m\ 
to  lie  distende<l  and  bile  flows  from  »hem  readily,  while  the  central  portion 
of  the  lobule  shows  a  diffuse  bile  staining.  Microscopically,  tlic  liver 
cells  are  of  a  diffuse  bright  yellow  color  or  contain  yellowish  or  yell.  >\^  i«li- 
brown  granules,  more  rarely  a  crj-.stalline  deposit.  Acccirdin:.'  to 
Xauwerck  and  Fuaerer,  dilatation  of  the  minute  intracellular  |.:i-si;rts 
is  to  be  obser^•ed.  The  pigment  in  question  is  calle«l  Lilirubiii,  mil  is 
believed  to  be  identical  chemically  with  hematoidin. 

Another  important  class  of  pigments  found  in  the  liver  is  thai  'ne  to 
disintegration  of  the  red  blood-corpuscles.  In  such  cases  the  heiiw  uli il>in 
is  .set  free  and  carried  to  the  liver,  where  it  is  metamorphosed  in  ciiilVrent 
ways.  Two  main  forms  of  pigment  may  \>v  mentioned,  lien  .tiidin 
and  hemosiderin.    The  principal  point  of  difference  between  tin  two  is 


Lancet,  2: 1898;  Montreal  Med.  .loum.,  27: 1898:898. 


NKCROSIS 


481 


that  the  latter  t-oiitttins  iron.  Should  the  blooci  destruction  be  moderate 
iM  .Itxree,  the  liver  appears  to  l)e  able  to  cope  with  the  condition  to  some 
extent,  so  that  the  heniatoidin  is  excrete.]  in  the  bile,  while  the  hemasiderin 
IS  ntained.  In  fact,  a  minute  quantity  of  iron  can  be  detected  even  in 
n..rmal  livers.  A  pathological  increase  of  pigmentation  is  met  with  in 
all  ca.ses  of  advanced  pas.sive  congestion  of  the  liver, 

H«a»orid«oita.— Hemosiderosis  in  the  liver  results  in  all  cases  where 
thm.  IS  extensive  destruction  of  the  re.1  corpuscles  of  the  blood,  such 
as  occurs  in  severe  sepsis,  pemicioas  anemia,  malaria,  hemoglobinemia, 
III  tfrtam  cases  of  cirrhosis  of  the  liver,  severe  bums,  and  in  variow: 
intoxications  The  iron^ntaining  pigment  is  deposited  in  the  liver 
Mh,  particularly  at  the  periphery  of  the  lohults,  but  also  in  the  tissue 
s|«urs.  1  he  pigment  is  of  a  golden  color  and  may  be  differentiated  from 
...irnbiri  by  the  fact  that  when  sections  are  treated  with  hydrochloric 
ari.l  and  potassium  ferrocyanide  the  Prussian  blue  reaction  is  obtained 
I  erls  test).  In  exceptional  instances,  hemosiderin  is  found  :n  the 
skin,  iniiroiis  membranes,  the  intestinal  wall,  the  pancreas,  spleen,  and 
otiur  orKuns  as  well  as  in  the  liver.  This  condition  has  been  termed 
iwmoehromatotia  (v.  Recklinghausen)  and  has  been  studied  in  this 
.•onlimnt  especially  by  Opie'  and  Maude  Abbott.'  Manv  cases  are 
..>s,Kmt.-<l  with  cirrhosis  of  the  liver  (cirrhose  pigmentaire)  or  pancreas 
(iliiil'ite  hronz^),  or  InMh. 

In  nialaria,  the  pigment  found  in  the  liver  and  other  oreans  is,  in 
|«.ri  hemosulenn  and,  in  part,  melanin,  the  latter  a  pigment  elaborated 
i«,v  tlie  |)rotozo6n  that  causes  the  disease. 

Otlier  pigments  found  in  the  liver  are  of  extraneous  origin,  as,  for 
.xample.  coal  dust  and  silver  fargj-ria).  In  some  cases  the  amount  of 
nntliramtic  pigment  taken  into  the  system  has  been  excessive  and  has 
r«a,  „.,|  the  general  circulation,  some  of  it,  therefore,  being  deposited  in 

■"  Tv '!'■•.."!'  «nt'»racotie  lymph-node  may  soften  and  rupture  into  a 
v'ln.  \\e|,.h  has  reportwl  a  ca.se  of  cirrhosis  of  the  liver  due  to  coal 
j.i«-n.„t.    One  of  us  (J.  (i.  A.)  has  met  with  a  case  of  silicosis  of  the 

Necrosi8.-\ecrasis  of  the  type  commonly  known  as  coagulation 

><■<  msis  ,s  not  uncommon  in  the  liver.     Large'areas  of  a  pale  vellowish 

•':  T  aiH  opaque  apj  -arance  are  frequently  to  be  observed  i;i  c(;nnection 

111  J'ptic  pr.K-e.sses  w. thin  the  district  drained  by  the  portal  svstem. 

"  ■'My  in  oases  of  appendicitis.     They  are  found  also  in  edampsia  and 

:"    ullow  atrophy.     Less  extensive  necrosis  is  seen  in  the  various 

mm,.  {^yeTs,  typhoid,  diphtheria,   variola,  cholera,  glanders  and 

•    nnia.  and  as  a  result  of  various  intoxications.     Sometimes  multiple 

'  ■'    ^m-as  of  necrosis-focal  necroies-are  met  with,  which  are  visible  to 

'    "M^.;..  eye  as  grayish  or  opaque  yellow  dots  the  size  of  a  pin-head  or 

^      I  iHsp  are  small  areas  of  necrosis  of  the  liver  cells,  or  perivascular 

'  Joiirn.  of  Exper.  Med.,  4:  1899: 279, 

'  .rourn.  of  Pathology,  6:  1900:  ,315. 

'  Adami,  Sajoug'  Encyclopedia,  article  Cirrhosis. 


4K2 


Tim  UVER 


II 


(•olItH'tionft  of  .iiimll  hjiiimI  •vIIs  n-!M>inl>linK  lyinph-follicli'.M.  'ITn-  <lciiih 
uf  the  wWn  tippt'un  to  lit*  tlii<>  iNirtly  to  llit>  «linH-t  action  of  the  toxin 
ntiii  {Mrtly  to  olwtnictivi'  iiiiiiiitioiiM  witliin  tlit*  rapillarira  (we  vol.  i, 
p.  IN) I). 

Fm.  I2t 


Multiple  focal  nfcmurs  in  the  liver  of  •  rabbit  nibjected  to  exiierimenlal  ilanileri. 


PR0ORU8ITK  MITAM0RPH08U. 


-f!£ 


H3rpArtrophy. — Tlie  liver  may  lie  enlarj^ed  in  a  variety  of  (■oinliiic!!?. 
such  as  passive  con);estion,  inflammaton'  infiltration,  cysts,  and  tlllll(l^. 
Kvcry  iiurease  in  size,  therefore,  is  not  to  \ye  reganlwl  as  hyix-nrojiliy. 
The  term  hypertrophy,  strictly  s|)eakin>;,  applies  to  the  enlarpiu-  nt  of 
individual  cells,  and  this  is  seen  to  a  limited  extent  in  many  r»'[i:iniiivf 
processes  going  on  in  the  liver,  but  the  condition  is  practioally  alwavs 
coml)ined  with  an  increase  in  the  numl)er  of  the  cells — numericiil  livpr- 
trophy  or  hyperplasia. 

Hypertrophy  of  the  liver  in  this  .sen.se  is  e.s.sentlally  a  coniixn^iiton 
process,  and,  moreover,  local.  The  existence  of  a  jjeneraliziil  Iivjht- 
trophy  is  doubtful.  The  liver  is  an  organ  that  exhibits  iiikIci- cirtain 
circumstances  a  striking  degree  the  power  of  repair.  Aciiirlii.-:  to 
Ponfick  and  von  Meister,  one-half  to  three-quarters  of  tlie  livt  r  .  liii  t-e 
removed,  and,  while  th»  original  sha|H-  is  not  restoretl,  tlie  p  >  liiiinc 
substance  undergoes  compensatory  hyperplasia.  The  |ir"\i>tini 
lobules  l)ecome  gre.itly  enlarged,  there  Jwing,  however,  but  liMe  "?«■ 
formation  of  parts,  iiegeneration  of  this  onler  is  well  swmi  (ji^ 
where  portions  of  the  liver  are  destrf)ye<l,  as  by  traumatism.  -.  :•  ^>u^p. 
or   various  degenerative  processes,  for  example,   in    advaiut-''   pA^'ive 


TUMORS 


483 


a  ..  ...p...  a,  n-Kenrntion.  rather  tha,.  u.  the  eff«.,  ,.f  th?!,.nen."i. W 
rh.-  ..ewlv.forrn«J  conn«.  ve  ,k,ue.  an  expUnation  that  ha^^ S  U^' 
|.lva,K-«i  IV  »rol,fer»tinK  liver  t-elN  aA-  r»^>^ni.e,l  bv  the  art  tZ 
tl...v  ar.  lajv^r  tUn  n..r,„al.  the  cytoplasm  .tai,.,  .leeplV/Jhe  nuc m 
.^  laa-.  n.h  .n  chmmat...  and  often  sUs  evidence,  of  mito^L"  S 
r..mlar  arranKement  of  the  liver  loj.ule,  L,.  however.  nT.  alLether 
rj-,.n.lu.t.l  n.,h  the  p^iUle  exception  of  acute  v.||,.«  a.lh  The" 
.h.  „e«  celU  Kmw  mto  the  stn.nia  and  n-pUre  ,h..e  that  h.*^  e  umler 

Tnmon.-I'he  new.^rro*th.,  found  in  the  liver  nmv  \^  primar*  or 
^^^t^t  Tl*"!  °'  '^"""'"■^-"■^»-  or  epithelial-  tvpe.^^   ?riS„  v 

■.•»..v.l.. ,.,  a  n,l,.  .„,1  i,  „Hv  ,J Uoi.  li/   I,  i,  .^....liiXh';  Z^ 

Flo.  IjJ 


<  .vemom.  of  li,„.     ,;„,.,  .„p„r.n.-,.     ^A(.«  hil.Urt  . 

I.n.«,,  or  p„r,,lish-K>,l  color  and  is  shari,ly  define.!  f,x,n.  tlu-  liver  sul> 
""  ■.     I    „,ay  Ik.  surrounded  by  a  fibUs  capsule      W  en  rJf  in, 

•'"■  Hil.,r.ed  vessds  «^-  h  '      .  ^^"'"'^'"'  '^  frequently  observed  in 

'f'"''ii-'  .holkto  t^^^^^^^^  ^""V^-"  "^"'^"^  pr..Fr.  although 

'lolds  to  the  former  v,ew.    Owing  to  dilatatii!,,  of  the  tubules 


!  r  1: 


484 


THE  LIVER 


i 


!■  I 


we  may  get  an  adflnocystoma  consisting  of  more  or  less  numerous  cysts 
or  groups  of  cysts  filled  with  clear  fluid.  Such  tumors  appear  to  jm 
developed  from  outgrowths  of  the  bile  ducts  in  the  periportal  connective 
tissue. 

We  have  recently  met  with  a  case  of  lipoma.  The  ppvwth  was  tlic 
size  of  a  jfreen  pea,  situatetl  on  the  dome  of  the  liver,  and  was  well 
encapsulated. 

Fio.  120 


:*il'*»a,  ! 


Cavernous  anKioina  of  the  liver.  Wimkel  N.i.  -i,  willimit  iHular.  .N.irmnl  Iimt  li"ue  i» 
"liiiwn  above  anil  I"  the  left.  The  fibrous  Iralieiuhr  of  tlie  bl.Kiil  tumor  are  well  *<n  ilnni 
Dr.  A.  G.  NichoUs'  collection.) 

Primarv  sarcoma  is  exce.ssively  rare  in  the  liver.  It  (xciirs  us  ;i  siiifili' 
iarjje  mass  or  as  multiple  circumscrilH'd  iumIiiUs.  Uoiiml,  spiiidle- 
celled,  and  melanotic  forms  are  de,scril>ed.  They  swm  to  iM-^'in  in  the 
neighlwrhootl  of  ves.sels.  Ford'  has  n-corded  a  case  of  primary  s:iicoina 
occurring  in  a  cirrhotic  liver. 

In  lymphosarcoma  a  lar^e  luimlier  of  lymphoid  cells  arc  fouml  iii  the 
portal  sheaths  and  in  the  iiitralohular  capillaries,  while,  in  M.lilitiDii, 
lyinphomatous  nodules  are  scattered  throughout  the  organ. 

Secondary  sarcomas  are  not  iincommoii  in  the  liver,  and  iin'  "f  <'ll 
tyjH's.     The  pigmented  forms  are,  however,  the  most  import.iin.    Uitn 
the  excepticm  of  the  hing,  the  liver  is  the  most  fre(|uent  scat  i 
tiitic  deposit  in  the  case  of  the  melanotic  new-gn)wtiis.     Wi 
either  circumscrilH'd  pigmented  ntMlules,  or  a  diffuse  iiitiltraii 
form  of  yellow,  gray,  or  hlackish-hrowu  streaks,  wliich  fjiv 
an  apjiearance  somewhat  like  granite  on  section. 


liirtas- 
rt  then 
,  ill  the 
If  liver 


'  .\iner.  Joiirn.  Metl.  Sri.,  120:  1!)00:  iVi. 


CARCINOMA 


485 


Alixed  fornw,  fibrosweoint  and  mTouieoiu,  are  also  described. 

Hlock  has  descril)efl  a  melanotic  endothelionu. 

HypeniephromM  are  occasionally  met  with  in  the  liver 

CarcinoiM.-By  far  the  most  important  and  frecjuent  tumor  of  the  liver 
IS  the  carcmoma,  which  may  be  primary  or  secondary.  The  com- 
l.arat.ye  frequency  of  the  two  forms  may  be  gathered  from  Hale  White's 

If'S^f  'r  ""pf^"""  ^'  ^""."'^  ^0  "^'^  "^  P"™*^  carcinoma 

an  1  240  of  secondary.    Primary  carcinoma  seems,  therefore,  to  be  de- 
(•idt'dly  rare.  ' 

''hree  main  types  of  primary  cancer  are  described.  In  the  firet— 
canctr  musif-there  is  usually  a  single  large  mass  of  new-growth  occupy- 
in^'  the  greater  part  of  a  lobe,  usuaUy  the  right.    Not  infr^uently,  in  fhe 

Fio.  127 


l.iv. 


I..v.npho„rcom.  nodule.     Zei..  obj.  A.  wi.h.mt  „cul»r.     (Krom  the  collection  o. 
Dr.  A.  ti.  Nicholls.) 


m 


mi'liLorhood  of  this  are  to  be  seen  a  few  isolated  nodules  representing 

>   ;.r  jv^ii  ish-yellow  color,  occasionally  somewhat  redden«i.    Com! 

Mr.  in.  v  I   tie  cancer  juice  can  be  scraped  awav.     As  a  rule,  the  mass 

n  I,?.  ;  ''''^•'""^^«'  f--/'-  Jiver  substan"ce,  but  at  ^a'r     of  tl  e 

^^SJ:X:^T""  ""^  -f'-i"«  «*  the  centre,  and,  if  situated 
is  n  .  ZuZ  tL'T'  '"Y  '^'''''  V^bil'^^ti""-  General  metastasis 
«.n,,  r  '  "?;  u-  ''7'-,«"bstance  m  the  immediate  neighborhood  is 
«>m  ...  .M-d,  atrophic,  and  the  vessels  are  often  occluded. 

tmlZZ  .  ■"'•'""'«*«  1  nodular  cirrhosis-the  inflltrattoff  eax- 
cinomatous  curhcis  of  Perls.    The  liver  is  more  or  less  enlalg^d  ^e 


480 


THE  LIVER 


capsule  thickened,  and  the  surface  warty.  On  section,  numerous 
bands  of  connective  tissue  are  to  be  seen,  in  which  a  few  islets  of  liver 
substance  still  remain,  but  which  contain  nodules  of  cancer,  the  size  of 
a  pea  or  larger,  of  a  whitish  or  pale  red  color,  and  of  soft,  juicy  coiisisi- 
ency.  VMiere  the  no<lules  have  originated  in  a  preexisting  adenomatous 
ne\v-growth  they  are  of  a  grayish-brown  color,  firmer,  antl  not  so  jiiicv. 
Invasion  of  the  portal  vein  and  liver  capillaries  is  not  uncommon. 

Fio.  128 


^^■^^^^ 

^^Ksi  * "  ^Si^ 

k 

^^i  ■  % 

g 

^ 

"mm 

m 

1 

■/      1 

1 

1 

Primary  carcinoma  of  the  liver.     (From  ilie  Hatholttgical  Department  of  tlie  lit- 
Victoria  Hospital.     Case  of  Drs.  C.  K.  Martin  and  W.  F.  Hamilton.) 


t't.f' 


In  the  third,  a  rare  form,  there  is  a  carcinomatous  infiltration  of  tlie 
Glisson's  capsule  originating  from  the  larger  bile  ducts.  Tlu'  nuilules 
of  new-growth  in  the  portal  districts  are  closely  packed  and  ofltn  fused, 
gratlually  dimiiiLshing  in  size  as  one  passes  from  the  hilus  to  the  pt  i  iplieral 
portions  of  the  liver.  Icterus  is  common  in  this  form,  owing  to  coiiipres- 
.sion  and  obstruction  of  the  bile  ducts. 

Carcinomas  of  the  liver  originate  either  from  the  specific  pan  i  >  Iniua 
or  from  the  epithelium  of  the  bile  ducts.  Acconling  to  their  lii>inloi;i(:il 
stru(!ture,  we  can  divide  them  into  the  cylindrical-celled  adenocarcinoiM. 
medullary,  and  sciirhous  forms.  The  carcinoma  with  cirriiosi^,  aminl- 
ing  to  several  ob.servers  (Hanot,  Frohmann,  Ziegler),  is  tievi  li 
a  cirrhotic  liver  by  atypical  proliferation  of  the  newly-foiii 
cells. 

Secondary  carcinomas  of  the  Hver  arise  by  direct  extensio;. 
metastasis.     .\s  the  growth  in  the  liver  may  attain  to  a  (oi 


[led  in 
I  liver 

r  from 
leralile 


CARClXO.\fA 
Flo.  129 


487 


Secndary  carcinoma  of  the  liver:  medullary  form.     The  necrosi,  and  «,f,e„in,  of  the  cancer 


Fig.  130 


■^.iary  carcinoma  of  the  liver.     Winckel  obj.  No.  3,  without  ocular, 
collection  of  Dr.  A.  G.  NichoUs.) 


(From  the 


488 


THE  UVER 


i 


size  and  may  dominate  the  clinical  picture,  it  is  sometimes  difficult  if  not 
impossible  to  discover  the  primary  focus.     Carcinoma  of  the  gall- 
bladder and  of  the  bile  ducts  often  spreads  dirt-ctly  to  the  liver,  but  canct- r 
of  the  pyloric  end  of  the  stomach  only  does  so  when  there  has  been  prt'vi- 
ous  adhesion  of  the  stomach  to  the  liver.    The  occurrence  of  metastases 
in  the  liver  is  common  in  cancerous  disease,  particularly  so  when  tiie 
primary  growth  is  in  the  gastro-intestinal  tract,  pancreas,  cesopliaj;iis, 
uterus,  or  larynx.    They  arise  from  small  clusters  of  carcinoma  ct-ILs, 
which  have  been  broken  off  from  the  main  mass,  and  have  reaclit'(l 
the  liver  as  emboli  through  the  portal  vein  or  the  general  circulation. 
Wherever  they  lodge  they  proceed  to  grow,  infiltrating  and  destroying;  or 
compressing  the  liver  tissue.    At  first  they  take  the  form  of  multiple 
miliary  nodules  scattered  through  the  organ,  but  soon  fuse  into  masses 
the  size  of  the  fist  or  larger.     Where  they  reach  the  surface  they  project 
as  whitish  bosses  covered  with  congested  serosa.     Not  infreqiientl\ , 
softening  and  liquefaction  take  place  in  the  larger  nodules,  which  there- 
upon collapse  somewhat,  giving  rise  to  the  characteristic  umbilication, 
The  consistence  of  the  nodes  depends  in  general  upon  the  character  of 
the  original  growth.    The  liver,  as  a  whole,  may  be  enormously  enlaif;eil. 
On  section  the  secondary  masses  are  whitish  in  color,  often  soniewlmt 
broken  down  in  the  centre.    The  larger  nodules  are  of  an  opafpic  vel- 
lowish  color  with,  sometimes,  radiating  striae,  the  result  of  degeneration. 
Mucinous,  cystic,  and  calcareous  degeneration  are  common,  as  well  as 
hemorrhagic  infiltration.    Where  the  liver  cells  are  pressed  upon  ihcv 
are  reduced  to  flattened  scales  of  a  brownish  color  (brown  atropli\  i. 

Oytta. — Apart  from  paruitie  eysU,  blood  cyits,  retention  or  bilis  cysts, 
and  congenital  cysts  should  be  mentioned.  Congenital  cystic  disease  of 
the  liver  is  often  associated  with  congenital  cysts  of  the  kidneys,  a  coiuli- 
tion  which  it  closely  resembles. 


CHAPTER    XXII. 

THE  BILIARY  PA.S.SAGES. 
ALTKSATI0M8  DT  THE  LDMHTA. 

DiUUtion.--DiIatation  of  the  bile  duets  is  due  to  obstruction  to  the 
free  outflow  of  bile.  The  causes  of  this  are  very  varied.  The  chief  that 
may  be  mentioned  are:  swelling  of  the  mucous  membrane;  gallstones 
parasites,  and  tumors  within  die  ducts;  external  pressure  from  enlarged 
yinph-nodes  or  tumors  involving  the  neighboring  glands,  duodenum 
liver,  or  pancreas;  uiflammatorj-  adhesions  about  the  ducts;  the  pressure 
of  aneurisms,  a  displaced  kidney  or  liver.  Obstruction  is  one  of  the 
pre<hsposing  causes  of  infection  and  inflammation. 

Tlie  cy-stic  duct  may  j>ecome  occluded,  leading  to  dilatation  of  the 
«all-  ladder.  Most  of  the  bilian-  substances,  including  the  pigment 
are  in  tune  absorbed,  so  that  the  organ  is  found  to  be  greatly  distended 
with  a  rlear,  coloriess,  viscid  fluid  something  like  mucin  (hydrops 
>rm-wfek^).  Occasionally,  it  is  thin  and  limpid,  like  water.  The  wall 
of  ihe  l)ladder  is  usually  thin  and  semitransparent,  unless  thickened  bv 
previous  inflammation.  ' 


XNTLAMMATIONS. 

Iiiflainmation  of  the  bile  passages  (ehotaagiti.),  or  of  the  gall-bladder 
^cholecystifas),  is  brought  about  by  to.xic  or  infective  agents  which  may 
re.  ,  the  liver  m  several  wavs.  One  very  frequent  mode  is  for  bacterid 
to  „nade  the  passages  from  the  intestine  (ascending  infection).  In  -nanv 
cases  the  or^ranisms  are  e.xcreted  by  the  liver  through  the  bile  (desceudina 
v^rtujH),  as,  for  example,  in  typhoidal  cholangitis  a    i  cholecystitis! 

n  eet.on  may  also  occur  dirough  the  blood  stream  ,atogJir  in- 

feofinu),  or  by  the  extension  of  inflammation  from  orine  parts 

111.  presence  of  calculi  or  carcinoma  in  the  region,  parasites  in 

he  Wiary  passap,  will  naturally  predispose  to  inthmimation  and 
in  ution,  and  will  aggravate  any  such  conditio..,  that  previouslv  exist 
The  microorganisms  usually  found  are  the  B.  coli,  the  pyogenic  cocci, 
tlie  Hiplococcus  pneumonia",  and  the  B.  typhi. 
gal'LoX  °^  '"^^"'"^t'""  is  catarrhal,  purulent,  membranous,  or 

Cholangitis—Acuta  CaUrriul  Ohol«igiti«.-Acute  catarrhal  cholan- 
friti>  s  a  not  uncommon  afTection.    When  secnnHarx-  to  gastroduodenitis 
■t  .s  t  u.  usual  anatomical  basis  of  the  disease  known'clinicallv  as  caiarrkai 
lau  <i<n:    In  some  cases,  cholelithiasis  and  hydatids  in  the  liver  or  bile 
pa>s,;:,.s  give  rise  to  this  form  of  cholangitis.     In  most,  if  not  all  of 


i     *e 

i 


490 


THE  BILIARY  PASSAOES 


thoni  the  infeetiun  is  of  the  Hscendiiifr  type.  Acute  caturrhul  jamidife 
is  Dccasionully  iiict  with  also  in  typhoid  fever,  pi.eumonia,  secoiidarv 
syphihs,  and  .some  other  iiifectiouii  diseases. 

As  patients  rarely  (ht-  while  they  are  the  subjects  of  this  condition,  it 
is  ratljer  difficult  to  say  what  are  the  anatomical  appearances  presented. 
The  mucous  membrane  of  the  common  bile  duct  is  said  to  be  a  little 
swollen,  but  not  particularly  reddened,  and  the  ampulla  of  V'ater  is  filled 
with  a  grayi.sh,  slimy,  mucinous  plug,  which  is  sufficient  ■  obstruct  ilie 
free  outflow  of  bile  and  thus  to  produce  jaundice.  The  liv  er  is  probalily 
slightly  enlHrge<l,  the  bile  capillaries  dilated  and  full  of  bile.  Should  the 
prt)ce,ss  l)ecc)me  chronic  it  is  apt  to  spread  to  all  the  bile  pas.sajte>, 
including  the  gall-bladder.  The  cystic  duct  may  in  time  Imoine 
occluded.  The  walls  of  the  biliary  ducts  Anally  become  thickened  mid 
the  muco.sa  presents  polypoid  outgrowths. 

Suppuntive  OhoUngitii. — Suppurative  cholangitis,  some*imes  also 
called  pUegmonooi  eholuigitii,  is  due  to  pyogenic  infection  of  the  i>iliarv 
passages.  It  is  usually  a.s.sociated  with  or  may  supervene  upon  the  catar- 
rhal form.  The  causes  are  similar  to  those  of  simple  cholaii^ritis. 
Cholelithiasis  and  certain  of  the  infective  processes,  such  as  pyemia, 
typhoid  fever,  pnemnonia,  and  influenza,  may  be  mentioned  in  particular. 
Probably  in  most  cases  the  infective  agents  travel  up  from  the  intestine. 
One  ca.se  that  we  have  seen  appeared  to  have  originated  from  a  plilejr- 
mor.ous  duodenitis.  In  .some  instances,  again,  the  infection  is  prolialily 
hematogenic,  the  pyogenic  microorganisms  finding  in  the  damaged  l)ile 
pa.ssages  a  favorable  situation  for  their  growth. 

Gholecystitis. — Suppurativa  OholecTstitii. — The  suppurative  pnx  ess 
is  not  luicommoidy  restricted  to  the  gall-bladder  (suppurative  dmle- 
cystitis).  The  wall  of  tlio  gall-bladder  is  oetlematous,  infiltrtited  with 
iiiflaniniatory  pnxlucts,  and  more  or  less  distended  with  mucopus  iiiixed 
with  bile  {cmpyima  of  the  gall-bladder).  The  organ  is  not  infre(|iieiitly 
covered  externally  with  a  layer  of  fibrinous  exudate,  and  may  Ix-  adiien  iit 
to  the  neighl»oring  vi.scera.  Such  a  condition  may  be  the  stariintr 
point  of  a  septic  peritonitis.  Especially  is  this  likely  to  occur  if  perfora- 
tion of  the  gall-bladder  have  taken  place.  Fistulous  comniiiiiiditinns 
with  the  hollow  viscera  or  with  the  exterior  sometimes  result.  <  >thtr 
complications  are  multiple  ab.sce.s.ses  in  the  liver  and  geiunlizeil 
.septicemia. 

The  occurrence  of  suppurative  cholecystitis  in  the  course  of  tyjihoi.j 
fever  has  received  considerable  attention.  Chiari  noted  that  tlie  typlioid 
i)aeilliis  .sometimes  |)ersists  in  the  bile  pas.sages  for  months  aft-  r  the 
apparent  cure  of  the  typhoidal  attack,  and  recent  oKservatioi-  have 
proved  that  it  may  remain  even  for  years.  This  fact  is  of  imp  rraiuf 
in  connection  with  the  etiology  of  cholangitis,  cholecystitis,  aliM  >  -s  of 
the  liver,  and  gallstones.  It  may  po.ssibly  also  explain  some  i-  -•-  of 
reinfection. 

Membranous  or  fibrinous  cholecystitis  is  exceedingly  rare.' 


'  HoUeston,  Trans.  Path.  Soc.,  London,  53:1902:405. 


TUMORS 


491 


PeiiebolMTititii  and  P»riehol»iigitii.— Perieholecvstitis  and   pericho- 
lai.ptis,  or  inflammation  around  the  jjall-bladder  and  bile  passaees 
IS  usually  to  be  traced  to  inflammation  of  tlie  wall  of  these  structures' 
1 1  may  be  simpie,  ruppuratlve,  or  productive. 

CholelithiMU.— The  term  cholelithiasis  b  applied  to  the  condition 
in  which  calculi  are  found  within  the  bile  passages,  together  with  the 
results  that  spring  from  them.  Biliarv  calculi  are  found  more  than 
twice  as  frequently  in  females  as  in  males,  and  asuallv  after  middle  life 
The  most  important  single  etiological  factor  is  infection.  In  a  large 
pmportion  of  cases  the  B.  coli.  pyogenic  cocci,  and  not  infrequently  the 
B.  typhi  can  be  demonstrated.  Stagnation  of  the  bile  also  assists  bv 
leading  to  the  absorption  of  the  alkaline  substances  and  the  production 
of  an  ac-d  bile,  which  favors  the  growth  of  the  microorganisms  concerned 
.\  slight  catarrh  is  the  result,  leading  to  an  outpouring  of  mucus  in 
which  the  various  pigments  and  salts  are  pr^cipitatetl  (see  vol.  i,  p.  872). 
The  most  common  sites  for  calculi,  in  onler  of  fretjuencv,  are  the  gall- 
bladder, cvstic  duct,  cystic  and  common  ducts,  common  duct,  and  hepatic 
duct,     fhey  are  rare  in  the  intrahepatic  ducts. 

Calculi  in  the  gall-bladder  may  lead  to  c-atarrhal  or  suppurative  chole- 
cvstitis.  with  necrosis  and  even  perforation.  In  this  situation  thev  are 
often  single,  and  may  be  large  enough  to  fill  up  the  whole  cavitv.  .si,me- 
ti.nes  they  give  rise  to  little  or  no  disturbance,  and  at  death  the  gall- 
l)la(lder  is  found  to  Ije  thickened  an.l  c<)ntrdcte<l  about  the  calculus,  with 
perhaps,  a  few  adhesions  about  it.  Fistulous  communications  at  times' 
occur.  According  to  Courvoisier.  communication  with  the  e.xterior  is 
the  commonest  event,  .^trumpell  and  Murchison,  however,  state  that 
the  cholecysticoduotlenal  fistula  is  the  most  frecpient.  An  e.xtremelv 
rare  form  is  the  cholecysticogastric,  an  example  of  which  one  of  uV 
(.\.  (r.  .\.)  has  had  an  opp<irtunity  of  recording.' 

ralculi  in  the  common  or  hepatic  ducts  mav  lead  to  complete  obstruc- 
tion, tlu  pnxluction  of  jaundice,  dilatation  of  the  ducts,  inflammatory 
an,  productive  changes  in  and  alxnit  the  ducts,  with  also  inflammatory 
an.  cirrhotic  changes  in  the  liver  and  pancreas.  Occasionally,  large 
jralNtunes  may  ulcerate  through  and  become  impacted  in  the  intestine 
arc  iiionia.  usually  of  the  cylindrical-ceiled  variety,  affecting  the  gall- 
t^la.Mer,  mav  result  from  the  irritation  of  a  calculus.  It  often  spreads 
to  tlif  hver  l)y  contiguity. 


PROORCSSIVE  MCTAMORPB08S8. 

Tumors.— Tumors  of  the  bile  passages   are   most  common  in  the 
Mniiin   of  the  ampulla  of  Vater.     PapiUomu  and  cysUdenomu  are 

IViin.iry  carcmom  oorurs  most   frequftiflv  near  the  ampulla   or  at 
iiK-  jinction  of  the  common  and  cystic  ducts.      It  is  usually  cyl.n- 

•  Montreal  Med.  Jour,  27 : 1  sO*« :  %2t). 


;1 


492 


THE  BILIARY  PASSAOES 


dnciil-celled  in  type.  Secondary  carcinoma  is  clue  to  direct  extension  of 
carcinonm  of  the  duodenum,  pancreas,  stomach,  liver,  gall-bladd.r 
or  the  neighboring  lymph-nodes.  Duval'  has  reported  an  apparently 
unique  case  of  aMUnoau  of  Vater's  diverticulum. 

Primary  connective-tissue  tumors  of  the  gall-bladder  are  rure. 
ribroBtt,  Upoaa,  mjrsoiiM,  and  ureoau  have  Iteen  met  with.  Villous 
paiiiUoBU  is  occasionally  found.  The  most  frequent  new-growth  in  this 
situation  is  nniiioiu.  It  is  of  the  cylindrical-celled  variety  and  usunllv 
associated  with  gallstones. 

'  Joiirn.  of  Exper.  M«l.,  10: 1908:4. 


CHAPTER    XXIII. 

THE  PA.\(  REAS 

OOHOnriTAL  AHOMALIBS. 

C.MPLETE  ibMiiMof  the  pancreas  occurs,  hut  onlv  in  tetmes  that 
,m.sent  other  senous  defects.  A  portion  of  the  head  mav  be  selrlje 
from  the  rest  const.tut.ng  a  ptaena.  ainn.,  which  lies  upon  the  aiuerior 
surfa..  of  he  duodenum.  The  organ  may  aUo  be  dl,id,d  into  t^oZZ 
or  unequal  parts  connected  by  the  pancreatic  duct.  The  Uil  may  "^ 
a..a.l,e.l  to  the  head  by  a  fibrous  band  c-ontaining  the  duS  ^nd"iieN 
Or,  a,.u,,.  the  pancreas  may  l.e  bifid  or  lobulafd.  The  duct  of  W.mme 
may  discharge  .nto  the  stomach  or  into  some  unusual  part  of  the  intrt  ne^ 

at'ihe  hrr„  I  "  '^r""°'  '"™  ^  r^'""  ^^'^  .he  common  bi  eZi 
plii«  aSl""  r  '^"  •"'"•^""'^'  «»>o»gh  rare,  anomaly  is  the  so^alled 
ptncrew  unnUn,  form.ng  a  more  or  less  complete  ring  about  the  duo- 

,1  ■'  Tk  T  ^'  ""  •^."'"y  *"■  *'*™'*  panci^as.     This  is  usuallV 

mnd  .„  the  duodenum  or  je  unum.'  less  often  in  other  parts  of  the  small 

.•s,me  or  .n  the  stomach.     Wright  has  teconled  one  Le  c^umngln 

the  ab<b,n.nal  wal   .n  the  region  of  the  umbilicus.-'    OccasbnaTv   the 

aUrrant  pancreas  is  found  at  the  tip  of  an  intestinal  di^Slu     ' 


OIBOULATORT  OISTITRBAROES. 

Tlie.f  are  romparatively  unimport^.nt.     Aetiv.  hyper«ini»  is  met  with 

hypenimi.  occurs  ,n  con.lit.ons  of  general  pa.s.sive  ct.ngestio„.     Hvne7- 
;  ;;;m  '.f  the  pancreas  ..s  said  also  to  ..e  pil^sent  in  ca£  of  pemicbus 

S.,ull  hemortug,,  may  take  plac-e  into  the  sul>stance  of  the  panc^as 
.  -  s  Z^T  V^"  "'^'"'-  ;"  ^™^'""»^  ""'^  °«''-  hemorrhage 
rh..:r..  also  occr  as  a  .^.sult  of  traumatism  and  in  the  affection  known 
a>^.norrha,,c  pancreatitis.     This  «,n<lition  will  l>e  r^fer^S^to  later 
A..emia  ,>  present  .n  conditions  of  systemic  a.iemia. 

'  Xicholls,   Montreal  Me<lical  .ro.irnal  2<»   IflOO  '«j 
•Jaiue-  II.  rt  right,  Jour.  Boston  Soc.  Med.  Sci.,  .5:1901 :  497. 


4M 


THE  PANCRBAS 


I 
I 


■  I 

IS 


orrLAMiiATioiri. 

PM»cre»titis.— Influiniiiatioii  of  the  panerea»— puMrMtiti»— ix  not 
very  «»tninon.  In  210  autopsies  of  which  we  have  notes  acute  infltnn. 
mution  was  found  in  (S,  in  only  1  of  which  was  it  the  cause  of  cleath. 

Acute  pancreatitis  is  usually  due  to  infection  with  microdrRanisins 
hut  may  on  occasion  result  fmm  the  action  of  toxic-  substances  reacliirii' 
the  jjland.  the  irritation  of  the  pancreatic  ferment  or  of  hemorrhiiKic 
extravasation.  The  infective  forms  arise  in  three  ways— through  I  he 
•oIikhI  stream,  through  the  excretory  duct,  and  hy  extension. 

The  hematogenic  type  is  simply  a  manifestation  of  general  septicemia 
and  IS  not  c-ommon  as  compared  with  the  frequency  of  general  sepsis. 
By  far  the  commonest  cause  of  pancreatitis  is  the  pas.sage  into  the  glim(i 
of  bacteria,  bile,  or  acid  stomach  .sec-retions  by  means  of  the  duct  ..f 
Wirsung. 

Ulcers  of  the  stomach  and  ducMlenum,  suppurative  processes  in  iind 
about  the  spleen  and  left  kidney,  (Kcasionallv  extend  to  the  pancwis 

Panc-reatitis  is  .vmfjc,  nuppuraHc;  or  specific,  and  mav  affect  the  dn,  ts 
the  lobules,  or  the  interstitial  tissue. 

Fra.  131 


Acute  »ial..<l.K'liiti^  with  r,h»trutti<,n  nf  the  ducts  leadimt  to  dilatation  of  the  acini.     I    ,<i 
obj.  No.  a,  without  ocular.     (From  the  collection  of  Dr.  A.  G.  Nicholl...) 

Sialodochitis  Pancreatica.— Catarrh  of  the  duct.s— sialodtH-hiii  paii- 
creaticu— which  may  Ik;  .simple  or  purulent,  is  due  to  the  action  .  f  in- 
fective microorganisms  or  toxic  agents  which  have  passed  up  tli'  liict. 
Duodenitis  seems  to  he  the  important  predisposing  cause.     In  o;     -ase 


SUPPURATIVE  PASCREATITia 


495 


tlmt  we  have  seen,  the  duct  and  ita  chief  branches  wen-  wuked  with 
i.iHainmatory  leukocytes  and  the  lininf;  epithelium  was  in  phicrs  de,s<iua- 
inalin^.  Owing  to  obstruction,  the  finer  iumina  were  «lilm„|  and  the  acini 
cmvertw  into  small  cystic  cavities,  lined  with  flattenwl  cells,  which 
as,,  in  places  were  catarrhal.  The  condition  MiKRestetl  the  dilatation 
of  the  tubules  so  wn  in  the  kidney  of  chronic  nephritis.     A  certain 

amount  of  inter>  t>  ..al  infiltration  also  ha.l  cKiurre,!,  but  it  hardly  amounte.! 
to  abscess  form  ition.  In  such  cuses  the  nmin  duct  is  not"ne<*.s.s«rilv 
always  o<x-liided. 


Ito.  lag 


iJin  ..iii..uiit  .,f  ciirnrrh.     The  «|)ei'impn  U  fnmi  the  »s.me  case  as  the  ln.t    h..t   ..    i      i  •  7 
"'« "•""'■     •-"•  "'-J-  '«"■  7.  -i.hou.  „..uUr.     (FrotTthe  :.l.e:,i!;:  .^  I'.r    A.  <"' Ni,!',.''! " 

Degenerative  Parenchymatous  Pwicwatltis.-Orth  .les<TilH..s  a  deirener- 
i'  'V.-  paremhymatmis  pancreatitis,  which  may  possibly  \^  the  samt  con- 
li-.'.n    poken  of  l,y  other  writers  as  cloudy  ^eili,  jr.     The  pancre  s 

•    iin.       .?  "^'"'"^'  '^^  '"""'1'"'^  ^*'^"'  "^  '^'  acini  pr;.sent 

,      '\v    "l^  i""^  degeneration,  anrl  necrosis.     I„  a  case  r^portc.l 

>    ..  Frnenkel  the  organ  was  dotted  througiiout  with  a  fatty  granular 

;-.    .lerived  from  the  degenemting  cells,  while  in  the  iS  a 

-      there  was  a  round-celle- '  infiltration.     This  form  of  pancTeatitl^ 

1  nil  1;"]^"""'  "'''"'  P"""""""'''  '""'^  "^  ♦>Pf""''  f""'  Pye-nia. 

i".SfT^;i.f"r"**'-~''^"PP"r''''^'^  pancivatiti-s  is  by  far  the  most 
!  form  of  pancreatitis.  It  may  be  acute,  even  gang^-nous. 
"•   "'   '^'^"'"•^-     Diffuse,   purulent    infiltntion    may  occur    oi^ 


Ilr 


»i;., 


406 


THE  PANCRSAS 


deKiiite  abetcmiM's  may  be  furmmi.     AImk-tsw!*  are  often  multiple  and  of 
small  Hiie,  but  larjje  Miiif^le  abscesuteM  occur  in  some  cases  fonned  by  llie 
confluence  of  smaller  foci.    'ITie  multiple  pancreatic  abscesses  .hoiih'- 
times  met  with  in  (generalized  septicemia  are  hemato^^enic  in  ori);iii, 
due  to  the  lodgement  of  infective  emlN>li.     Suppurative  procfsws  in 
structures  adjacent  to  the  pancreas  may  extend  into  it.     \\f  imve  iiift 
with  one  case  in  which  an  extensive  perinephritic  alwc-ejw  had  hiir*t 
int»    »he  peritoneal   cavity,  eventually  discharKinjf  into  the  stoniiich. 
Int        tally  it  caused  gangrenous  infiammntion  of  the  lower  end  of  the 
spleeu  and  the  tail  of  the  pancreas.     More  fretjuent  ure  those  nines  iliic 
to  the  nivH.sion  of  the  {wncreas  by  way  of  the  duct  of  Wirsung.    Since 
the  common  bile  «luct  uiid  the  |>ancreatic  duct  usuiilly  empty  by  a  comtiKMi 
orifice  into  the  intestine,  it  c-an  readily  be  underslofMl  that  inflamniiilorv 
proces.ses  in  the  duodenum  and  bile  passages  nre  apt  to  extend  into  the 
pancreas.     In  such  cases  the  svmptoms  are  usually  acute  and  an-  [inic- 
tically  identical  wi»h  those  of  the  soKralled  hemorrhagic  pmcn-iitiiis 
(c|.  v.).    'I'he  ca.ses  occur  generally  in  young  adult  males  ttncrconiiniuilv 
terminate  fatally  in  from  two  to  four  days.    'I'liere  is  usually  an  nciite 
duodenitis,  which  may  also  l)e  associated  with  cholangitis,  choleljtliiiisis, 
and   even    acute   interstitial    hepatitis.      Exceptionally,    the   affcdicm 
becomes  chronic  and  life  may  be  prolonged  for  some  months  or  for  a 
year  or  more. 

Pancreatic  aKscesses  may  rupture  into  the  peritoneal  cavity,  ;;ivinp 
rise  to  a  septic  peritonitis,  or  may  Ik-  dischurge<l  into  the  sfoniiK  h  or 
intestine.  In  a  case  recorded  by  ("hiari,  u  se(|uestrum  of  the  pniK  reus 
was  pa.ssed  per  anum  with  complete  recovery.  Snudl  ubs<t'sscs  mav 
possibly  become  encapsulated  or  inspissated.*  Fibnisis  is  a  constiint 
accompaniment  of  chnmic  suppurative  pancreatitis. 

Aeiitt  Hemorrhagic  Paner«»tltii.— Closely  allie<l  to  iho  la.,  •,  icntione.1 
form  is  the  affection  known  as  acute  hemorrhagic  pancreatitis,  so-cilled 
from  the  fact  that  the  pancreas  is  more  or  less  completely  infiltrated  with 
blood.  The  pathogenesis  of  the  condition  is  not  entirely  clear.  I  Icmor- 
rhage  into  the  substance  of  tiie  pancreas  may  result  from  traiiniii  and 
disease  of  the  vessels,  as,  for  example,  arteriosclerosis,  fudy  dcLMiicr- 
ation  of  their  walls,  and  embolism,  quite  apart  from  iiiflarninaiion. 
'~  such  extravasations  of  blood,  if  not  quickly  fatal  and  if  not 

'S  to  ilestroy  the  pancreas,  are  followed  by  a  certain  ;iinoii, 
ot  .  'mmation.     The  general  consensus  of  opinion,  Inuvcver, 

seems  t  in  most  cases  the  inflammation  is  the  cause  <<(  ihp 

hemorrhage,  vjuite  often,  fat-necrosis  of  the  pancreas,  pt-ripMiirreatir 
fat,  the  fat  of  the  omentum  and  mesenterj-,  is  present  also,  and  it  i:  .ly  be 
that  the  blood  extravasation  is  to  l)e  explained  on  the  gromid  of  •  dsiori 
of  the  vessel  walls  by  the  lil>erated  pancreatic  ferment  or  the  .f  iloii  of 
suppurative  inflammation. 

Hemorrhagic  pancreatitis  is  found  most  often  in  al«;holir-  :?  -  'm'^' 
persons,  usually  in  those  over  thirty.  The  disease  is  ushered  in  -'iddenly 
with  intense  pain  in  the  epigastrium,  nausea,  and  voniitim  The 
abdomen  becomes  rigid  and  hypertympanitic.    The  temperai"-'  may 


CHRONIC  PASCRBATITIS 


497 

Ik-  m.HJen,tHy  elevat«|      ('«„,,i,«,io„  i,  ,he  rule.    The  patient  fie- 
.,u....tly  dies  follaps,.!  ,„  fro,,,  two  to  four  duy,.     The  dU,e  ,„«7 

hnw.-ver.  become  m.l«cute  or  eve,,  chmuic.     ( W,  ai*  ofte,,  .ni.taken 
f..r  «UHtnc  uk*r  l..l,«ry  cohe.  or  acute  int-  ^n„«I  obstruction.     Patient" 
u,.milv  K.ve  a  history  of  ,Jppe,«ia  or  of  .v.npto,„s  pointing  to  cho  " 
l..l..as.s.     fit*'  has  wntten  an  excellent  ,nono«raph  oli  the  sSbject 

he  pancreas  .s  found  to  In-  e„l«,^^.  fir,n.  „„,1  densely  i,  filtn-ted 
wuh  h  .kkJ,  often  ...  large  clots.     The  a.ljac*nt  cellular  tissue,  the  ome^ 
......  the  root  of  the  n.e.se,,trn-.  and  the  les.ser  ,,eritoneul  cuvitv  may^n- 

a...  bl.Hxl.        here  .nay  also  In-  a  s.nall  a,nou,.t  of  blo,xl.stai,.'ed  fluiSTh, 
.1..-  K'e..eral  aUiominal  cav.ty.      .M..^  „r  less  extensive  fat-necros  s  I 
..s..ai  y  present.     The  ...Ha.n.nation.  no  doubt  resulting  from  inSn 
.nay  be  ...tense,  lead.ng  to  suppuration  or  even  gangrene  of  the  on^a"! 
.VutI    akes  place  probably  from  pressure  upon  the  ^liac  axis  as  sJ^ 
K.s,ed  by  V.  ^e,.ker.  from  shoc-k. or  fn.m  sep7      The  nerve  Sis  of  "he 
stMiuhumr  ga,,gha  have  bee.,  found  to  Ik-  deg.-       .,e.l  with  a.,  interstitial 
e..  .Kyt,c  .nhltrafon.     Degenerative  changes  ..ave  also  been  obrervS 
..   he  |H-np«ncre«t,.  IVc,nian  corpusc-les.'    The  common  associatS 
of  .I..-  .•,..>.  .t.onw.th  cholang,tis  «,.d  cholelithiasis,  suggests  that  C" 
.nal  ,.,f..ct.«n  .s  an  unportant  factor.     The  i.npaction  of  a  gallsto.'e 
...  the  a,npulla  of  \  ater  .nay  lead  to  the  entra.u*  o(  bile  un.ler  presX 
.....    I.e  pan.reat.c  .luct.      Fat-necrosis  an.l  he.norrhagic  pa„cre.Ttit^ 

av,.  iH-eu  prod,.c*d  experimentally  by  the  injection  of  bile.  h\?lSlo  c 
...... ...I  odMT.m.«t.ng  substanc-es  into  the  duct,  or  ev^.."  l.v  si.."pe 

i.^ra..o..  u  the  ,h.ct.  .\lcohol  and  dietetic  ern.rs  ,.,av  act  by  settinZD 
a  .l..o.i..n.„s  wh.\.h  thereupon  extends  to  the  pancreas  iCS  "."^ 
-....'  .ases.  the  fatal  attack  is  the  last  of  the  series  of  uS  r,  ii" 

n.  ...  from  old  hemorrhages  along  with  rece.u  clots.  Should  the  patic.t 
M.n  .v..  for  any  lengtl,  ,.f  ,i„„,  necrotic  portions  of  d.e  ghwd  mav  rmne 
s.'.|...s.rate.l  „„d  ,nay  lie  in  the  centre  of  absc-ess  cavi  es  which  bu-r 
...,,.  .s..|.arge  into  the  aUlominal  cavity,  the  stomac  .  o  ttest  ne 
ChroiUc  P«.cr,.titi..-Chronic  pa.icreatitis.  lik.  'the  acute  for,,, 
•^  H.  ,,„„p/,  suppurative,  an.l  .pnfi,.  There  is  alwavs  a  more  m: 
Y>  NM.Icspre...  prtKluction  of  fibn„.s  tissue,  which  lea.ls  lo  i.„rnUion 
t^.\;,T:'".*'''"*"''''^^P""'^"-''^'''"'=  sdcmsis  or  fibrosis  o    the^^ 

m  T  •        'i*^  secreting  structure.     The  whole  organ   there- 

for,  ..r,H„es  hanler  than  normal.     The  most  fre.,uent  causes  are^T- 

i..e  excretion,  an<l  congenital  svphilis.  ^ 

c^3  '11 'rLvT  '-  f '1"^"'  "™«>-»^  "O'rtewhat  cnlarg«l.b„t  is  us:.n)h 
c<..Ml  r,d,K   diminished  in  size.     On  section,  it  is  hard  ai.d  resis,, 
cu  „,,-  .Kcasionally  containing  grittv  material. 
H.s.o|og,caliy.  there  Ls  a  notaW.  increase  i„  the  amount  of  c-onnec- 

\  li'.ston  Mp,1.  and  SurR.  Jour,  120:  1SS9:  ISI 

■^^  :.rth.n,  Inference  Handbook  of  the  .Medical  Science,  6: 1003: 456. 


4d8 


THE  PANCREAS 


tive  tissue,  with  more  or  less  atrophy  of  the  glandular  elements.  In 
the  obstructive  cases  the  newly-formed  tissue  is  mast  marked  about  the 
ducts.  Opie  distinguishes  two  forms  of  tibmsis,  a  chronic  interlobular 
pancreatitis,  in  which  the  connective  ti.ssue  is  most  conspicuous  Ix'twccii 
and  around  the  lobules,  the  islands  of  Langerhans  being  involved  only 
late  or  not  at  all,  and  a  ebronic  interacinar  pancreatitis,  in  which  the 
fibrosis  about  the  lobules  is  less  pronounced,  but  connective-tissue  |»ro- 
liferation  is  extreme  round  about  the  islands  and  even  within  tliein. 
Pearce  has  pointed  out  that  iti  the  lesions  of  congenital  syphilis  tlie 
islands  of  Langerhans  escape. 


Fio.  133 


Syphilitic  pancreatitis,     iteiciiert  t»l>j    Sn.  7,  witlmut  ocular.     (Dr.  H.  1>,  liollc-fi'u'-  <;i-?.* 

Calculi. — The  pre.seiice  of  calculi  is  one  of  the  most  potent  cMiiMstif 
chronic  interstitial  pancreatitis  and  pancreatic  ab.scess.  Likf  liihiirv 
(rali'uli,  they  are  originally  brought  about  by  catarrh  of  the  duel.  When 
large  they  nuiy  bring  aboiit  obstruction,  with  dilatation  ainl  even 
cyst  formation.  Pancreatic  calculi  are  single  or  nniltiph'.  imiiiil, 
oval,  or  irregular  in  shape,  and  of  a  wliitish  or  grayish-broun  culnr. 
(^hemically,  they  are  comfMxsed  of  carlK)nate  or  phosphate  i'  lime, 
They  may  l)e  minute  or  c|uite  large.  One  reported  by  St  Iripiiiann 
was  r>  cm.  long  l)y  1  cm.  bnmd.  Owing  to  the  proliferative  iriflin:  niation 
resulting,  a  large  portion  of  the  secreting  structure  of  tlie  ;  'iiereas 
may  "oe  destroyed  and  glycosuria  result. 

Tuberculosis.— This  disease  is  rare  in  the  pancreas.  Oip  lase  of 
primary  caseous  tul)erculosis  is  reported  by  Sendler,  but  tliis  m<  i-*  to  lie 
unitjue.     tjecondary  tul)erculosis  is  also   rare.     Dissemiiuitti'    miliary 


SIMPLE  ATROPHY 


499 


tuhrrculosis  .s  recnle,!  as  afrectin^  the  pancreas,  S«t  the  foci  a«.  small 
an.l  few  ...  numl,er      Nearly  all  the  oases  ai^  J„e  to  the  extem.ro 

' «'"';:"r  '  l-^^f  *-  ^7'"  /he  ly„.ph-.,.Hles  a..cl  other  ..eighb«rin«  Zc- 

tur, ,s.  It  .s  he  lymphoid  str,.ctures  within  the  pa..o.^as  which  became 
.nyolvcl.  Ihe  organ  see.„.s  to  have  sjK-cial  powers  of  self-Jefei^eTr 
|.  .s  s..rpns...g  how  often  .t  escapes  v..„  wh^,  completely  sun^.nded 
m  tul)erculoii.s  disease.  *^        .<  ^unuunueu 

SyphiUs-This  disease  is  also  .rein  thepaiK...  ,.  Chronic  indurative 

KitlKT  the  whole  organ  or  the  ,.,..„;  only  may  '«  involved.     Gummas 
ar..  ,Kra.s,o..ally  observe,!.     Wh.:.  n.ur  M„    ,;c.i..t  of  exit  of  theT^ 
jau.Hhc.  .nay  result  fro...   the  pre.ssum     Syphilitic  en.lar te n^fs  may 
also  occur,  leading  to  hbrosis  of  the  organ.     Re,.ter'  ha.s  found"£ 

jr::i;;;f ""'"  "■  ^'"'  '"'-•'•'»' »'-- '- « -se  of  chrome  zt^ 

RETROOEBSSIVE    METAMORPHOSIS. 

Simple  Atrophy.-.Siinpie   atn.phv  occurs    in   old  .,.,.   .,„,.    :„    ,u„ 
■narasnins  of  mfec-tivc  or  .-hronil.  disease.     The  'iLntl^r  L  'sm^ 

Kio.  i;t4 


S'':'::  :';,;":;,;:':;'['*•"' ""  "r'""-  '''" ™"'"'>r  fat  is  .iin,i„ishc.i. 

-■■■  u.t,  «ah  .soniewhat  ...crease,!  rcsista..ce,  the  lobules  are 
'  ^''-  f-  Ilyg.  u.  InfcHM.,  .54:  li»0():4r). 


500 


THE  PANCREAS 


M 


I; 


small,  and  the  interstitial  connective  tissue  is  relatively  increased.  When 
atrophy  is  extreme,  fatty  globules  and  crystals  make  their  appearance 
in  the  feces.  Acconling  to  Demme  and  Biedert,  the  fatty  diarrhwas  of 
children  are  associated  with  atrophy  and  fibrosis  of  the  pancreas.  Atrojiliv 
of  the  lobules  may  also  be  secondary  to  interstitial  fibrosis.  In  many 
cases  of  diabetes  the  pancreas  is  found  to  be  shrunken,  but  diiTers  some- 
what in  appearance  from  the  pancreas  of  simple  atrophy.  The  organ  is 
small,  flabby,  and  relaxed.  It  is  brownish  in  color  and  rather  Hat  on 
transverse  section.  There  may  be  a  compensatory  increase  of  the  fat 
in  the  neighborhood.  Histologically,  the  secreting  cells  are  wasted 
while  the  interk  J^'-'-.r  connective  tissue  is  distinctly  increased.  There 
is,  in  addition,  an  interstitial  infiltration  with  round  cells  which  extends 
from  the  periphery  for  some  little  distance  into  the  lobule  (Fig.  1.54). 
Opie'  has  shown  that  in  a  considerable  proportion  of  cases  the  islands 
of  Langerhans  are  in  a  state  of  hyaline  degeneration.  This  he  thinks  is 
the  cause  of  pancreatic  diabetes,  the  degeneration  interfering  with  tlie 
production  of  the  internal  secretion  of  the  organ. 

Fktty  Degeneration. — Fatty  degeneration  of  the  secreting  cells  is  com- 
mon. It  occurs  in  pancreatitis,  passive  congestion,  in  the  course  of 
infective  fevers,  antl  in  poisoning  from  mineral  salts. 

Fatty  Infiltration. — Fatty  infiltration  occurs  in  general  obesity,  and  in 
jases  where  the  intra-alMloniinal  circulation  is  interfered  with.  It  niav 
also  be  compensatory  to  atrophy  or  fibrosis  of  the  pancreas.  On  section, 
the  organ  is  found  to  contain  more  or  less  numerous  pads  of  fat,  sepa  raiinj; 
widely  the  lobules,  which,  as  a  result,  may  be  markedly  atropine.  The 
condition  predisposes  to  hemorrhage  into  the  substance  of  the  pancreas, 
possibly  of  the  nature  of  an  infarction. 

Fat  Necrosis. — This  curious  iiil'ection  is  characterized  by  the  formation 
of  areas  of  degeneration,  varying  in  size  from  that  of  a  pin-head  to  lliat  of 
a  pea,  or  even  larger,  in  the  pancreas,  omentum,  or,  in  fact,  in  any  of  the 
fatty  structures  within  the  abdomen.  The  areas  in  question  arc  of  a 
dead  white  appearance,  sometimes,  but  not  invariably,  surmundcd  by  a 
hemorrhagic  or  inflammatory  zone.  They  are  soft,  or  iiavc  i.'ritty 
centres.  Occasionally  the  contents  licjuefy,  forming  small  cysts.  W  lien 
in  the  pancreas  the  foci  are  situated  in  the  interstitial  stroma.  (  axs are 
on  record,  however,  in  which  fat-necrosis  aflFected  the  omentnni.  while 
the  pancreas  itself  was  free.  The  contlition  is  usually  associated  with 
acute  or  chronic  inflammation  of  the  organ,  tumors,  or  oii>i ruction. 
The  researches  of  Hildebrand  and  Flexnerhave  proved  that  fat-Mccro.<is 
is  due  to  a  liberation  of  the  fat-splitting  ferment  of  the  pancreaiir  secre- 
tion, which  acts  upon  the  fatty  substance  of  the  pancreas  and  adjacent 
parts,  converting  the  fats  into  fatty  acids  and  subsequently  i'  '  >  sahs 
formed  by  the  combination  of  the  fatty  acids  with  calcium.  Severe 
cases  are  sometimes  as.sociated  with  extensive  hemorrhage  inti.  tiic  pan- 
creas, pancreatitis,  or  the  se(|uestration  of  large  portions  of  i'  organ. 
Death,  therefore,  is  not  an  uncommon  result. 


'  Opie,  Jour.  E.xper.  Med.,  5:  1901 :  397. 


tiM 


TUMORS 


501 


Caldfication.— Cal(  ification  is  observed  in  connection  with  fat 
nefTosis,  nitrapancrea  c  extravasations  of  blood,  pancreatitis,  and  fatty 
infiltration.  "' 

Self-dige8tion.-A  condition  to  which  more  than  a  passing  reference 
should  be  made  is  the  so-called  self-digestion.    A  pancreas  thus  affected 
has  a   peculiar  dead  white,  sometimes   slightly  glazed,   appearance. 
Ln.li'r  the  micros«.pe,  in  the  milder  grades  of  the  affection,  here  and 
thert-  through  the  pancreas  can  be  seen  lobules  or  portions  of  lobules  in 
which  the  nuclei  are  undergoing  fragmentation,  appearing  like  small 
particles  of  pigment,  while  the  outline  of  the  cells  is  lost.     In  the  most 
advanced  condition,  the  whole  substance  of  the  pancreas  presents  a 
diffuse  opaque  api)earance,  somewhat  resembling  ground  glass,  staining 
strong^-  with  eosin.     No  nuclei  are  to  be  seen,  and  only  the  rough  out- 
lines of  the  lobules  and  ducts  remain  to  indicate  the  character  of  the  orjran 
The  condition  was  first  adequately  described  by  Chiari,  who  attributed 
It  to  the  action  of  the  digestive  ferment  on  the  pancreas  itself.     It  is 
fn-queiiti.v  found,  being  present  in  03  per  cent,  of  autopsies.    It  is  not 
unlikely,  however,  that  in  some  cases  it  occurs  as  an  agonal  chantre  or 
even  some  itt  e  time  l,efore  death.     In  general,  the  longer  the  timi  that 
has  e  apse<l  after  death  the  more  advanced  the  condition.     But  time  is 
not  the  only  factor.     ^\  e  have  noticed  that  extensive  self-digestion  may 
be  pn-sent  as  early  as  three  hours  after  death,  while  in  other  cases  the 
romlitioi,  may  be  scarcely  noticeable  even  at  the  end  of  from  thirty  to 
forty-eifiht  hours.     I  his  suggests  that  the  physiological  condition  of  the 
Slan.1  at  the  time  of  death   may  be  of  importance.     If  the  acini  be 
oa.l«   with  ferment  we  would  expect  to  get  rapid  self-digestion.     On 
^e  other  hand,  if  the  ferm-'  has  been  discharged,  the  action  would 
M^-  irT"^'^-  "•'*  «""^'°^'-  •"  '^^'  ^-"^^tion  that 

out  if  at  the  moment  of  t      ..  .ne  pancreas  were  in  a  state  of  rest,  \t 

3u- orTiri"*!"  Tf  ^^r.  '"'"r-  ^°^^'"y'  t°"'  »•>«  condition  of 
ad.litx  or  alkalinity  <.t  the  blood  and  tissue-flui.ls.  depending  in  some 
measure  on  the  nature  of  the  bacterial  flora  in  the  iShs  mav  haTI 

p..i  Kane  duct  and  modify  the  condition  therein.    Lastlv,  the  amount 

1  nvt'  '"-^  ?'  ^'^"^  ""^  '^'  ^•^*^™"»  temperature  would.  To 
uoui)t,  have  some  influence. 


PROGRESSIVE  METAMORPHOSES. 


rITs  ""^  •'■'"i'?YJ"™°'^  °^  **'*'  P*"<^'*«s  ««-  somewhat  rare. 
":••  '"  "'^  «"tOF'>s  at  Milan,  found  132  rases,  divided^ 
S  ;.:,;'  :'"7f,^'  \f=  '''«'-7'"-.  2;  cysts.  2:  syphiloma.  1.  In  1514 
pHn. ;;  n-n  '^  ^^^^'^J^^  General  and  Royal  Victoria  Hospitals. 
Pr-.„r.v  earcmoma  occurred  6  times  and  adenoma  once.     It  appears 

'  Ann.  univ.  di  med.  e  chir.,  283:  1885: 5. 


im 


i   : 
t   ■ 

I   I 

i    : 


802 


THE  PANCREAS 

Wia.  135 


Adenoma  of  the  pnnrreas,  arisitm  frmn  in  island  of  Langerhans.  Winckel  No.  .1.  »iili„ui 
ocular.  The  tumor  lie»  to  the  rmht  and  is  separated  fmm  the  normal  pancreatic  li— iif  li.v  i 
thin  connettive-l ■     'e  capsule.     (Knim  the  c.illeclion  of  Ur.  .\.  G.  Nichohs.) 


Fi.i.  V.iO 


^iii^Z'fj;^ 


."!:*  ^ 


Adenoma  of  the  pancreas  arising  from  an  island  of  Langerhans.     Leiti  obj.  X" 
oculu.     (From  the  collection  of  Ur.  A.  O.  Nicholls.) 


Cysts 


503 


rom  tins  that  carcinoma  is  l,y  far  the  most  common  primary  new-growth 
Hcnigngrowths  are  ext-essively  rare.    Adenoma  of  a  tubular  character 
ami  flbiMdenom  are  described  (CVsaris-Demel;  Biondi).     One  of  us 
(A.  G.  N  )  has  recorded  for  the  first  time  a  case  of  adenoma  arising 

roiii  an  inland  of  Langerhans}  A  similar  one  has  lieen  reported  recently 
In  Helmholz.  borne  of  tht  so- .ailed  pancreatic  cysts  are  to  be  r-Iasse<l  as 
cystadenoniM.  of  which  there  appear  to  be  two  yarieties,  multilocular 
cvstomas  and  papillomatous  cystomas.' 

'rTT^'i'""'-''.,"?',"*  '"  ''"^  ''"•«  '^"^  ^^-  It  is  usua:  y  situ- 
atcd  m  the  head  or  tail  of  the  pancreas.* 

Lymphosarconu.— Lymphosarcoma  probably  wcurs.  In  the  only 
case  we  haye  seen  that  seemed  t.)  come  under  this  category,  the  pancreas 
was  much  enlarged  an.l  ncKlules  of  new-growth,  haying  a  soft,  white 
apiK-arance,  were  found  between  the  lobules.  Microsconically,  th -re 
was  a  diffuse  inhltration  of  the  organ  with  lymphoid  cells,  which,  in  purts. 
were  aggregated  together  into  definite  clumps. 

C«rcinom».-Carcinoma  is  ordinarily  met  with  in  the  head  of  the  organ. 
It  IS  usually  of  the  snrrhom  tyf^.  but  medullary  and  colloid  cancers  are 
.Krasioiially  found.  Carcinoma  o'  the  body  or  tail  is,  howeyer.  quite 
(onunon.  We  haye  observed  two  such  cases  lately  at  the  Royal  Victoria 
Hospital.  Pressure  upon  the  common  bile  .luct  from  a  growth  of  this 
kind  H'sults  in  icteru-s;  pressure  upon  the  duct  of  Wirsung,  in  dilatation 
an.i  evfn  cyst  formation.  In  not  a  few  cases,  if  the  pancreas  be  exten- 
sively inhltrated,  glycosuria  makes  its  ap()earance 

nistologically  these  growths  are  adcnocarcinomatous  or,  occasionally 
fyliiiilncal-celled  m  type.  •' 

.^.ondary  carcinomas  usually  arise  by  the  extension  of  a  primary 
|rruw,h  in  the  stomach  duo<le„„m,  ampulla  of  Vater,  or  the^iliary 
winuimn'     "''''''^'  ^•''  '^'^  '^'"<'<'  »"•  'ymph-stream  are  not  nearly  so 

Cystc.-Apart  from  the  cystadenomas  alK)ye  mentioned,  cysts  of  the 

ot  its  intralobular  radicles  (ace  pancreatica),  to  hydatid  disease,  or 
to  (DMgenital  peculiarities.  ' 

of!h!"nT""'*^"rf- ""'  '''?'"r'  '"  ■'^"•"^♦""'•'' '"  '^'^  neighborh,K,d 

0  .    .a  ic  eas  with  .l.sease  of  which  they  are  cH-casionally  connected. 

of  H  Mi    ;•    Hi  "  '"  ^""'r*"'"'  ^"''in»«tive  necrosis,  and  effusions 

01  iiiiul  III  the  lesser  peritoneal  sac. 

•Imir.  of  Med.  Research  (\.  S.,  ,3):  1902:385. 
'  .Inlitis  Hopkins  Ho.spital  null.!  IS:  1907:  \Ho. 
'  "^ei'  liaiisohoff,  .\mpr.  Med.,  2: 1901: 13,S. 
*  I  -r  literature,  see  Geo.  .\.  Boyd,  Trans.  Chicago  Path.  Soc-.,  4:  1899-1901 :  191. 


if  •  .. 


CItAI'TER    XXIV. 

THE  PEHITONEIM. 

The  peritoneum  is  a  delicate,  connective-tissue  membrane,  containing 
elastic  fibrils,  and  covered  with  a  layer  of  flattened  endothelial  «'ll.s. 
The  deeper  parts  contain  the  bloodvessels  and  lymphatics,  the  latter  (tf 
which  are  in  functional  communication  with  thealxlominal  cavity,  which 
is  thus  to  l)e  regarded  as  a  large  lym[)h-space.  The  peritoneal  membrane 
invests  the  diaphragm,  alMloniitial  wall,  and  the  various  organs  contained 
within  the  abtlominal  cavity.  Furthermore,  the  lymph-channels  an-  in 
direct  communication  with  those  of  the  pleura!  sacs  and  anterior  medi- 
astinum. Consecjuently,  the  great  majority  of  the  disorders  of  the  |Mri- 
toneum  are  secondary  to  disease  of  the  underlying  viscera  or  contiguous 
serous  sacs.  In  this  connection,  the  most  important  factors  are  various 
infective  conditions,  notably  of  the  digestive  tract,  less  often  of  tiie  liver 
and  portal  system,  and  of  the  female  genital  apparatus.  The  chanictcr 
and  intensity  of  these  infective  proc-esses  are  dejiendent  largely  on  the 
nature  of  the  invading  microorganisms.  The  extension  of  the  lesion  is  in 
many  cases  assisted  by  the  movements  of  the  intestines,  and  modified  or 
localized  through  the  ageiu-y  of  the  great  omentum  and  of  adhesions. 

CONGENITAL  ANOMALIES. 

Lawson  Tait'  has  recordefl  a  case  in  which  the  mesentery  was  com- 
pletely absent,  the  pertoneal  investment  covering  only  a  small  ixntion 
of  the  circumference  of  the  intestines  and  passing  directly  from  on<'  coil 
to  anotiier. 

The  mesentery  may  be  abnormally  long  or  short,  or  may  present 
defects  in  its  substance.  The  latter  condition  is  of  practical  iniporiance. 
smce  coils  of  the  bowel  may  l)ecome  pn)lapsed  through  tlie  oj-diiiij:, 
residting  in  obstruction  or  strangulation. 

Pocket-like  diverticula,  abnormal  folds  and  duplications,  and  prolonga 
tion  of  the  membrane  into  jK-rsistent  inguinal  canals  are  not  uiicoiuiiion. 

The  great  omentum  varies  i..uch  in  size,  Ijeing  long  or  short,  or.  ,ii.'ain, 
almost  completely  absent.  Bifurcations  and  partial  defects  ai.  more 
common. 


OIRCULATORT  DISTURBANCES. 

Being  in  intimate  relation.ship  with  .so  many  of  the  viscera,  a 
itself  vascular,  local  circulatory  disturbances  of  the  peritoi! 
easily  brought  about.     In  tiiis  "connection  such  conditions  u: 

'  Dublin  Quart.  Jour,  of  Med.  Sci.,  47;  1869: 85. 


.(■ing 
!  are 
ilam- 


Peritositis 


505 


mation  of  the  gastro-intestinal  tract,  hernias,  obstruction,  and  tumors 
arc  of  importance.  '"■""it 

Hypereinia.-AeUTe  Hypewmk.-Active  hyperemia  is  met  with  in  the 
first  stages  of  inflammation  an.l  as  a  result  of  the  sudden  liminution  of 
.ntra-ab<lom.na  pressure  sn.ch  as  is  caused  by  the  removal  of  a.scit^ 
flMHl  or  large  tumors.     Inflammatory  hv-peremia  mav  be  ^neralized 

PMslve  Hyp6rtn.l..-Passive  hyperemia  results  fmm  obstruction  to 
the  portal  circulation,  either  directly  .'r  -n  disorders  of  the  liver  or  ind^ 
ryctly  from  he  heart  oi  lungs.  The  .es.sels  of  the  great  omentum 
stomach,  and  intestines  become  greatly  distended,  and  in  long-standine 
cases  here  is  a  transudation  of  clear,  waterj-,  slightly  yellowish  fl  iJH 
into  the  abdominal  cavity  (a,c./«;  hydrops' j^fitJeC^^^^LlX 
tinged  with  bile  or  bloojl-pigment.  Not  infrec^ently,  s^ft  geUtTnous 
oflhe  iSreL        '^  ""'  endothelium  can  be  detected  upon  tfe  surfa" 

Interesting  forms  of  intra-alxlominal  effusion  are  chylous,  chuliform 
and  j^seudochyous  a.cte.s.  The  distinctions  between  Lse  thi£  W 
already  l)een  discussed  (p.  111).  "^^ 

Asdtic  flui.l  may  be  free  in  t'he  alnlominal  cavity,  when  it  tends  to 
olect  in  the  pelvis  and  flanks,  if  the  patient  be  in  a  •r;cumben  TsSon 
Im   when  excessive  may  fill  the  greater  portion  of  the  abdomen      In 
eh.l.  ren  the  fluid  often  collects  between  the  layers  of  the  greatTmentum 
.Wrop  omniU).     The  presence  of  ascitic  fluid  leads  tolToTZ 
Hen>.on  of  the  abdomen    with  pressure  upon  the  contained  vlcem 
upward  dislocation  of  the  diaphragm,     'fhe  thoracic  organs  maTb^ 
m      ered  with  and  serious  disturbance  of  circulation  and^re  pSon 
n^  u  t.      In    long-standing   cases  the  peritoneal  membrane  £comes 

tZlr*^  P'T"''  "  -'"'™''^'""  P*''"-'^-  appearance. 

Hemorrhage.-Extravasations  of  blorxi  occur  into  the  abdominal 
eavny  and  into  the  substance  of  the  peritoneum.  The  more  exten  h^ 
etfusH.ns  occur,  as  a  rule,  from  traumatic  ruptui^  of  various  LgansL 
urs„„,,  of  an  aneurism  or  of  the  sac  in  a  tubal  gestation  orTa  ^  as 
^u>  result  of  operations.  Operations  about  the  liver  and  bSe  pfssages 
p  mnilary  where  there  is  jaundice,  are  not  infrequently    oIlowST; 

Je  ;i;'\S't'T'""'   »'^'"-K--     I-rge  effusions   often   SS 

Ueatli,  while  smaller  ones  may  be  absorbed,  leaving  blackish  brown 

a.ns  on  the  peritoneal  surfac-e,  the  result  of  the  chemical  iteS 

1 1  las^^eiif '"^^"  ^"^^ ''' '"'-"-  "p-  ^^^  ^-^^^^ 

Pft.rhia-  or  small  ecchymoses  occur  in  all  forms  of  active  and  nassive 

INFLAMMATIONS. 

a/^vn'S^rJl!-    '"fl»'"'nf*'"°'"'   of  the  peritoneum-peritonitis- 
are,  ,.  n,  rall^  speaking,  not  unlike  those  of  the  other  serous  membranes. 


806 


THE  PERITONEUM 


i  : 


On  the  whoh',  however,  they  tend  to  Ix-  puniU-nt  or  fihrinopurultnt 
rather  than  fibrinous  ami  scrofihriiious. 

We  may,  perhaps,  with  (Irawitz,  divick'  jHTitonitis  into  primari)  and 
»rctmdary  fornw.  Primary  jH-ritonitis  is  ulso  calhtl  "iiliopathi'c"  or 
"rheumatic."  owinj;  to  the  iliHiruhy  of  assij^nin^  the  condition  to  ii 
definite  cause.  It  is  theoretically  |)ossil)Ie  that  toxic  agents  of  a  chcinic  iij 
nature  circulating  in  the  hIcKHi  miglit  reach  the  peritoneum  atwl  set 
up  inflammation  in  the  absence  of  any  other  ItK-alization,  but  litllc  or 
nothing  is  known  in  regard  to  this  wcurrence.  The  overwhcliniri}; 
nu'-ber  of  |x'rit«mitides  are  s«>condary  to  disease  els«>where,  usually  of 
the  alxloininal  viscera  or  of  the  adjacent  senius  sacs,  [.^-ss  oft<-n"ilic 
inflammation  is  hematogenic  in  nature.  It  is,  morefiver,  practically 
c-ertain  that  all  form.,  of  |H'ritoneal  inflaminati<m  are  due  to  the  aciivitv 
of  pathogenic  microorganisms.  Trauma,  by  lessening  the  n-si^iin^' 
power  of  the  memljrane,  or  by  damaging  the  structure  or  c-onfimiity  u{ 
the  hollow  viscera,  is  an  im|Mirtant  etiological  fat-tor. 

Flexner'  defines  primary  |)eritonitis  to  lie  "a  condition  in  which  ilic 
inflammation,  usually  diffuse,  of  the  serous  cavity  takes  place  without 
the  mediation  of  any  of  the  contained  organs,  and'  indejx'ndentlv  of  mmv 
surgical  ojjeration  upon  these  parts."  This  form  is  due  to  microi,rjr,iii- 
isms  which  reach  the  membrane  through  the  blood  stream  or  the  Ivmpli 
channels,  or  again,  through  the  lumen  of  the  Fallopian  tuln-s.  (.S-cVol.  j, 
p.  287.)  It  is  conc-eivable  that  bacteria  may  pass  through  an  intact 
ujtestinal  wall  and  set  up  jieritonilis,  but  whether  this  ever  (xcnrs  is  not 
easily  proved.  At  all  events,  bacteria  may  on  occasion  pass  flirons;h  in 
the  absence  of  any  gross  lesion  of  the  iiitestine  or  anv  solution  of  its 
continuity,  as,  for  example,  in  those  forms  which  complicate  ascitis. 

Of  KX)  cases  of  acute  {xritonifis  (not  including  tulx'rculoiis  lonnsi 
studied  by  Flexner,  12  were  primary.  Microorganisms  were  foinul  in 
10  of  these,  in  !»  of  which  there  was  but  a  single  form  of  germ,  in  tli.-se 
cases,  an  inflammatory  fix-us  in  almost  any  part  of  the  bodv  iiiav  i.i-o\  iilc 
the  infecting  agent. 

Flexner  also  divides  the  .secondary  pcritonit  Jes  into  exogenous  imd 
endogenous.  The  former  class  are'examples  of  wouiid-infcdinn.  ilie 
bacteria  having  been  imported  from  without.  In  the  eiidogciions  lorin 
the  infective  microorganisms  come  from  the  intestinal  tract.  ( »!'  .'M 
cases  of  the  former  tyjx-,  25  were  single  and  9  were  multiple  inf. ,  lions. 
The  organism  most  frequently  found  was  the  Staphyhx-occus  .niitiis, 
and  ne.xt  to  that  the  Streptococcus  pyogenes.  The  B.  coli,  when  im  Miit, 
was  generally  a.s.s()(  iated  with  these  other  forms.  In  the  latter  \-\»-  of 
IX'ritoiiijis  the  infection  is  usually  multiple.  Here  the  B.  coli  un-  most 
frequently  found;  next,  the  Streptoc(XTUs  pyogenes;  and  th. n  Loth 
combined.  As  Flexner  correctly  points  out,  the  few  ca.ses  of  pnininy 
peritonitis  that  do  occur  are  examples  of  terminal  infection. 

The  most  common  cauise  of  peritonitis,  then,  is  .sornc  form  .f  .,;  tro- 
intestinal  di.sease,  usually  ulceration  and  perforation.     In  this  < d  ;  ution 

'  Phila.  .Med.  Jour.,  2: 1898: 1019. 


il 


PERITONITIS 


507 


iipiK-ndicUis,  intestinal  «l,.stru<H.,n.  gastric  ulcer,  strangulated  hernia 
a.,.l  .lysenterv  are  of  .,n|M,rtHn.r.  A.nonK  other  etuilogieal  factor,  mav' 
l».  inentionecl  .holecystitis.  cholanKitis.  hepatitis,  splenitis,  mesenteric 
thrombophlebitis  infeete.]  mesenterir  gla,„{,s,  and  inHammution  of  the 
IHlvir  vi.s<-er«  ( )(Ta.s,oi,aII y.  the  infecti.m  spreads  from  the  pleural 
Hivities.  and  the  eondition  f,.rms  part  of  a  Ki-neralimJ  miiltisenxsitis 
N.ine  few  ea.se.s  are  hemttloK.-nie.  the  primary  focus  of  infeeti....  l^inif  in 
some  other  part  of  the  ImmIv.  ** 

Am,nlinK to  fherhara.ter  of  the  exudati<,n,  we  ean  ,la.s.sify  .peritonitis 
«s  flbrinons,  Mroflbrinous,  flbrinopurulent.  .uppmtlye,  ami  hemoirluKie. 
ih.-  eh  -acter  of  the  inflaminHiioii  de,x.mls  lar^r,.|v  on  the  nature  of  'he 
iiift'ctmg  microorpini.sms. 

The  acute  purulent  exudar.s  are  commonly  due  to  the  B.  coli  Strento- 
(•.M-..„.s,.^taphyl(K-occus,and  the  DiphK^cncuspneumoniie.  The  B  tuU- 
( Miosis  and  the  GoiKK-mrus  are  more  apt  to  excite  sul)chronic  and  chronic 
itiHainmation. 

With  reganl  to  the  distributi.,n  of  the  lesi.ms  in  ,K.rit<.nitis,  surgeons 
rMcrally  recognize  localavd  and ,/,/«..  forms.  Whether  an  inflamm^on 
ot  the  ,H-ri  ,.nea  meml,ra.ie  w.il  s,,read  an.l  iK-come  generali^nl  depends 
a  p..Kl  deal  on  the  nature  of  the  infecting  micnkirganism  and  the  resiTting 
IH.wer  of  the  m.livi,!u.al.  \N  here  the  B.  coli,  B.  tuix-rculosis.  and  Gon.^ 
.".n.s  are  at  work  ,,la.slic  or  fibrous  a.lhesions  are  apt  to  form  about 
|l..;  l.n.nary  fm-us  of  irritation,  which  more  or  less  perfectly  wall  off  the 
in  -  t.v..  agents  an.l  preyent  their  cxten.Mon.  In  typhoid  feyer,  on  the 
o  HT  hand,  ,x.rito„.t.s  resulting  from  perforation  is  almost  inyariably 
f.  lal.  <.«ing  to  Ih,-  lack  of  such  reactiye  inflammation.  The  omentum 
pa.vs  an  ,m,K.rtant  part,  also,  in  ,K.ritoneal  inflammations,  as  one  of  us 
(•  '..  A.  ),  has  ,M,intcd  out.  Whereyer  there  are  inflamed  areas  in  the 
al«  ominal  cayity  the  omentum  ap,H-ars  to  .search  them  out  an.l  applies 
-to  tiicm  with  great  rapul.ty.  U-coming  adlie«-nt  by  plastic  an.l  ater 
-  hl.n>us  a.lhesi,,„s.  It  is  wcll.kn.,wn  that  the  omentum  in  this  way 
^.•r^  often  sayes  the  situation  and  preycnts  a  general  peritonitis.  The 
-«•. ;.rr.-Mcv  is  in  part,  at.ribut.    l.  „.  the  fact  tluU  leuk.K.tes  a,*  pJen! 

.lie  fibrinous  .leposit      In  this  connection,  Durham^  has  shown  in 
"1    <..st- of  experimental  animals  that  at  the  en.l  of  one  hour  after  the 

11'  Srf  "ll    'T.'"- 'r  f  '"":•*"""  '^"^  f^"'""""'  «•"••  -"t»in-^  rela- 

W  J  f  ■  .1  '/"'^"P*'""'  '^  '''»•  i"  the  main  to  the  attachment  of 

,11  :    ;  '  '  '"^^''"'  "^  *'"'  ^'''■"^  «m*-ntum.     In  animals  that  died 

?    •  *"  forty-eight  hours  after  inoculation  with  an  efficient 

"not  UK,  great  a  numln-r  of  bacteria,  the  ,>eritoneal  flui.l  was  found 

..'  u.,  '^frnTl^  ""  '""""'  "^"'''  "'"">-'''  ^•'■«""'»--'  K^»«-^''s  could  l,e 
HI  from  the  oinentum.  This  probably  explains  how  it  is  that  the 
«.:,  1  n.noyed  from  the  peritoneal  .-ayity  in  Operation  cases  so  fr..quentlv 
'>  M.M,(,..     rhe  omentum  thus  may  become  attached  to  any  of  the 

;  I  li'-  Crpfit  Omentum,  I'hila.  Me.1.  Jour.,  1  •  1S98-3-3 
^.^- 'M,  the  Mechanism  of  Peritoneal  Infections,  Jour,  of  Path,  and  Bact.,  4:  1897: 


I  I  3 
i   '- 

\ 


508 


THK  PERITONEUM 


alHloiiiinul  vi.s«f  ru  tliut  un-  iiiflunuHl,  often  forming  a  complete  barrier  to 
tlie  pronrt'sx  of  the  iiiflainmatioii,  und  in  the  same  way  may  close  in  imt- 
foratioiis  of  th«'  hollow  vistvm  or  aUlominal  wall.  The  protective  pow.r 
of  the  omentum  is  often  well  seen  in  cases  of  iR'rforafive  appen(licilis, 
and  it  is  curious  !iow  it  will  s«'ar(li  «)ut  anil  wrap  itself  about  the  diseasiil 
structure.  In  some  cases,  the  protecti»»n  is  but  temporary,  however, 
theomental  vessels  U'c-ornin>;thromlK)se«l  and  theoigan  itself  gangrenous.' 
The  morbiil  anatomy  of  acute  peritonitis  varies  according  to  the  nature 
and  intensity  of  the  infection.  In  owes  of  low  virulence,  such  as  are 
occasionally  met  with  in  ascites  and  passive  congestion  of  the  abdominal 


Fki    137 


V.x.w-ni<w  i«.rf..ratioM  nf  ti.e  lower  end  of  the  ascending  colon.  The  illuslration  .hl.h  i> 
nntural  «ze  -how,  well  the  ,.uri..u,  rai*d  and  ,«Tforated  condition  of  the  mucous  n.cn.l.rane. 
and,  at  n,  the  ojiening  thmuKli  the  muwle  wall.     (Adami.) 


viscera,  the  serous  stirfai-e  of  the  intestines  presents  little  more 
shrill  loss  of  lustre,  with  here  and  there  a  trifling  deposit  of  . 
fibrin.  In  the  ordinary  form,  during  the  first  stage,  there  is  i 
congestion  of  the  .serous  membrane,  especially  where  the  coils  of  i; 
come  into  contact.  A  little  later  the  serous  surface  becomes  tli 
lustreless  and  the  contiguous  surfac-es  become  slightly  adherent  ti 
the  deposition  of  threads  or  yellowish-white  flakes  of  fibrin,  h 
instances  there  is  hut  little  effusion  of  fluid,  but  not  infrequent!. 
IS  a  moderate  e.xutlation  of  somewhat  turbid  fluid  containing  soti' 
ceous  ma-sses  and  flakes  of  a  yellowish  color.  This  exudate  t. 
gravitate  to  the  most  dependent  parts,  namely,  the  pelvis  and  the 


i\r\ 


tli.'iii  a 
iciite 
ii;,rked 
■i  -line 
i!!  :iMd 
,v'ii>;h 
1  -oine 
•'.rre 
r  ilta- 
:.'s  to 
.  iks. 


ii.}- 


CHROMC  PKRITOXITIH 


509 


r.  other  «^  the  exudation  is  m..re  turbi.l  and  .lefir.itely  purulent 
n  <u.es  which  have  la.,t«l  .,«tne  little  time,  we  ,n«v  have  n-lativelv  itde 
luul  poured  out  but  we  find  small  po<ket3  of  thi.ic.  vellowish-Kft^n  put 
iKtween  he  coils  of  intestine  whU  are  somewhit  firmly  Erent 
or  abou  the  liver  and  spleen  It  in  not  very  unc-ommon  for  the  uTto 
mrrow  through  the  intestinal  wall  and  find  vent  in  that  way  (fJuI) 

thus  becoming  inspissated  or  even  cahifie,!,  while  they  J-ome  Si 
off  by  dense  fibrous  adhesions.  '"f^  'xfome  wulleU 

The  peritonitis  that  supervenes  ujx>n  p,.rforation  of  the  intestine  is 
particularly  virulent  and  the  exu.latU  i.rfeculent  as  well  a    m     |en 
Ihe  aWonrien  usually  contains  a  consi.lerable  <,uantitv  of  dirtv.  b^wn 
...'bui  fluid  having  an  offensive  fecal  odor.    Th'e  intestines  in  ir  t^nlus 
ar."  usually  much  distended,  owing  to  paralysis  *   n">nitis 

A  peculiar  form  of  peritonitis-the  wkt»  hemoTrluglc-should  b, 
mentioned.  Here  there  appears  to  \^  a  subac.  '.  tv,H.  ..f  inflamm  ic^ 
...  which  a  membranous  deposit  c-on.aining  «l>  u'ldant.  i.eXS  "d 
:a,„llanes  ts  laid  doj.^.  These  capillaries  n-adilv  rup  urand  h  re 
.s..sually  a  considerable  outpouring  of  bl,K.|  into  the  alllo.m-.Xuvkr 

eiron  c  Peritonitli.-t  hn.nic  peritonitis  may  result  from  the  acute 
f..r.n.  which  has  un.lergone  a  series  of  relaj.ses  t  r  a  gradual  ainelLa  n 
.n  ..s  scyeray.  or  may  develop  insidiously  from  .fc  ,ir.!J  ke  aS 

Fr|  ..nitis.  I  IS  usually  at  fii^t  hx-al  and  is  in  almost  every  ...seccLXy 
'» .lisease  of  one  of  the  alHlominal  viscera.  Kxcei  'ioindlv  ir  „.„  "^ 
1.V  extension  from  one  of  the  other  ser..U3  mc..;bnm;.s       '  '  '  "'"^  '""^ 

Ue  may  conveniently  divide  chronic  yK-ntonitis.  ^lu.,,  wcll-dcvelone,! 
...to  ,1)  chronic  exudaUve  peritonitis,  in  which  there  is  a  cc.ns  derabl  S' 
|K...nngo  serous,  serofibrinous,  or  fibrinop-.rulent  ex,  |  Z,  '  ,  "' 
^as,,c  adl...sions.  fibrous  bands  In-ing  fewilrab.c,  if  "  ^0^^  in^T;;:: 
«d  adhesive,  presenting  less  fluid  exudation,  but  ^yi,l  s,,,„eXt  ,mmcr  ^! 
a...  hrm  organizing  adhesions,  often  leading  to  sa  cc  ilT  i  on  o!  t  leZ 
an.  ..i)  chronic  hyperpUetic  peritonitis,  whrn-  there         "  „fi    Ino,  s  ^ 

ex...late.  at  first  fibrinous  or  h»n  nopurulent.  gradually  undergoes  organ! 

i.    ...         ••"s- P»"'-  -^nat.,  ij.  laOl:  1.     lor  l>ili  norauhv  Firhnr-f   r,,i     i 
K'-;  i.i,ckt!i.|)e(iie.  "  -r-ijini  .    '••iPti"r-t,  fctik-nbcrg s 

=  I  -r  literature,  see  Hale  White,  Guv's  Hos,  .  Hen    40  •  IsOo  •  1  •    x    n    r   v  ,. 


510 


thu  pkritosevm 


ization  and  hyaline  ilr)(en«>rutiiiii,  •«»  ilmt  tin-  viH<-«TH,  lint  «'s|)«»ciii||v 
the  liver  nnti  sph-eii,  iire  i-nvereil  with  u  thirk,  |)e(iHv  white,  curtiliiKinoi^. 
Iitokinf;  nieniliriiiie,  wliic-h  Ims  iM-eii  i-<iin|>tin-<l  to  iM>r(vluiii  or  the  i(  in^' 
of  H  cuke  (Xiii-kerpis.<u>rKHne).  'I'he  si-nwa  of  the  intesliiies  iiiitl  ineMn- 
tery  inuy  also  \w  involvetl,  thiiiiKli  iisiiiilly  to  a  lesn  extent.  The  onicri- 
tuni  is  foninMHily  foiniil  to  U*  thi*-kene<l  an<l  eoiiverteti  into  a  iJitiM' 
filinius  conl  traversinjt  the  nji|H'r  |>ar(  of  the  aiNloiiien.  The  nieseniirv 
may  al.no  U-  .shorteiml,  so  that  the  intestines  lie  in  a  Iwll  close  lo  flu- 
vertebral  colinnn.  Scutti-ml  adhesions  may  U"  fonixi  here  ami  tlurf. 
There  may  l»e  a  relatively  larjp-  etTnsion  of  fhiiil,  n'.s4'nil>lin^'  ilmi  in 
ascites,  hut  at  times  ii  is  fiiirino|>urulent.     ( ><-casionally  then-  is  no  tliiiil 


Km.  I.IN 


11 'i 


»■     •■^» ,  , 


L. 


ijtr  I  !'••.-'. 


Ctiniiiii-  iKTihipiitilis  niil,  li.viiliiii-  tr;iiir'f..rmalir)n  iif  the  I'xiiliili'  ihvolnMr..-ii.-  1  !i 
(lliswinV  laiiMilr  i-  rlimwii  iiiln  fuMs  fr.im  »lM|ih.v  nf  the  livi'r  lureni'li} i»a.  l.fili  ..I  \  >  ; 
witli.nii  11,  ulur.     (Kniin  tho  ri.llreli.in  .if  Itr.  A.  Li.  .Nichcills  ) 

exudate,  ami  the  whole  alMloininal  cavity  is  ohiiteratcd  l>v  the  ml 
of  tlie  visceral  and  parietal  layers  of  the  [HTitDiiful  nu  inhraiic. 
Mie  capsule  of  the  liver  is  chiefly  itnolved  (perihepatitis),  tiic  |>l 
sijins  are  very  similar  to  althoujjh  not  identical  with  those  of  ;. 
cirrhosis  of  the  liver.     Peritonitis  of  this  tyf)e  may  l»e  secondaiv  i 
lithia.sis   and    ix-richolecystitis    (.\ich<«lls;    Huhler),  trauma    ill. 
and  passive  conjfeslion  (v.  Wunschciui  j.     Occasionally,  it  is  foi;': 
result  of  tuln-rcnlosis  or  carcinosis  of  the  |)eritoneum.     Pr(il)ali! 
cases  infection  of  a  low  fjnide  of  vinileiiic  is  flu-  direct  vaw-v. 

Tuberculosis. — A  common  form  of  tul)erculixsis  of  the  per 
is  that  in  which  small  isolated  tul)ercle.s  are  found  scattered  .■ 
membrane,  chiefly  along  the  bloodves.sels.     This  is  usuallv  a  m 


111, ion 

WluTe 

!^~i(•i^l 

■   pliic 

'..K- 

:-.K'hl, 

. '  :i.s  a 

■u  all 

,-■11111 

r  the 

.-ta- 

ABSOKMM  CnffTSXTS  OP  THE  PERITOS'EAL  CAVITY       51  j 

Ii.m  of  «  K^,H.r«li«H|  miliary  i„r^.,i„,..    The  ...iH-nle,  mav  Ik-  c.pM 
l.>  a  sm„  1  amoum  .,f  hl.r.n.  „,„l  thm-  may  U-  sliKht  c-,>„K.Mion  in  K 
n.M,'hlH,rlu.Kl      I.KHl  ,H.n.o,.i,is  i.  als,.  ,„H  wi.h  in  „mn...-,io„  wT, 
n.Ur,i,l.„..  „|,vru..on  of  ,h.  l.,wH,.     Fh.i.l  .xu.la.ion  .nav  U-  h  an  v 
In  «  few  ms.«n„.s.  th,.  iri«a,„m„tio„  ass.unr.  the  hv,,..rpl«Hri,.  .v.i' 
n«M.u  ...  .he  ,.nHlu<.,K.n  .,f  „  sen,HI,ri,„„,s  exudate  AiX  un.le  i.,' 
..rp..u/«....n  a,ul  hyaline  .ransforma.io.     S.raje.k.,;'  irerritk;'  Xi.holN') 
A  f.w  s,.„„er.Hl  ar..as  „f  .as^-alion  he.      m.l  then-  will  .,f  en  d  e  th^ 
.  I...  ., ,  „.  nature  of  the  aff«t.on.     A  ihinl  variety  is  that  which  re.nan^ 

Mrniiy  I.K-ahze.  .  us y  to  the  n-^ion  of  the 'apiH-n.lix  an.l  mZ 

I  lure  ,„„y  U.  sunply  a  .liffuse  thi<ke„in«  of  the  il/testinal  wa  I  a7  S 
,K„„    without  easeafor,.  or  there  tnay  l«  „u,nerous  fihrous  a.lhesion 
alK.u,  the  affeeteci  part.     N.n.eti.nes.  also,  the  omeutun.  u.ul  mese,,  erj 
an    ,huken«l    a.ul    eon.raet«l.     The    tissue    hyix-rpiasia    alx.ut    S 
..  UM.  mylM.  so  Kr..at  that  eases  have  Wn  M.ilstuk.',,  for  careinoma 
l.iirti>:iiu*  has  stu<he(l  this  form.  "loma. 

Fn  lul^rniiosis  of  the  p-rilon.  um  the  infec-tion  mav  \^  hemat.Mfenous 
or  v,„,.hoj.-e„o.ts.  or  ap.  .•       ,  arise  hy  extension  from  the  i,'.!^-  u" 
liillo|.mn  tiilies,  or  pleur  i,.s.  ' 

SyphiUs.  -Little   or  .^  is  ,|e«nitely  known    with    nvanl    to 

■  I .'^  ","'•:  FH-ntoneuni.     L.uuvrea..x>  iH.iieve.l  in  the  existence  of  ^ 

;l.r„M,.-  M.lhesive  an.1  inenihrMooiis  ,K.ritoni.is  ,l.ie  to  svphilis.  .K-eiirrin^ 
i..   .1..  Ir,...    an.l    ...-as ionally   in    a.lults.     Meirinuhain'    re^-o^^     ,wS 
ni-  ..I  .hnmie  ,K.ri,..n,„s  with  ,.-riiu.,mti.is.  whiVli  prol^l.lv    started 
fn  M.  ,Mimma..Mis  hver.      Pn.l.at.ly.  all    muI,  eases  a r..  se,.on.la  "t 
il  Siiot"^'  "'  "'"  '■''''--     ''"-"^  *^~  o^  'he  ..ritoneum 


ABNORMAL  C0KTEHT8  OF  THE  PBHITOHEAL  CAVITY. 

bloli' bt'rili' '" ■' •   '""•■  '■"""""  """"  '"^*»'  '^•"""•tory  .xudat... 
Pneumoperitoneum,  or^as  in  ,1„.  (K-ritoneal  <«vitv.  usuallv  results  fro.n 
r  ,.t„re  of  some  vis.-us  ,n  .omm.ini.-a.ion  with  the  outer  air  su, h  a 
-  M„>na<- 1  or  intestine;  less  often  from  the  aetion  of  p.s-,  nxlu    ,?^ 
>n  T„or,M„,sms,  notahly  the  B.  Wekhii  an.l  the  H.  <.,|i      ^     '  ^ 

^'•-'l  "s  tins,  the  contents  of  the  stomach  or  bowels,  gallstones,  urine 
''L  hTh  ''"       '7  'V".\T«F  >"to  the  peritoneal  <.avit^-      The  sc^alled 
fr     b«he.  •  are  der.ve,l  from  a  variety  of  sources.  ap,HM„li,.s  epjS 
«  '<!'  Lave  iK-come  detache,!.  sul.serous  fibroids  of  the  uterus   o?  ries 
Kl  MM.,n,nihe,|  or  calcified  embryos.     .Swabs  and  ga  i  e  pads  h"'e 

:;o;::;::  In  stihl:^;;;^  "'^"'"'"'"  --'^  '>■  -^^^ '-  '^^ 

■  Aii:;.    \\i,.n     ,„p,j     ^j,       ^.    jj^2 

■Ifi.iv  <  liioaKo  Path.  .'Soc.,  .April    100'' 

.Nd.  soc.,  1 .  32(,.  .  .St.  B^rth.  Hosi,.  Hep.,  1S93:  1. 


'*.  ^  ? 


512 


THE  PERITONEUM 


i 


PR0ORE88IVI  METAMORPHOSIS. 

Opaline  Plaques.— Small,  opaline  plaques  are  occasionally  found  on 
the  peritoneal  surface  as  a  result  of  chronic  irritation  or  slight  inflam- 
mation. They  occur  chiefly  on  the  liver  at  points  of  pressure  and  upon 
the  spleen.  The  spleen  may  be  ctjvered  with  a  thin,  pearly  sheet,  or 
with  numerous  round,  elevated  spots,  looking  like  drops  of  white  wax 
or  paraffin.  Passive  congestion  of  the  spleen  seems  to  be  associated 
with  the  condition  in  many  cases.  Histologically,  the  patches  are 
composed  of  hyperplastic  connective  tissue  having  a  tendency  to  undergo 
hyaline  transformation. 

Tumors. — Apart  from  the  new-growths  originating  in  the  various  ab- 
dominal viscera  that  encroach  upon  the  cavity,  tumors  of  the  peritoneum 
are  most  often  situated  in  the  great  omentum,  the  retroperitoneal  con- 
nective  tissue,  the  radix  mesenterii,  less  often  in  other  parts.  Amoiij;  the 
benign  growths  may  be  mentioned  lipoma,  fibroma,  myxoma,  chondroma, 
osteoma,  hemangioma,  and  lymphangioma.  Dermoids  and  teratcm 
also  occur. 

One  of  the  most  important  and  interesting  new-growths  is  the  retro- 
peritoneal lipoma.    This  is  rarely  pure,  but  is  usually  formed  of  an  ad- 
mixture of  fatty,  fibrous,  and  mucinous  constituents.     The  growth  Ix-gins 
retroperitoneally,  generally   in  the   neighborhood  of  the  left  kidnev, 
or  in  the  root  of  the  mesentery.     It  is  difficult  to  diagnosticate  and  frradii- 
ally  increases  in  size,  leading  to  more  or  less  distension  of  the  abdomen. 
It  may  become  quite  enormous.     Waldeyer  has  recorded  one  sixty-tliree 
pounds  in  weight.    When  the  tumor  is  of  large  size,  the  al)di)inen  is 
swollen,  soft,  and  fluctuating,  giving  the  sensation  of  In-ing  filled  with 
fluid.     A  dry  tap,  however,  would  exclude  ascites  ar.d  should  always 
lead  one  to  suspect  retroperitoneal  lipoma.     A  coil  of  intestine  can  often 
be  made  out  on  percussion  crossing  oi)liquely  over  the  front  of  the  tnmor. 
Cases  are  generally  inoperable  when  discovered  and  invariably  end  fatally, 
partly  owing  to  the  enormous  pressure  and  partly  to  a  sarcomatons  trans- 
formation to  which  this  form  of  tumor  seems  particularly  prone.    One 
of  us  (J.  Cr.  A.')  has  collected  forty  examples  from  the  literature  and  has 
recorded  two  other  cases,  in  one  of  which  the  tumor  weighed  foriy-five 
pounds.  These  growths  probably  originate  from  cells  of  connectiv  c-tissue 
origin  which  have  l)ecome  nipped  in  between  the  renculi  in  the  jiiocess 
of  development. 

Another  important  primary  growth,  although  not  at  all  common,  is  the 
endothelioma.  This  occurs  in  the  form  of  multiple  small  |)1.ii|iks  or 
warty  excrescences,  or,  again,  diffii.sely  in  more  or  less  extensixt  -heels. 
It  begins  in  a  proliferation  of  the  lining  endothelium  of  the  (^nity  or, 
po.ssibly,  from  the  perivascular  lymphatics.  The  condition  i  some- 
times associated  with  the  effusion  of  fluid,  occasionally  bloody.  I'^'ether 
with  the  deposit  of  fibrin,  so  that  it  simulates  a  chronic  j>i..  luctive 


'  Montreal  Med.  Jour.,  25:1897:529  and  620. 


CYSTS 


513 
Histologically,  the  growth 


infliimmation.    Metastases  are  not  common, 
resembles  an  alveolar  carcinoma. 

Matas'  has  recorded  a  curious  case  of  primary  myxoiwiom.  of  the  great 
cnentum,  which  produced  extensive  seconda,^  growths  throughoufSe 
peritoneum  with  a  mucoid  ascites.  «"ugiioui  me 

Secondary  malignant  growths  are  common,  and  here,  again,  the  omen- 

Ti.\TT    Y^  '">  '"'"'^■^-     ^'  '"*y  ^  eonvert^into  a  short 
thick,  hard  cord,  running  transversely  across  the  upper  part  of  the  abd"' 

Fio.  139 


"- "-  "■  "-ndiu,  colon,  oji^ru^  ;^™:rrr  '■ ""'"'"' "''''""'"  "'"^=  »• 

pmsta,.  Tulfi;i!^„  ,  t'-  P^"'^'*'^'  '"*«^''"^'  "terus.  ovAries.  and 
task  V  i ,  '^^7'P'*^  melanotic  sarcomas  are  also  found,  arisinc  bv  n  eta-s- 
Xlr  •Z^T^'''"^'''^  «f  the  choroi.l  of  the  ev;  or  She  skTn 

ami  pa,'. sitic  ^       "'^  '^^  ''"'"''  ^'^•^'*^"^'  hemorrhagic,  dermoid. 

'  Phila.  Monthly  Me<J.  Jour.,  Decemlwr,  1899. 


3:t 


SECTION  IV. 
THE  NERVOUS  SYSTEM. 


CHAPTER    XXV. 

THE  STRUCTURE  OF  THE  NKRVOUS  SYSTEM  AND  11^  BEARING  UPON 

of  n.a„v  cells,  in  which  for^T:to.^l  up "ft^^sr^^^ 

stunuhLs  is  able  to  uAtiate  a  motor  excitation     iCthT.Jr     '^"'"'^ 

r:;.ir''-'-'-  - « '^^  -i  of  i;!'::::;:;:^^^: 

six  t  t^i&~  «'^^      St£ 

"vera,.ivitv*and  fatigue  and  iuT/'  . ""''  "'  ."'  «'""'nution  under 
tions,  .nake  k  pSfe  thatSrrn""''';:^  """.!  pathological  condi- 
n..tri,i^,.  eiemeft  of  the  ne  ..!?„    ^Jromoph.hc  substance  represents  a 

nuclear  ae.iv"ritsstah^h,r.^r?-  l^-""^'  '*  "'"^'  ^'  «-^  «  P"^"'^*  <>' 
nuclear  .  hroma'tln.  ^         *"""'  ^"'^  ""'  ^•^™''^'  'o  those  of  the 

Ca^lwir^^l  J,^X'"'/*"n  ^i^''^^'  ^'^''  Beelchowski. 
hy  fine  fil.rils  which  ftS  !  nT*  ^^u  •  ""r^'?  "J"'^"  '^  «^"  *"  ^  ««■"?'«! 
the  nu.  l..„s  and  can  tTnll,"  r*""!  '"  "'T  •^'>' "'  ^''^  ^"  surrounding 
and  tl...  .xi  ^Ider  ^n  he  otrer""' '"'"  '"  '^"'^"•^^  '^^  '''^  ""«  ^and! 


in    ' 


!■ 


ii 


516 


THE  STRUCTURE  OF  THE  NERVOUS  SYSTEM 


The  dendrites  are  protoplasmic  processes,  with,  in  many  cases,  very 
rich  arborizations,  large  at  their  origin  from  the  cell,  gradually  becominj; 
thinner  like  the  branches  of  a  tree.  They  are  simply  an  expansion  of 
the  cell-body,  serving  to  increase  and  facilitate  its  connections  with 
neighboring  cells.  The  axis-cylinder  process  is  usually  single  and  of 
regular  caliber  from  its  origin  to  its  termination,  although  some  cells, 
e.  g.,  those  of  the  posterior  ganglia,  have  two  axis-cylinders.  It  may 
give  off  collaterals  at  right  angles  which  have  the  same  characters  ns  it 
has  itself.  On  leaving  the  gray  matter  of  the  centre  the  axis-cylinder  or 
axone  becomes  invested  with  a  myelin  sheath,  and  it  is  collections  of 
these  axis-cylinders  with  their  sheaths  which  form  the  white  matter  of 
the  brain  and  cord.  Clothed  in  the  sheath  of  Schwann,  they  form  the 
peripheral  nerves.  Some  nerves  (sympathetic  system)  have  the  sheath 
of  Schwann  without  the  myelin  covering. 

The  axone  is  made  up  of  a  bundle  of  fibrils,  and  on  reachiiij;  its 
destination  splits  up  into  a  terminal  arborization  almut  a  second  cell, 
terminating  in  small,  button-like  bodies  (end  feet),  which  lie  in  contact 
with  the  cell  walls. 

The  neurone  in  this  simple  form,  as  an  independent  unit,  is  not  without 
detractors,  among  whom  may  be  numliered  such  authorities  as  NissI, 
Apathy,  Bethe,  Durante,  etc.  Apathy,  by  means  of  his  special  method 
of  staining,  has  studied  the  neurofibrils  very  closely,  and  asserts  that  thev 
act  in  two  ways.  Certain  ones  penetrate  into  the  ganglion  cell  ami  are 
then  resolved  into  the  elementary  fibrils,  anastomosing  freely  ainoiig 
themselves  and  thus  forming  an  intracellular  network,  then  reuniting'  to 
form  the  primitive  fibrils  of  the  axone.  The  second  class,  in  ciitcriiip 
the  ganglion,  do  not  penetrate  into  the  cells  of  the  ganglion,  but  resolve 
themselves  directly  into  elementary  fibrils  and  form  an  extracellular 
network.  Later,  they  reunite  into  primitive  fibers  and  enter  the  cells 
of  the  ganglion. 

Apathy  asserts  that  the  motor  fibers  do  not  commence  in  the  cells  of 
the  ganglion;  they  are  nothing  but  the  continuation  of  the  scnsorv  Hhrils 
after  the  interposition  of  the  nervous  network,  the  ganglion  cells  Ikmu^ 
intercalated  in  the  course  of  the  conducting  fibers  like  the  battery  in  a 
network  of  telegraph  wires.  In  other  wortls,  the  fibrils  do  not  coiiunence 
nor  terminate  in  any  place,  neither  the  sensory  nor  motor,  neilhei-  at  the 
periphery  nor  in  the  centres,  but  form  a  great  system  of  continuous 
conduction  paths,  just  as  in  the  chv-ulation  the  arteries  tlimii-li  the 
capillary  network  are  continuous  with  the  veins.  Bethe  aL'iei  ^  with 
Apathy  in  these  statements,  but  gives  to  the  extra-cellular  ncrvork  a 
greater  emphasis.  He  states  that  the  greater  numlier  of  fibrlN  .  ■  from 
one  neurone  to  another;  the  sensory  become  motor  without  jiassiiig 
through  the  cells  of  the  ganglion. 

Apparently,  however,  the  death  blow  was  given  to  the  nenm 
by  the  discovery  by  Bethe.and  later  by  Raiman,  etc.,  of  what  i*  < 
by  them  as  autogenous  regeneration  in  the  peripheral  part  of  a  ■ 
The.se  observers  maintain  that,  developmentally,  the  peripl 
fibers,  including  their  axones,  arise  in  the  embryo  by  a  fu-i 


tlieory 
iilered 
iiene. 
1  nen'e 
.'f  long 


THE  STRUCTURE  OF  THE  NERVOUS  SYSTEM  5,7 

chains  of  celb  placed  end  to  end.  ThU  pericellular  or  catenary  theory 
of  the  ongm  of  peripheral  nerves  has  been  extended  bv  some  ev7n  toThJ 
dendnt^  and  axones  of  the  cells  of  the  central  nervoi  sTteT 

\\.lhelm  H«  (1886)  was  the  fi„t  to  maintain  from  his^ emb'ryoWical 
studies  that  the  neurone  was  an  independent  unit.  everne^eXr 
bemg  a  process    rom  an  embryonic  n^e  cell  (neurouZt)  ^l^Z- 
parches  of  Golg.  supported  this  view,  and  the  ^recent  work  of  R   G 
Harrison*  has  most  satisfactorily  confirmed  it.     He  foundThat  by  cutting 

r.e,  although  they  hldLl-i^e^^^^^ 

.amb^i?;:-^isrsx;^xs^ 

prevented  no  autoregeneration  will  occur      T  ncrprr!'  oi    ^  ^  . 

1.  In  young  dogs,  in  whom  the  lumbosacral  cord  and  the  Pnr«.»^„j- 

of  an  extracellular  nnn  r^.*„-  i  '""'^"^  l^"ecuy,  out  give  no  evidence 
another!  n^^Xlete"  nZuJ'  ^.^«P^"?ence  of  one  neurone  on 
so  th.t  [f  tl,„~  1  *^   i.^'    V   "'™"-^ ' "  '^^'""  •«  often  I'm  ted  to  one  svstem 

■"•i....,i™l  indewndm-  f^r,;  phvaoloRioal  ,„,|  „.en  .  p„hologi<,l. 

.-,  which-b^et'  r.eSt^'^iicSnLrof^r  r.s 

'Au„,v,uc  Ke«.„era^o„  ^n  .h    v    ^""*f^'""«  Jer  periphoren  \erven. 


1    in 

■i 

ll 


518 


THE  STRUCTURE  OF  THE  NERVOUS  SYSTEM 


Fio.  140 


systems  being  made  up  of  several  relays  of  groups  or  neurones.    Barker 
has  classified  them  as  follows: 

1.  Neurones  connecting  the  sense  organs  of  the  body  with  the  central 
nervous  system  (peripheral  centripetal  neurones;  sensory  neurones  of 
the  first  order;  sensory  protoneurones). 

2.  Neurones  within  the  central  nervous  system,  connecting  the  end- 
stations  of  the  axones  of  the  peripheral  centripetal  neurones  with  other 
}K)rtions  of  the  central  nervous  system;  and  neurones  which,  in  turn, 
connect  the  end-stations  of  the  latter  with  still  higher  portions  of  the 
central  system  (sensory  neurones  of  the  second  order  and  of  higher  orders). 

3.  Neurones  connecting  the  central  nervous  system  with  the  volun- 
tary muscles  of  the  body  (lower  motor  neurones). 

4.  Neurones  within  the  central  nervous  system  which  enter  into 
conduction  relation  with  the  lower  motor  neurones  and  throw  the  latter 

under  the  influence  of  other  centres. 
Neurones  connecting  the  pallium, 
cerel»ellum,  etc.,  with  the  lower 
motor  neurones. 

5.  Projection,  commissural  and 
association  neurones  of  the  telen- 
cephalon. 

Neuroglia. — Neuroglia  is  tin- con- 
nective tissue  of  the  central  nervous 
system  filling  in  the  spaces  In-tween 
the  nerve  elements  and  foriniiij;  a 
support  for  these  and  the  vessels. 
It  takes  the  place  of  the  parenchy- 
matous tissue,  if  this  be  destrDvell, 
as  does  the  fibrous  tissue  in  otlier 
organs.  In  the  adult,  two  main 
types  of  neuroglia  cells  are  found, 
nucleus  and  straight  unbnwuliinjj 


Glial  ceUa  with  multiple  pntceiweit,  from  a 
caae  of  congenital  multii>le  gliumatosis  of  the 
brain.     (Sterti.) 

viz.,  spider  cells,  having  a  round 


processes,  and  other  cells  with  thicker  processes  profusely  branchiiii,-;  the 
former  are  found  chiefly  in  the  white  matter,  the  latter  in  the  gray  matter 
about  the  bloodvessels. 

It  has  been  asserte<I  by  Metchnikoff  and  others  that  in  inflaiiiniatorv 
and  degenerative  conditions,  the  neuroglial  cells  have  a  phagocyli(  ;i(  tioii 
on  the  degenerated  ti.ssue.  Marinesco  maintained  that  wheiicMr  the 
achromatic  sul)Stance  of  the  nerve  cell  suffers  injury  there  is  a  siimula- 
tion  of  the  surrounding  neuroglia  cells  to  phagocytic  activity.  (Vr- 
tainly,  where  there  has  Ijeen  a  severe  lesion  of  the  nervous  sy-ti  'n,  the 
neuroglia  cells  hypertrophy  and  proliferate  secondarily  ami  nv  fre- 
quently found  increa.setl  in  number  about  the  degenerating  ncr\f  (elk 
But  it  is  doubtful  if  this  is  evidence  of  a  phagocytic  action.  ( V  rictti  in 
his  experiments  could  not  satisfy  hiin.self  of  their  phagocytic  d;  vacter. 
In  a  more  recent  communication  Marinesco'  limits  the  phagocyi    action 

'  La  Semaine  MM.,  27: 1907: 115. 


NEUROGLIA 


519 


of  the  ''satellite"  (glial)  cells  to  the  removal  of  dead  neurones  and  desiir- 
nates  it  necrophagy  rather  than  neuronophagy  * 

There  are  not  a  great  variety  of  pathological  changes  seen  in  the  neu- 
rone.  Under  the  action  of  destructive  agencies  affecting  the  cell  or  its 
axis-cylinder,  a  series  of  changes  in  structure  may  occur?  which  may  go 
on  to  absolute  degeneration  and  necrosis.  In  the  early  stages  of  these 
retrogressive  changes  which  are  confined  to  the  finer  histological  ele- 
ments of  the  cell  and  do  not  affect  the  nucleus,  regeneration  of  these 
elements  and  return  to  normal  appearance  and  function  are  quite  possi- 
ble It  Ls  only  when  the  disease  Has  advanced  far  enough  to  affe^e 
nucleus  that  the  cell  is  doomed.  Our  knowledge  of  theL  degenerative 
changes  is  confined  to  what  occurs  in  the  large  somatochrorae  «lls  of  the 

TZ  follows     *  ^"^''"'  *'*'•    '^'''^  ""^""^^  """y  ^  '"™™«* 

anil-  ^:^i£^-^'  ^'''''  ^*™^*"™'  '^^-^^^  •"  ^^^  chromatin 

towaiS^'tr'^^Sei;.'''  ""''"  "°  '""^''  """'"^  ""'™''  '"*  "•^"^- 

3.  Vacuolization  of  the  cell-lxxly  and  granular  degeneration  of  fibrils 

4.  lotal  necrosis. 

In  the  first  stage  there  b  a  homogeneous  swelling  of  the  cell-body  the 

Nissl  bodies  become  irregular  in  shape  and  size,  and,  later,  are  seen  to 

be  broken  up  into  fine  dust-like  partWes.    This  change  com«s  n 

ome  cases  m  the  perinuclear  part  of  the  cell;  in  otheil  it  begins  about 

the  periphery,  or  it  may  appear  -,.  a  diffuse  chromatolvsis 

Simultaneously  with  these  cha..ges,  or  probably  a  little  later  definite 
changes  .K-cur  in  the  fibrillary  network  of  the  cell  It  becomes' leidil 
met  an.  the  fibrils  themselves  less  regular.  Up  to  this  stari^^ne^ttn" 
B  p.)s,s,l,le.  but  If  the  process  advance,  the  nucleus  no  iSger  holi  T(^ 
«■«  ral  position,  but  becomes  ec-centric;  at  the  same  time,  the  fibrib 
undt-rj;,,  H  process  of  granular  disintegration  and  fragmentation,  vacuoles 
appear  m  the  body  of  the  cell,  and  the  protoplasm  h^  a  granuW  ap^ar! 
extn;,l,..l  rr  ^"R^^T^'^'«  P«"Phery  of  the  cell  and  is  Elly 
abil.  ''"    ^"'^  '*"  ""'^"^    ^''''^   "P   «"d   '^   q»iekly 

Chromatolvsis  appears  to  be  the  primary  stage  of  the  retroeressive 
process.  It  occurs  as  an  effect  of  overactivity  anclfatigue,  in  to^rbb^ 
«.n.l.tK>ns.  febrile  conditions,  after  section  of  the  axone,  etc.,  but'unS 
Wab le  circumstances,  the  process  may  stop  here  and  a  more  or  less 
rapid  return  to  the  normal  occur. 

beerT£rtr'  Ti!^"  ^r"  • 'P""^'."'  °"  *^'^  ^*'°'°P>^^'  ^^^^tor  have 
Been  <lt.seril>ed.      Ihus.  Mannesco  described  (1)  alterations  due  to 

mr„,  traumatism;  (2)  primary  alterations  in\he  cell  duTto  dLc° 
act..,,,,  mostly  toxic,  or  of  nutritive  disturbances.     The  former  e  a 
atters,.,ti«n  of  the  axone,  consists  in  central  chromatolysis  with  disulat^ 
-jent  ot  ,be  nucleus  to  the  periphery.    The  latter,  while  they  may  ntf^ 

he    hrornatic  substance  of  the  whole  cell  diffusely,  are  most^marked 
'"  " ^"^  peripheral  zone,  and  are,  therefore,  represented,  at  leS 


520 


THE  STRUCTURE  OF  THE  NERVOUS  SYSTEM 


\  >•' 


temporarily,  by  a  peripheral  chromatolysLs  without  displacement 
nucleus. 


^f  the 


But  these  characteristics  are  by  no  means  always  distinct.  Otiier 
observers  have  describe<i  specific  alterations  in  the  cells,  dependent  on 
the  nature  of  the  poison,  maintaininyr  that  in  the  earlier  stages,  at  \vmt, 
of  acute  arsenical  poisoning,  the  picture  is  quite  different  from  that 
which  is  seen  in  acute  phosphorus  poisoning.  In  the  later  stages,  and 
in  chronic  cases,  these  specitic  peculiarities  are  lost. 

The  structural  changes  in  the  nerve  eel!  following  solution  of  continuity 
in  the  nerve  fibers  are  practically  the  same  as  those  which  follow  the 
action  of  poisons,  and  may  go  on  to  total  destruction  of  the  cell.  The 
intensity  of  the  reaction  depends  on  the  severity  of  the  lesion,  Ijeinjj 
greater  if  the  nerve  is  cut  than  when  merely  compressed,  while  a  still 
more  intense  reaction  follows  if  the  nerve  be  evulsed. 

After  section,  or,  better  still,  evulsion,  of  a  motor  nerve,  the  cells  first 
show  an  increa.se  in  vo'  ime;  they  may  become  almost  double  in  size  and 
rounder,  and  the  fibrillary  network  shows  certain  indefinite  stnutiiral 
changes.  The  tigroid  bodies  break  up  into  fine,  dust-like  particles, 
first,  perhaps,  in  the  region  of  the  nucleus,  later  about  the  margin; 
then  the  nucleus  may  wander  toward  the  periphery. 

Waller  was  the  first  to  point  out  that  the  interruption  in  continiiitv 
of  the  nerve  fibers,  whatever  be  the  cause,  whether  an  incised  wound  or 
a  vascular  lesion,  is  followed  by  structural  changes  of  a  degenerative 
character  in  the  fiber  distal  to  the  lesion;  that  is,  in  the  part  separated 
from  its  parent  cell,  or  more  exactly,  as  Cameron'  mrintains,  from  its 
parent  nucleus,  since  the  nucleus  is  the  nutritive  centre  for  the  nerve  cell. 
This  is  termed  secondary  degeneration,    llius,  if  we  have  a  lesion  of  the 
motor  fibers  in  the  internal  capsule  of  the  brain,  we  get  secondary  def^iner- 
ation  in  the  direct  and  crossed  pyramidal  tr:        ■  '<escending  depnera- 
tion.     If  the  lesion  be  in  the  posterior  roots  betwtf  ii  the  ganglia  and  the 
cord,  or  in  the  course  of  these  fibers  in  the  posterior  columns,  we  have  an 
ascending  degeneration  in  the  posterior  columns  of  the  cord  up  to  their 
terminal  arborization  about  the  cells  of  the  second  relay  in  tlie  nuclei 
of  Goll  and  Burdach. 

These  retrogressive  changes  l)egin  immediately  and  apparentjv  simul- 
taneously in  the  whole  extent  of  the  peripheraf  fiber,  progressin;:  more 
rapidly  the  farther  away  from  the  nutritive  centre  the  lesion  i>.  First, 
the  myelin  sheath  swells,  then  it  breaks  up  into  large  and  small  ^'I'lmles, 
giving  the  fil)ers  a  varicose  appearance.  The  globules  are  of  a  fatty 
nature  and  stain  black  with  osmic  acid  (Marchi's  method).  I'ltse  fat 
particles  are  carried  away  by  leukocytes  and  probably  other  in  u'rating 
cells  which  originate  from  the  va.scular  connective-tissue  eleniem- 
Simultaneously  with  these  changes  in  the  myelin  there  is  s\^ 
the  axis-cylinders  with  a  varicose  appearance  of  the  neurofi!>riU. 
later  become  finely  granular.  They  soon  break  up  and  are 
their  place  being  taken  by  proliferated  glial  tissue. 


\mf  of 
which 
)rbed, 


Brain,  1906:  332. 


I   > 


ABIOTROPHY  AND  EXHAVSTIOS  CONDITIONS  521 

Secondly  Atrophy  of  the  Second  Order.-Secondary  atrophy  of 
u  nerve  fil.er  may  oc-eur  a.s  a  phase  in  secondary  deKeneration  followinif 
separation  fmm  the  parent  cell.     It  may  o«tur  abo  in  the  central  8tump 
which  st.ll  lemams  m  connection  with  the  cell.  i. ...  a  celluloi,etal  atroph/ 
I^sHles  these  forms,  a  dehn.te  itnluction  in  volume  .f  the  ^J^eater  numli; 
of  the  fibers  .n  a  tract  may  occur  even  when  there  is  no  interruption  in 
their  contmu.ty,  when  they  are  in  close  anatomical  and  physiologica" 
e.,.mect.on  with  centres  which  have  umler^une  secon.lary  de^nerafion 
This  has  been  termed  by  v.  Monakow.  secondary  atrophy  of  Ihe  secTd 
onler We   would   prefer   to   term    it   the   at^phy VphysioS 
inactivity  (vol  .  p.  802).  or  disuse  atrophy.    Thui.  ie  Imve  c\2  o 
he  neurone -f  the  secj.nd  onler  following  destruction  of  the  neurone  o 
tlie  hrst  order,  and  vice  vena. 

ReReneration,  in  the  sense  of  the  formation  of  new  nerve^lements 
probablv  never  occurs  in  the  central  nervous  svstem.    The  reijeneration 
of  the  chromatophilic  granules  ha.s  been  mentioned.     In  ^0^0™!™^ 
nenes,  degeneration  always  occurs  in  the  part  .listal  to  the  section  from 
he  parent  cell  l,efore  regenerative  processes  begin.    This  consisuT 
the  growth  of  ax.sK.yhnder  processes  out  from  the  cientral  end  which  push 
aen,.s.sthe  cicatrLx  and  penetrate  into  the  peripheral  segment.     S 
describes  the  growing  extremitv  of  the  voung  fiber  as  Dos^^in^^  „ 
.erminal  ball,"  which,  if  it  b^mes  impacted  i'n  one  ofTheCSr! 
stK-es.  may  become  enormously  swollen  and  enlarged.     (Vol   i  n  57?^ 
Simple  atrophy  of  the  neurone  may  occur  (1)  in  chSc  cond  lions  where 
a  slowly  acting  tox^n  cireulating  in  the  system  causes  an  imprmentTf 
nmntion  in  the  cell,  not  sufficient,  perhaps,  to  cause,  in  the  firs^p^c^ 
Ney  .lehnite  .structural  changes  in  it,  but  just  sufficient  to  prevenU 
m  ,n  aining    its   long   ner^•e-processes,    which,    therefore    .legenerate 
his  degeneration  commences  at  theextreme  periphervof  theaxisSlinder: 
ater  on  the  cell  itself  atrophies.     (2)  The  same  thing  occur^b  Zl .' 
t-ons  in  which  there  is  an  inherent  congenital  lack  of  vitali  3  b  the 
neurone,  in  conditions  of  abiotrophy.  ^ 

Abiotrophy  and  "IxhausUon"  Condition8.-.4s  we  have  «i«.«.i„ 

seen,  fatigue  and  exhaustion  of  a  neurone  are  charac^ri::i  nlmS 
0  a  .lisappearance  of  the  chromatolytic  bodies  in  the  nerve  eel  and 
le,enerat.ve  changes  in  the  myelinated  fibers.     According  to  trewdl- 

3lT T,  «^^^'->^«"«^  R«"-V  the  tissues  of  L  organ  are 
nonm.||.Mn  a  state  of  equilibrium,  and  when  one  degenerates  its  olace 

of  trr,,«  th  of  Its  neighlwrs  tends  to  crush  it  out  *'^ 

l.M  (^ndition  may !«.  brought  alxjut  either  bv  increased  consumption 

1  '^  ";■  "^'^^f '^•"-.♦^  «f  the  cell,  or  by  a  diminution  of  the  reZat  v^ 

TA^  a  .i'fi,:!"'  Z\  ;r ""'"""r "^  --^nizable  by  the  disap,£arance 
^  t^n  II  and  fibers  and  the  secondary  overgrowth  of  glial  tissue  filling  in 

1"  Mich  affections  as  occupation  palsies,  we  have  this  state  of  an 

tiR  alls.    In  other  cases,  we  may  have  a  reparative  power,  relatively 


ii  1  ! 


lii^ 


I*  ■ 

IS* 


: 


A22 


rir»  STRVCTURB  or  the  nervous  system 


insufficient  for  the  normal  functioning  of  the  cell.  This  is  usually  due 
to  the  action  of  toxiiw  in  the  blood,  alwlu.l.  lead,  syphilis,  etc.,  and 
the  result  varies,  de|)endinj{  upon  whether  the  toxin  has  a  selective 
action  on  any  particular  part  of  the  nenous  system  and,  again,  on  the 
relative  activity  of  the  various  systems  o.  neurones.  Among  diseases 
of  this  nature  Edinger  has  classed  peripheral  neuritis,  tabes  dorsulii, 
lead  paby,  sulwcute  combined  sclerosis,  etc. 

Or,  again,  individual  systems  are  congenitally  too  delicate  to  carry 
out  their  normal  function  during  the  usual  span  of  life.  There  is  ap. 
parently  an  inherent  lack  of  vital  nutrition  in  certain  systems  of  cellT 
sc  that  thpy  gradually  die— very  much  like  a  plant  when  the  nutrition 
of  lU  roots  IS  interfered  with,  the  distal  parts  fading  first— and  their  plure 
IS  taken  by  glial  tissue.  To  this  condition  Sir  William  Cowers^  has 
given  the  name  "abiotrophy."  (Vi.le  vol.  i.  p.  809.)  It  is  seen  in  sev.ral 
members  of  a  family  being  affecteil  similarly  without  any  appamnt 
sufficient  cause.  The  various  types  of  Friedivich's  ataxia,  the  fumih- 
form  of  primary  optic  atrophy,  peroneal  type  of  muscular  atn.phv 
amyotrophic  lateral  sclerosis,  etc.,  are  all  included  under  this  ciitej.'on.' 

'  Lancet,  London,  1:1002:1003. 


I  !• 


-1^ 


CHAPTER    XXVI. 

THE  BKAIN. 
OOVOIMITAL  AVOMALIBI. 

TiiK  central  nervoas  system  w  formed  by  the  invaKination  of  the 
superior  Kerm.nal  ayer  of  tfie  embryo.  'ITiu.,.  there  is  produced  a  shallow 
hmow  the  medullary  groaie,  runninR  axially  along  the  dorsal  aspect 
The  ceHs  along  the  majyn  of  thb  proliferate,  ,0  that  two  elonS 
KlRes.  the  meduUary  fold,,  arise,  which  gradually  meet  and  coaS^ 
forming  the  m«/«//«ryca««/  Uter,  the  medullary  tube separaSS 
the  superfacial  ecto,lenn  and  becomes  an  independent  structure 

l-he  primitive  brain  consists  in  a  s...ries  of  vesicles  or  dilatations  of 
tlH.  anterior  end  of  the  medullary  canal,  while  the  rest  becomes  the^rd 
TlK-  lumen  of  he  primitive  medullary  tube  persists  throughout  life  as 
the  ventndes  of  the  brain  and  the  central  can^of  the  cord  It  is  lin^ 
In  a  .nembrane  the  .p.,«fy,^,  which  Is  compased  of  a  single  layer^ 
dm  e.1  epithelial  tHb  and  a  supporting   'ruclure  of  modifiS  glia 

There  are  three  chief  vesicles  from  whi.  ♦he  brain  Is  derived  formini. 
^jcveb:  the  fore-brain,  the  mi.l-braiM,  and  the  hhd-lW  S 
firs  ,.s  subd.v.d«l  into  two  parts,  the  pn..sen«^phalon  proper  and  the 
thalamencephalon.  From  the  former  ari.se  the  lateral  veStricks  the 
cer^Lral  hemispheres,  the  olfactory  bulbs,  and  the  corpus  Sum 
rhe  second  vesicle  forms  the  third  ventricle,  the  aquedTct  of  sS" 

hal  ;rr  '*"'  °^  '*•";'"'  "?*  ^P'P**^^''^-  '"'^  Kvjophvsis,  the  o7J 

ha  am,,  the  corpora  quadngemina,  and  the  crura.    The  third  primary 

mule  IS  dn.ded  into  two  parts,  the  epencephalon,  which  goes  to  fon^ 

the  ,K,n.s  and  cerebellum,  and  the  mesencephalon.  formingX  medS 

Ob  .M.«ata.    The  fourth  ventricle  is  derived  from  both  portions. 

In  the  production  of  anomalies  of  development  it  Is  a^neral  rule  that 
tho^  structures  which  go  to  form  the  mast  highly  differentiated  Zt  oS 
of . lu-  ..ram  are  most  likely  to  I.  involved.  Thei^fore,  we  findlnCS 
mo^t  often  and  most  extreme  in  the  fore-brain,  less  often  in  the  hS 
bra..,,  and  very  exceptionally  in  the  mid-brain. 
.|no.nahe.s  of  development  may  be  conveniently  and  naturally  classi- 

0^  .nnation  of  certain  part,  of  the  nervoui  system.     It  is"  1  always 

C  ibuLlTKlK-  !"•    ^'^""^  hypoplasia,  in  which  the  parta  are 
formul  bui  lag  behmd  in  growth  and  development,  and  agenesy,  for 


524 


TIIS  BRAIS 


li 


tlM*  two  fdixiitiiHiH  an  often  u.<t.s«H-mte«i.  It  is  to  l>e  olMrrved  that  we  Imve 
to  ill)  with  two  iniiiii  t  ■  jh-m  in  ajjeiiesy,  one  in  which  the  defect  involvw 
tfie  Iwny  stnciuns  a  wt-ll  m  thi*  nervous  elements,  and  the  other,  in 
which  the  uhiiornui'ii y  h  i-oiiKneil  to  the  ner\ou.i  system. 

IVrhH|vi  ihi'  riMw  iiif<  i.  tinjc  ami  ini|M>rtant  anomaly  is  that  in  whiih 
the  meilulliiry  >:nHiv«>  iuU  to  close  p<i«teriorly.  He're,  the  vertehral 
arches,  the  inusilc,-' ,  niu  Megumeiit  of  the  l)ack  are  not  formed,  sci  iliut 
there  is  a  linmd  Iniire  ai<i  \^  the  dorsal  aspect  of  the  head  and  triinit. 
On  the  ex|Mtseil  ,;fi.<e  ||i  n-  may  lie  recofjnized  ruilimentarv  ncrvf 
suKstancv,  «)ver»Mi  'i  c  .ndriciil  epith«-iium,  which  forrespon<l-  to 
that  onliiiarily  mi-  ,^'  ,l,e  \tntricles  and  neiind  canal,  and  the  ani.ii,-r 
portion  of  a  high  \  \i  scnlnr,  cd  pin-arachnoid  und  dura.  T!  anUTJor 
portion  of  the  hn-in  i-  n-n  !i    fan-|y  well  drvelo|)e<l,  hut  the  Ikihc  of  the 


(h    n 


Flo.  M^ 


IP 


f  > 


Spina  Ijiliija. 


(From  Ihi!  SiirKic'ul  t'liiir  of  Ihe  Muntrval 
Gfneral  Hor.piial.) 


Anencepliuly. 


skull  and  tin*  spiniil  ('oliiinii  are  alinormully  ciirvcil.  This  coiilition 
is  called  craniorluchischisis.  Fr«'f|Ui'iitly,  the  malformation  is  i..i  >'■ 
extensive,  affectiiij;  only  the  lu'iid,  eruiioichUii,  <>r  the  cord,  rhachischuis 
(ipina  bifida,  vide  vol.  i,  p.  24t>). 

In  craiiioschisis  dieniiccplialy;  acrania)  the  vault  of  the  skull  i~  rnv. 
pletely  or  partially  defective,  )ii\'\\\^  to  the  head  of  the  fu'tiis  a  ili;u  irtrr- 
istic  cat-like  or  toad-like  ap|Mariuiee.      The  hmin  suhstaiuv  iiiv  tie 
alxsent  (anencephaly).  or  present  in  rudimentary  form.     Several  \;.iiiirt 
of  (his  malformation  may  iH-eiir. 

►    In  some  cisses  the  defect  of  the  skull  is  not  so  extensive,  hut  i 
to  particular  liKnlities,  while  the  ii.teijumcnt  is  almost,  if  not 
closeil  in.     In  this  way  is  formed  a  |M)uch  or  sac  which  contain^, 
injj  to  circumstances,  a  diverticulum  of  the  membranes  totr,t! 
fluid   (^meningocalej,  a  |M>rtion  of  the  brain  'cncapliaiocele), 


lited 
rejv, 
(iril- 
with 


COSaSMTAL  A \OAfAUES 


525 


Fin    143 


(o»BiBf»-«ae«9hftlo««l«;  htnto  etnhti,     'IV  miMt  .•omiiH.n  .lituatkm 

IS  III  the  m«Hiuin  line,  and  u.huhIIv  in  the  <Hrii)ifal  n-uitm  (mmlnfo- 

<«etph»towto  Mdpitolla),  or  at  th«>  f;lHl>ella  ( ■tiiliico-«iie«phalee«to  lia- 

dfittUM,  etc.).    Oenuiunaliv,  thf  defwts  ««•  found  at  the  vertex  or  the 

laii'ral  anil  infrrior  portion.^  of 

the  eraniurn      Some  of   these 

tuses  proliitbly  differ  etiologir- 

■lly  from  those  just  mentioned. 

Tlii'v  are  believed  to  lie  due  to 

traction  of  an  adherent  amnion 

on  the  skull. 

Ill  raMphaloMla  thenar  rontains 
memliratif.s  uiid  >>rain-suhstance, 
but  no  fluid.  Sometimes  an  oc- 
cipitiil  eiicephul(H-ele  contains 
tlic  (^ater  part  of  the  brain  and 
fonns  a  relatively  enormous 
p<>ii<h  hanging  down  the  back 
(notoncepfaaly). 

Aiialojtous  to  the  malforma- 
tions of  tha  brain  just  referred 
to,  we  have  a  ('orrf*spondin>; 
series  co!  fined  to  the  rord  and 
spinal  "ulumn.  Tlx  se  havi- 
tiln'iKJv  U-en  discu  >.s«-  (vol.  i 
|).  24(i.) 

Allit-d  to  the  mnditions  we 
ha\f  jii>t  descrilied  is  dilatation 
of  the  <<iifnil  neural  canal  'I'he 
ventricles  of  the  brain  niav  l)e 
•liliii'MJ  md  KIKfl  with  fluid 
(hjrdiocephalM  intemua  congenittis),  .,r  then  nav  !«■  a  .liffu..-  dii.  ,,i.,n 
"f  'he  .-.ntral  canni  of  the  f<ml  (hydromyelocele;  syringomyel  cele- 
myelocystocele;  taydrotrhMhii  interna). 

In  congenital  internal  hy.lr.K-eph,,I,is.  tiien-   is  either  a  unif.Tin  .r  « 
'^-n.•  .lilatafion  of  the  ventricles.  ,e  brai.    is  distend.Ml.  an.l  its  -     ,- 

Stan  .^  niay  b-  rediu-eii  to  a  thin  .sheet,  ll.c  lining  cj  tlieliiin  ..  the 
nem  !  ..inal  .m.  usually  Ik-  reeogniz.-.!  here  and  there  on  .l,e  iiH  ■  wall 
SIC      I'le  Iwnes  of  the  cranium  are  often  separatcl  one  f    ui  tlie 


iDienci-pliuiy.     (Mctiill  Meili    .1  Museum  > 


'•ll'-r.  -  that  .(.e  head  is  enlarged,  and  ,lcf.  -  is  of  ,  ssiti-a-  m  v  also 
I*  "iin.l.  In  rare  cas«s.  niptim-  ..•  die  .sac  ..kes  piace  ai  -irt  „r  d  r- 
"V  Mta-iitenne  life,  thii.s  ,,rodii.  iiig  a  seroiidarv  iranius-  hj.  .  ir,.how' 
ha,  M.scriM  liK-al  diU.tatiun..  of  the  veiitri.  Irs.  an  !.,rou>  ,<.  the  cir- 
uin.^,nl.ed  dilatation  of  r,e  cor<l  known  as  mvel-  vs-eHc.  Of  the.se 
...  uiriiUoxii.-,,  hydiwpB  of  tiw  iounh  and  tifth  ventrici«s,  ul  hydroM 
cysticus  coran  po8twiori8. 


^rankhaften  'ieschwui.te,  1  :  Isr,:!,  Berlin;  aLsf.  \  ircl,   .\rci: 


,  2T    i8*-H:W5. 


526 


THE  BRAIN 


•S 


i  i 

f  . 


i    i 

4 


The  local  dilatations  of  the  cord — myeloeyitoMto — are  associated  with 
defects  in  the  fusion  of  the  arches  or  bodies  of  the  vertebrae,  and  are  due 
to  accumulation  of  fluid  within  the  central  canal  at  such  points.  The 
wall  of  the  sac  is  composed  of  spinal  substance  and  the  meninges,  'i'he 
cavity  is  lined  with  epithelium  continuous  with  that  of  the  central  canal. 
Amnecphaly.— Complete  absence  of  the  brain,  anencephaly,  is  usually 
associated  with  acrania,  and  occasionally  with  absence  of  the  spinal  cord 
(amyelia).  At  times  there  is  an  abortive  attempt  at  the  formation  of  a 
pons,  medulla,  and  cord. 

OyelenMidialy. — One  of  the  most  curiom  forms  of  agenesy  is  cyclen- 
cephaly,  of  which  various  degrees  exist.  In  this,  the  anterior  portion  of 
the  prosencephalon  is  the  part  involved.  The  normal  division  into 
two  hemispheres  does  not  take  place  and  the  cerebrum  appears  as  a 
single  cyst-wall  enclosing  a  more  or  less  enlarged  ventricle.  In  some 
cases  the  eyes  are  fused  into  a  single  organ,  situated  in  the  middle  of  the 
forehead  (cyclopia)  and  providetl  with  a  single  optic  nerve.  The  nose 
may  be  rudimentary  or  absent.  The  lower  jaw  and  the  bones  of  the  face 
are  absent,  and  the  ears  may  be  situated  lower  down  than  normal.  In 
the  less  extensive  deformity,  the  two  eyes  may  lie  separate,  although 
closely  approximated  and  lying  in  a  single  orbit,  or  partially  fused 
(•ynophthalmia).    (Vide  vol.  i,  p.  241.) 

Arhinencephaly.— Defect  of  the  olfactory  bulbs— arhinenceplialy— 
has  been  described.  A  great  variety  of  malformations  are  frequently 
associated  with  this  condition,  such'  as  rudimentary  formation  of  the 
nose,  harelip,  cleft  palate,  and  alxsence  of  the  olfactory  nerves.  s\ti()tia, 
accessory  auricles,  anomalies  of  the  heart  and  great  vessels,  uinhilical 
hernia,  defects  of  the  diaphragm,  and  supernumerary  digits. 

Agyri».— Not  uncommonly,  defective  development  of  the  prosenceph- 
alon manifests  itself  in  partial  or  complete  alwence  of  the  convolutions 
(agyria),  or  of  larger  portions  of  the  brain  substance,  or,  agiiiii,  of  the 
commissures. 

Most  frequently  the  corpus  callosum,  fornix,  the  .soft  commissure  of 
the  third  ventricle,  and  the  corpora  candicatia  are  lacking.  In  aliscnce 
of  the  corpus  callosum,  there  is  usually  defect  of  the  gyrus  foruiiaius 
and  gjTus  hippocampi,  as  well  as  other  anomalies  in  the  convolu lions. 
Where  considerable  amounts  of  the  external  portion  of  the  ceivl.runi 
fail  to  develop,  we  get  fissures  or  deep  excavations,  usually  in  the  <  iiural 
or  lateral  aspects  of  the  brain,  which  are  bridged  over  by* the  nra<  Imoid, 
while  the  pia  <lips  down  and  covers  over  the  ba.se.  In 'such  cas.-  fluid 
accumulates  in  the  cavity  in  the  subarachnoid  space,  or  .sonu-iinics  in 
the  meshes  of  the  pia  and  in  the  sulnlural  space.  Defects  of  tlii  kind, 
due  to  primary  err(.."s  of  development,  constitute  one  form  of  v  liat  is 
known  as  poreneaphftly.  I.<>sions  not  unlike  them,  however,  an  occa- 
sionally produce*!  by  trauma,  va.sculur  disturbances,  or  inflaniii.ition 
(secondary  porencephaly). 

Extensive  defects  of  the  brain,  such  as  acrania  and  ancm  i'haly, 
lead  to  imperfect  development  of  the  cord  (atalomyelia).  In  su. '  <ases 
it  may  be  abnormally  short.    Again,  when  portions  of  the  brain  :■  .  lack- 


.f^ij^iK 


i 


CONGENITAL  ANOMALIES  fgj 

ing,  the  neurones  of  which  are  ordinarily  continued  into  the  con]  we 
get  symmetncal  or  asymmetrical  aplasia  of  the  corresponding  spinal 
tracts.  The  spinal  con!  may  be  entirely  absent  {mjtMtX  In  this  case 
It  IS  said  that  the  posterior  ganglia  and  the  sensory  nerves  may  be  per- 
feotly  developed  (Lionowa).  j  "c  per 

HypoplMia^The  weight  of  the  adult  human  brain  varies  within 
wi(e  limits  The  average  may  be  struck  at  1400  grams  in  the  male 
ami  about  1300  in  the  female.  As  examples  of  ex^me  Lite  St 
1*  mention«l  the  bra.n  of  a  Bushwoman  (871  grams)  and  that  of 
v-^lurpnieff  (2012  grams).  Under  pathological  Slldito,^  however 
these  hgures  may  be  widely  exceeded.  Thus,  Ziegler>  figures  the  bS 
of  a  microcephalic  jd.ot  Helene  Becker,  which  we^^hed  only  219  gra^ 
ami  \an  \Valsem'  describes  that  of  an  epileptic  idiot  which  reach^S 
T  '"^.fl'W^.^fght  of  2850  grams.  In  determining  the  S)per 
weigh   of  the  bram  m  any  given  case,  age,  sex,  race,  and  body  weiSt 

U.e  hrst  year  of  life  and  reaches,  practically,  its  maximum\t  the  age  oi 
seven  or  eight.  After  about  fifty  it  begins  to  decrease.  The  K 
mc-e«  have  larger  brains  than  the  black;  the  male  than  the  female.  In 
heam,y  human  beings,  according  to  Quain,  the  proportionate  weight 
of  tlie  bram  as  compared  with  the  body  as  a  whole  is  1  to  45 

HypoplMi*  might  be  defined  as  a  condition  of  the  brain' in  which 
He  h   r„  W  ^Tr'  t  "°™^' «>nfiKuration,  the  size  and  weight  of 
the  hrain  fall  notably  short  of  the  normal  average  for  the  particular 
"•ll'vulual  concerned,  laying,  of  course,    It.e  strei^upon  theSder 
ations  mentioned  a»K>ve.     As  a  matter  of  fact,  howeJ^r,  hvpopE  L 
||s.mlly  associated  with  other  peculiarities  of  developme.rsucha^ 

ZtZTt  '""^-^'1  ^^  '"^'^''"''  ^°™"''*'"  «f  '^^  convolutions,  and 
striKMiral  changes  in  the  ner\ous  suKstance. 

Microcephaly.-Hypoplasia  of  the  brain,  as  a  whole,  occurs,  and  may 

twTTh"  \^"'^r"'""«  '^™""^  "^  the' cranium  (rnTZ 
o     u     e  „,  SL  T  "  o^en  apparent  at  birth,  but  becomes  more 

huh  h  Ji    f ""«»  somHtic  development  goes  on.    In  some  cases, 

t'rtln  '}r  ""'  "^""'^  '^^  ^'"^  °^  t'^^'  °f  the  newborn  child 
A  a  r„le,  the  skull  presents  premature  synostosis  of  certain  of  the  sutures 

r, ;  '":.T^P°r^'?K  asymmetry,  and  other  peculiarities  of  assificatbT 
J  as  Wormian  bones.  The  brain  itself  is  nclTonly  small,  but  the  scheme 
of.lu;  involutions  is  much  less  complex  than  In  the  case  of  normal 

Ss  •  r  li  "''"P'"**  *'fh  «'•«'  ^^^  of  the  cranium  {micrencephL). 
the   ,1  TrT\  ''""*"'"/r'  ^•*''  •'"  •'^"°™«>  accumulation  of  fluid  in 

Lit/  tm/'„  .V  •.''^"/"'''^'  H^'^P'  ^''^*ricdarU  sive  internus),  or 
•>otr..    N,ine  authorities  have  attributed  the  hypoplasia  of  the  brain  to 

^  I.ehrbuch  der  speciellen  pathologischen  .\nalomie,  Jena,  1895:321 
.>curol.  CcntralbL,  13  ;  1899  :  578. 


i: 


5% 


THE  BRAIN 


the  presence  of  this  fluid,  but  while  this  may  be  true  in  some  cases,  it  is 
more  likely  that  the  hydrops  is  secondary  (hydrops  ex  vacuo)  in  most 
instances.  Undoubtedly,  hydrops  is  frequently  associated  with  anomal  ics 
of  development  both  of  the' brain  and  skull,  suth  as  arhineneephaly  and 
cyclopia.  When  the  brain  is  small  we  can  speak  of  hydrocephalic  mivren- 
cephaly.  All  the  ventricles  may  be  dilatetl  or  only  certain  portions  of 
them. 

Partial  BypoplMia. — Partial  hypoplasia  involves  usually  the  he-rii- 
spheres  of  the  cerebrum  and  cerebellum,  less  commonly  the  corpus 
callosum  and  the  structures  at  the  base.  In  the  case  of  the  cerebrum, 
it  leads  to  asymmetry  and  is  generally  associated  with  microgyria  or 
even  agenesy  of  certain  convolutions. 

Hypoplasia  of  the  brain  is  most  probably  due  to  a  primary  vitium  of 
development,  but  in  some  cases  may  be  the  result  of  pathological  processes 
acting  during  intra-uterine  life.  Premature  synostosis  of  the  crimial 
sutures  Is  at  work  in  some  instances. 

Hypoplasia  of  the  cerebellum  may  affect  the  organ  as  a  whole,  hut 
is  generally  unilateral.  The  condition  is  associated  with  hypoplasia 
of  the  olivary  Ixxlies,  pons,  and  medulla.  The  transverse  fibers  in  the 
pyramidal  tracts  of  the  pons  are  absent. 

As  might  be  expected,  micra«copic  study  of  the  tissues  involvnl  in 
hypoplasia  shows  marked  deviations  from  the  normal.  Certain  of  the 
ganglion  cells  of  the  cortex  are  lacking,  and  corresponding  with  tins  is 
an  absence  of  neuraxones  l)elonging  to  them.  There  may  be  a  rt'lative 
or  compensatory  increase  (macrencephaly)  in  other  parts. 

Microgyria. — Occasionally,  however,  the  convolutions  are  particiilarlv 
numerous  but  diminutive  (microgyria).  Or,  again,  owing  to  tleftct  of 
the  ner\-ous  substance,  the  convolutions  are  representetl  only  hy  n't  in- 
brane.  While  the  hypoplasia  is  most  marked  in  the  cerebrum,  the  cere- 
lieilum  and  basal  structures  are  to  some  extent  involved.  As  a  conse- 
quence we  find  lack  of  formation  or  tlefect  in  the  medullation  of  ctrtain 
fibers  in  the  pons,  medulla,  and  cord,  particularly  those  that  Ixcome 
meduUated  .somewhat  late,  such  as  the  pyramidal  tracts  and  colninns  of 
GoU,  less  often  of  the  anterior  columns  and  cerelx'Uar  tracts  {micrth 
myrlia;  atehmyella). 

HydrocephaluB.^In  not  a  few  cases  the  accinnulation  of  the  d  nhro- 
.spinal  fluid,  with  dilatation  of  the  ventricles,  comes  on  after  the  luiiin  is 
fairly  well  formed.  The  condition  may  a  •  -  during  intra-uteriiu  txist- 
eiice  and  the  hydrocephalic  head  prove  an  obstruction  during  pait;i'  iiioi 
The  enlar^i^ement  of  the  heatl  is  not  always  marked  at  the  (it  !.  hi 
gradually  increases  and  may  l)ecome  extreme.  The  cranium  1 1 
the  skin  is  stretched,  the  sul>cutaneous  veins  are  prominent.  :' 
fontanelles  are  enlarge*!.  Finally,  the  sutures  give  way,  and  th. 
Iwnes  l)ecome  separated.  The  meninges  are  distended'  and  ten^. 
dilatation  of  the  ventricles  may  l)e  so  extreme  that  the  substam . 
hemispheres  is  transformetl  Into  a  thin  -ae,  little  l)fing  left  hut 
arachnoid.  1  lie  sulci  are  obliterated  and  the  convolutions  iV 
The  basal  ganglia  are  flattened,  but  the  ceTebellum  usually  is  up 


ion. 
hut 

li-f.TS, 

.1  the 
iiinial 

The 
f  the 

[)ia- 
•|H'ar. 
'•ted, 


CONGENITAL  ANOMALIES  gjO 

The  fourth  ventricle  i.,  not,  lu  a  rule,  dilated.  The  hydrops  may  be 
.Lffuse  and  symmetrical  or  only  one  yentride.  or  a  portion  o^  one  yen! 
tru  e  may  be.nvolyed.  Dilatation  of  the  fourth  yentride  leads  to  prLIure 
on  the  cerebelum  pons,  and  cord.  The  fluid  in  the  yentricles  Ka^ 
colorless,  or  slightly  yellowish.  "' 

The  causes  of  hydrocephalus  are  not  well  understood.  It  has  been 
at  nbuted  to  inflammation  of  the  ependyma  and  to  interference  Withlhe 
re  ..rn  yenous  circ-ulation.  but  the  eyidences  of  this  are  hardly  <^n^icine 
rhe  pm  at  the  transyerse  fissure  has  lx*i,  found  to  l,e  indZted  Tnd 
thus  might  conceiyably  press  upon  the  yeins  of  Galen  iTet'rmal 
channels  of  communication  which  exist  at  the  transverse  fissure  b^™n 


Fio.  144 


H,vdn.i.eiilialuii;  child  a(ed  about  four  vrar.      m.^TT^^^^^^V 

^ZZ^tjr'  P"'"';?''"  **?  ^^''"'P''  "f  '^'  »'™'n  and  its 
Aol   ,Z'„rfl   -1     •u^'^T"'''^'""''  °*  """'  i"  «""«  «l>o"t  the  cord 

nj;        ,!      ^,'*'.'?P"-  »'■  hypoplasia  of  the  c-ord. 

thecmralcSTftl^morilTl'       '  '^'^T  ""'  •■'^^'"'"'-  '^'■'"'^''°"  »' 
^  ^      canal  with  more  or  less  encroachment  upon  the  substance  of 


530 


THE  BRAIN 


i  . 


thk  co«l.  The  condition  may  lie  merely  microst-opic  or  may  involve 
the  jfTt-ater  part  of  the  thickness  of  the  cord.  The  cavity  is  circular 
or  irregular  and  situated  in  the  centre  of  the  cord,  or  it  may  extend 
into  the  postericjr  horns  and  columns. 

rhe  changes  in  the  cord  are  referable  to  the  effects  of  pressure,  hiiiig 
chiefly  atrophy,  thickening  of  the  vessels,  and  slight  peri-ependvrnal 
(gliosis.  The  cause  is  unknown.  Some  iiave  suggested  a  secretory 
function  on  the  part  of  the  ependymal  cells.  Others  think  it  due  to 
va.scular  disturbances. 

Hjrpeiplasia.— Hyperplasia  of  the  brain  is  usually  associated  with 
a  corresponding  developmental  enlargement  of  the  cranium  {mm-ro- 
cephaly).    Two  forms  may  l)e  differentiated. 

In  the  first,  there  is  a  true  hyperplasia  of  all  the  elements  coniposinjr 
the  brain,  which  differs,  therefore,  in  no  respect  .save  that  of  size  from 
the  normal  brain.  The  enlargement  of  the  brain  due  to  hydro«'|)liahi,s 
should  not  be  confoimded  with  true  macrencephaly.  The  weight  of  the 
brain  in  this  condition  may  vary  from  1500  to  2200  grams.  Individuals 
possessing  abnormally  large  brains  have  occasionally  been  noted  for 
intellectual  vigor,  but  this  is  by  no  means  an  invariable  rule.  Idiots  and 
epileptics,  on  the  other  hand,  occasionally  have  large  brains.  In  luoiler- 
ate  grades  the  membrane^  are  put  on  the  stretch,  and  the  epidural  spat-e 
and  the  cavity  of  the  ventricles  are  encroached  upon. 

In  the  second  class,  the  enlargement  is  due  to  a  relative  increase  in 
the  amount  of  glia  (gliosis).  This  may  be  generalized  or  confined  to 
certain  districts,  convolutions,  or  parts  of  convolutions.  The  condition 
is  referable  to  a  primary  peculiarity  of  development. 

An  interesting  and  somewhat  obscure  affection  of  the  spina!  coni 
a.ssociated  with  hyperplasia  of  the  glia  tissue  is  known  as  syringomyeJii. 
This  ter  i  simply  means  cavity  formation  in  the  cord  (a'jiity^,  a  iliite), 
and  therefore  might  be  taken  to  include  such  conditions  as  liydroniyt'lia, 
hematomyelia,  pyomyelia,  and  hemorrhagic,  degenerative,  and  infiiun- 
matory  softening.  It  is  generally  taken  to  mean,  however,  a  condition, 
distinct  fmm  all  the.se,  which  is  attended  by  a  somewhat  varial)li',  Imt 
still  characteristic,  train  of  .symptoms.  The.se  are,  in  a  typicid  case, 
muscular  wasting  of  the  Aran-Duchenne  type,  lo.ss  of  thermic  and  |>ainfiil 
sen.sations,  with  preservation  of  tactile  sensibility.  Irregular  forms  are 
also  met  with  occasionally  which  recall  amyotrophic  lateral  -rlirosis, 
tal»es  dorsalis,  and  Frie<lreicli's  ataxia.  The  lesions  art-  ^'i  iicraliy 
found  in  the  cer\'ical  and  upper  ilorsal  portions  of  the  cord,  liiit  inav 
involve  its  whole  length,  and  even  extend  into  the  medulla,  | 
internal  capsule.' 

To  gross  appearance  the  conl  may  present  little  change,  altli 
is  unusual.     The  dura  is  normal,  the  pia-arachnoid  normal  or  l>i 
thickene<l.     The  coni  itself  may  pre'sent  a  natural  configurati  ■ 
collapse  on  removal  iiUo  a  riblwn-like  band,  acwirding  to  tiic 
the  pathological  change.     Sometimes  there  is  .slight  ciilarj;!-' 


and 

,iji  this 
dijihtiy 
or  may 

ll'llt  of 

ii,  and 


Spiller,  Hrit.  Metl.  Jour.,  2:  1906:  1017. 


iiit 


"i  Ii 


HYPERPLASIA 


531 


III.  posterior  part  and "heClrhl,      ^  B»)'  mailer,  »u.lly  o! 
■»  ("...,,1  to  coi,m„nfe,le .ill,  ilWs^'LT IS,     4i    '°°"'  '""""r 


Fio.  145 


ionof  Dr.  Colin  K.RU..MI.) 


|H.s,.,i   o  iK-tleS  ft^n   'n       •    "T'?'^.'''  ^'^'^on-'^-ctive  tissue,  sup- 
..f.en  i,.,.,™  „'"?  f."**  ♦lr««'n<l,nK  .legeneration.     The  nen'e  roots  are 


"ften  involved   atuT  tliereT,  r;^""''  "T^^"^""""-    .Ale  ner%'e  roots  are 


f-valin.  deLrXlnTIh-  l'"'"''""":-  J!'^ ---''•■^  commonlv' show 

hr..n,lM.si.sf  anT  ^n  u^^^^^^^^^^  "   ''''  '""™?-     i^'^H^sis  of  cells. 

■>,  ana  rupture  of  the  capillaries  may  take  place 

;r:;^i;:^i=  ^s-",:™'.'  -.""..-rThe  «e„„i,,- 


tliroii 


-i.    t!  mat  on     Thr^'"*'  '°  "'^^^'^  ''•^  degenerative  soften  £g  an  J 
Mm,  IS  of  ecto«]ermal  origin  and  is  produced  bv  the  pro- 


532 


1? 

;  '-i 

M5 


THE  CORD 
Fio.  u« 


Syrioffumyelia,  with  extenMve  cavitation  of  the  posterior  hfini.     (From  collectiun 
of  Dr.  Colin  K.  KuhwI.) 


Fio.  147 


m 


8yrilutomy«lia.     Lumbar  cord,  ahnwinc  ravitation  of  both  posterior  cornua  nn<l 
degeneration  in  the  pyramidal  tracts.     (From  collection  of  Dr.  Colin  K.  Il^ 


ulinf 


.i.J^ 


HETEROTOPIA  533 

liferation  of  the  epen.lymal  cells  of  the  central  neural  canal.  The 
..r.j;.nal  epemlvma  .s  repmsented  in  the  human  coH  by  the  cuboida! 
(ells  omung  the  hniUK  ep.thehum  of  the  central  canal,  and  small  groups 
of  celU  m  .ts  imm«l.ate  neighlKjrhood.  Syringomyelia  is  thus  to  Ke 
repirde,!  as  a  central  gl.os«  caused  l.y  the  pmliferation  of  the  ependymal 
M\s,  the  va.sc-ular  changes  which  accompany  it.  such  as  thickening  of 

he  vessels  thromlx,.s,.s,  emlK,l.sm,  and  hemorrhage,  being  responsible 
for  the  softenmg,  which  is  largely  of  the  nature  oU  necrofis  frSSi  lack 
of  nutrition  \  .rchow  iH-heve.!  that  syringomyelia  was  consecutive  to 
.•ongen.tal  hydromyeha,  and  tho.ight  that  the  gliosis  was  due  to  the 
proliferation  of  inclusions  of  embryonic  glia  celU  about  the  central 
(■aiml.  buch  embryonic  cells  may  take  the  form  of  diverticula  from 
the  neural  canal,  solid  ma,sses,  or  isolated  cavities.  The  pressure  of  the 
fluu  within  the  central  canal  is  here  supposed  to  play  an  important  part 
in  the  pro<luction  of  the  softening.  p"««mpan 

Another  theory,  held  by  certain  French  observer,  (Hallopeau ;  Joffroy). 
IS  hat  the  process  is  essentially  an  inflammatorv  one,  which  directly 
and  indirectly,  owing  to  vascular  changes,  leads  to  softening  and  cavity 
formation  {myehte  cavitaire).  ''  ' 

Another  view  is  that  obstruction  to  the  blood  or  lymph-circulation 

skull,  or  of  the  cortl  1  self,  and  meningitis,  lead  to  hydrops  of  the  canal 
and  secondary  dilatation. 

None  of  the  theories  pr(,poiinde<l  is  entirely  satismctory,  for  cases 
have  .K^a^ionally  been  met  with  which  cannot  be  explained  on  any  of 

h owX        '•     ?A  '^f  ''^"^''  '^'  P^P«"derance  of  evidence  goes  to 
show  tiiat  errors  of  development  are  the  most  important  factor ' 

Diasteni.tomyeli..-\Vhat  might  l.e  called  a  numerical  hyperplasia  is 
««..,  in  the  cx,nl,  in  the  condition  known  as  dlMtenutomy/luT  Jr^.f 
i:Z  1-    "'"'•    '^^••^"^"P'7'-  occurs  inTeTm^^reS: 

Diplomyeii8.--Diplomyelia,  or  the  formation  of  two  cords,  is  met  with 
in  (rrtaiii  double  monsters. 

^\Tl  T*  '""''  "''"  •'^  al»normally  long.    The  spinal  roots  may  be 
al..ionnaIly  numerous,  or,  again,  defectiye.  ' 

Kr..>  matter  may  Ix-  found  in  the  white  suKstance.  Many  of  these  an- 
K.anu,n..s  are  due  to  artefacts  pnuluml  in  se^-tioning  the  coiS  buTthere 
.  ,.,..lo„ Medly  cases  in  which  the  condition  is  due  to'an  error  of  deylp 

Schl! '!'.,';"%")■  *Ii'  ^''  '""""graphs  on  Syriugomyeiia,  with  full  bibliography,  see 
«;mt  iMLVT,  Die  >ynngomyelie,  Wien,  1895.  »    P  y.  "ee 


534 


THE  CEREBRAL  MENINGES 


TBI  OBtlBBlL  MDmrOU. 

The  covering  memhrenes  of  the  brain  are  three  in  number:  an  outer, 
the  dura;  a  middle,  the  arachnoid;  and  an  inner,  the  pia.  The  last 
two  are  so  intimately  associated,  anatomically  and  pathologically,  that 
they  practically  form  one  structure.  The  membranes,  owing  to  their 
relations,  are  liable  to  be  involved  in  pathological  processes  originating' 
both  in  the  brain  and  in  the  cranial  bones;  and,  further,  being  highly 
vascular  and  bounding  spaces  which  are  practically  large  lymph-channels, 
infective  agents  can  readily  reach  them  from  distant  or  adjacent  parts, 
and  may  set  up  rapidly  extending  inflammation.  It  should  lie  remarked 
that,  while  it  is  convenient  for  descriptive  purposes  to  a«lopt  the  regional 
method  of  classification,  it  is  almost  impossible  for  one  membrane  to  lie 
diseasc<l  without  to  some  extent  involving  the  others  and  even  the  brain 
itself. 

The  Cerebral  Dora  Ifater. 

The  dura  mater  is  a  tough,  inelastic,  connective-tissue  membrane, 
and  is  lined  on  its  inner  surface  by  a  layer  of  endothelium  of  a  gravish- 
white,  glistening  appearance,  which  serves  the  double  purpose  of  a  jxTi- 
osteum  for  the  cranial  bones  and  a  protective  covering  for  the  brain.    In 
adults  it  is  only  loosely  adherent  over  the  vault,  while  at  the  Iwse  of  the 
skull  it  is  much  more  closely  attachetl.     It  sends  three  processes  into 
the  intracranial  cavity  for  support  and  pro  tection  of  the  brain:  first 
the  falx  cerebri,  running  longitudinally  between  the  two  cerebral  hemi- 
spheres; second,  the  tentorium  cerel)elii,  on  which  rest  the  occipital  IoIks 
separating  them  from  the  hemispheres  of  the  cerebellum;  anil  third, 
the  fak  cerebelli,  running  vertically  between  the  two  lolies  of  the  cere- 
bellum.    It  also  sends  prolongations  enclosing  the  various  cranial  nerves 
and  vessels  as  they  make  their  exit  from  the  skull.    Around  the  nmrfiin 
of  the  foramen  magnum  it  is  closely  adherent  to  the  bone  and  is  coiiliii- 
uous  with  the  spinal  dura  mater.     In  certain  situations  the  «lura  splits  up 
into  two  layers  to  contain  the  various  venous  sinuses,  whith  plii.v  an 
important  part  in  connection  with  certain  infective  processes,    'rhiis, 
in  the  superior  Iwrder  of  the  falx  cerebri  lies  the  superior  longitiKJiniil 
sinus,  while  the  inferior  longitudinal  sinus  is  enclosed  in  its  iiilVrior 
IjonJer.     The  tentorium  cerebelli  encloses  t'le  two  lateral  sinuses  in  its 
posterior  convex  borders.     In  its  anterior  bo.  ■  lers  it  encloses  the  sniurior 
petrosal  sinus,  and  along  the  middle  line  of  its  upper  surface  nm^  tlie 
straight  sinus.    The  occipital  sinus  runs  in  the  attached  margin  ..f  the 
falx  cereljelli. 

On  the  outer  surface  of  the  dura  run  the  branches  of  the  jiuMuk 
meningeal  artery.  The  veins  of  the  dura  are  connected  with  tho  <.  of 
the  scalp  by  nuuieri^us  branches. 


THROMBOSIS 


OZBOULATOKT  DIlTUSBAirOll. 


535 


CoilgMtlon.-ConR,.stion  of  the  dura  19  commonly  met  with  in 
8ss«K-.at.on  wuh  .nflammatu.,,  of  the  dura  or  other  membranes,  or  where 
tlure  L,  an  mcreaae  m  mtracranial  pres.sure  from  any  cause  ZyiH 
o  course  that  that  pres-su,^  I.  not  eLssWe.  In  such^crCon'^^mS 
of  the  calvarium,  the  dura  weeps  blood  rather  freelv  "  •''novai 

Anaini».-Anemia  is  met  with  in  death  by  blee«Hng  and  in  all  forms 
of  .systemic  anemia.  »      "  m  an  lunns 

Hemorrh«ge.-Hemorrhage  may  take  place   upon   the  surface  of 
he  dura  (epidural),  into  its  substance  (intmdural).  or  l.eneaJh  [rj^ub- 
.lurai).    Ihe  commonest  cause  is  traumatism,  such  as  concus^,ion  and 
fracture  or.  again,  disease  of  the  adjacent  bony  structures.    MertMs 
the  bleeding  IS  often  due  to  rupture  of  the  middle  meningeal  arterto; 
Ttlel.    f  r^Jr    u^'  h<''norrhage  does  not  necSri?v  c2^ "J 
at   he  site  of  the  blow,  but  may  take  place  on  the  opposite  JdeTy 
contrecaup)  or  at  some  other  part.      When  the  injury^rsevere    fatd 
(xmsequenc^often  follow,  owing  to  compression  if  L  bmTn      H 
to  be  remembeii    that  serious  symptoms  do  not  always  come  on  immedr 
ately  on  receipt  o  the  injury,  but  the  patient  may  walk  away  afterTatfa 
rep.n«l  as  a  trivial  accident,  and  may  die  a  few  houS^ later   u„fe» 

o t  rf'  """n^  ""''•  'r'"^-    '^^^  '^^  Wood  tends  to  LvJtete 
to  (he  rioor  of  the  cranial  cavity,  and  may  interfere  with  the  vitafTnSes 
there,  although  sometimes  it  remains  curiously  localized  to  Se  rerion 
of  origin.    Where  the  hemorrhage  has  been  slow  or  nfth^Ji        f 
^zing  the  blood  Ls  found  dott  Jol^ven  d"ii^  ^i'/IhTc'cIT 

<Ti:;  ;■  u'l'^'lr  ''"  ^t^"  P'**^-  ^^  "°'  ""-""»-  event  inTe 
use  ,f  fractures,   here  may  be  more  or  les.s  inflammation  of  the  brain 

and  meninges,  and  even  absc-ess-formation.    Extradural  hemoihace  S 

(xrasionally  met  with  in  the  newlK,m  child  as  the  result  oTadiEu 

or  mstrumental  delivery.    This  is  .lue  to  laceration  ^Se  vessel  from 

o    „  •       ■[  I     -Y  ^'J*"  "■■*  '"  *  P^*'"''"'  fo™  of  spastic  paralysis 
y«jm.      Ihe   same   condition   occurring   during   intra-uterine    life 

TlJomhn^-i    "n    ''^7°'r*'««^  "»  ^a^-s  of  traumatism. 
Thrombosu.-ThromlKxsis  of  the  venous  sinuses  of  the  dura  is  of 

of  .  ';:;T'''''  T""^""^  '""^  >*»  «>«•">•«  "f  ^rave  import.     In  on^  Isl 
U,    I.        ,    J    •  .    "*  ««'t<'"«ration  in  the  quality  of  the  blood 

sudden    .ISenTof  the  V      'r^J^l^r^^^'''  ^'"^  «'^'  Particularly 


i 


If 


If 


ifi-i.'i 


9    <J 


,f 


I 


586 


THE  DURA 


The  condition  is  met  with  in  maraamat,  profound  anemioM,  summer 
diarrhoea  of  children,  and  in  the  agetl  'I'he  longitudinal  sinus  is  the 
site  of  election  for  the  pnKess,  hut  the  transverse  may  lie  involved. 
Qildema  and  rupture  of  the  menin|{eal  or  cerebral  vessels  are  sometimes 
foun«l  as  a  result.  In  another  ckss  of  cases,  the  condition  has  an 
inflammatory  Iwsis  (Ikromboslnimlui)  and  is  analogous  to  thromlMiphle- 
bitis.  ITiis  is  seen  in  meningitis  and  certain  injuries  to  the  crHiiial 
bones.  Perhaps  the  most  common  caase  Is  suppurative  otitis  me<iia, 
complicate*!  with  necrosis  of  the  petrous  Iwne.  Ilere  the  lateral  siiiits 
is  apt  to  be  involvetl.  We  have  met  recently  with  a  case  of  thromlMisw 
of  both  choroidal  sinuses  in  puerperal  septicemia. 

There  is  at  first  inflununution  of  the  wall  of  the  sinus,  followe«l  bv 
clotting  of  the  blow!.  The  vessel  Is  filled  with  a  dirty,  necrDtic-k)okini< 
substance,  of  a  grayish-red  appearance,  and  its  wall  Is  often  of  a  yeiltm-- 
Lsh-green  color.  ITie  process  may  extend  into  the  jugular  vein.  The 
dura  is  apt  to  lie  involveil  in  the  vicinity  and  there  may  be  foci  of  siippu- 
ration  lietween  its  layers.  Super\-ening  upon  the  affection  we  may  ^t 
meningitis  and  abscess  of  the  brain.  As  the  condition  is  infective, 
metastatic  alxscesses  may  be  formed  in  various  parts  and  a  pi'iieral 
septicemia  induced.  When  middle  ear  disease  Ls  the  primary  cause,  the 
alxscess  is  most  likely  to  lie  found  in  the  temporosphenoidal  lol»e  or  in  the 
cerebellum.  In  marantic  cases,  or  where  the  infection  is  mild,  the  throm- 
bus may  be  absorbed  or  become  organized,  provide^l  that  the  i)aiient 
live  long  enough. 

nrrLAMMATIOHI. 

PMhymeningitis. — Inflammation  of  the  dura  is  called  pachymenin- 
gitis. It  Ls  diviiled  into  external  and  internal  forms,  according  to  the 
surface  of  the  membrane  chiefly  involved". 

PKhymeningitii  Iztama  AenU.— Pachymeningitb  externa  acuta  Ls 
asually  due  to  traumutLsm,  such  as  fractures,  gunshot  injurits.  and 
cutting  wounds  of  the  skull,  or  to  the  extension  of  disease  fnmi  the 
neighboring  luine,  as  in  caries  of  the  petrous  bone  and  osteomyt  litis. 
Occasionally,  it  is  secondary  to  erv.sijielas  of  the  scalp,  owinj;  to  int.  rtion 
extending  through  the  veins  of  the  diploe.  The  dura  is  ((nictMed, 
swollen,  and  softened,  and  there  is  an  exudate  which  may  1m'  mtoih, 
seropurulent,  or  purulent.  The  surface  of  the  membraiit'  is  i.Tavijh- 
white  or  grayish-yellow,  and  in  some  cases  covere<l  with  extra  i-ated 
blo«jd.  The  proce-ss  may  spread  to  the  pia-arachnoid  or  to  tL-  lirain 
itself.  When  not  fatal,  the  exudate  may  become  absorl)e(l  or  .  >  -ted. 
Not  infrequently  the  membrane  remains  thickened  and  is  adlu  m  nt  to 
the  skull. 

Pachymeningitis  Bxtena  Chronica. — Pachymeningitis  exterim  (•  onica 
.arises  from  trauma,  local  bone  disnisc,  atld  sunstnike,  iti  c:;  iiere 
infection  does  not  take  place.  The  dura  is  thickened,  owin>;  i'  pro- 
liferation of  the  connective  tissue,  and  in  some  cases  there  is  a  i  lation 
of  b«>ne. 


PACHrMBNiNaiTIS  /STERNA  HSMORRHAOICA  .^7 

may  b^  simple  or  purulent  -""o"'.  aiw  lewl  to  it.     ITie  exudate 

'rh.«.  a  delicate  coSve..  tue  .^m  Ze  U  7  ^.T"*^  '^'V^'''"-^'''- 
..-.UininK  an  abundancl^f  ^l^Je^J^n  wJu.  ™n'  ^^"'^^  '^"™' 
.he  tenuity  of  the  vessel,,  atll  iwiil^t  ,h'^'^ '"''*'•  ^'"f- '" 
.heir  wall,  unde.^.  hemorrharS  ,  tk«  puS^^CrkT  T^^^^^ 
a.u  diapedesw,  into  the  substance  ot' xh^Z^r^ ^'^'''' 
and  upon  it,  surface.    The  extr«v«««»m„  ;     newiy-ronned  membrane 

r;'ir.riinel^ri^-T^^^^ 

pvin^  the  whole  a  laminat^  aErance  'l^./Til''^''  °'  ^'•""• 
shiwtish  and  prone  to  relaose  ^^™  1  n""*  P""****  1^  essentially 
al.sor»HH|,  but  fhe  larSr  onTtr.  I  •""*■/  *'f'™^'««t'ons  may  h^ 
while  f,«m  .Le  to  E  aTresh  exSaZ^^'T ''  T^"^'  ''  "'  «"• 
niemhrane  takes  place  Vt  ,hT„ff2"  °"  ""'^  """'''*''■  formation  of 
»)«..n.es  firme3mo,*d;iLl^"  PT^r-  "'^"•'*  '"^'"''™"« 

p«^n..  of  sH^uXo^i^  Zn^^f  r"  '^"'^'.^  "'  '™^  ^"^-  '^''•- 
whi.  h  te„,k  toTorocrjl  "h  Z'"*^  ""?'"'*'  '■"'■"^•^  inflammation. 

.hem  in  collect  of  flSidL^Tn'^h  T  "-^TT"-^  «"''  '™«"'  «' 
^^.y/roma  dure,  m^ris  hv^J^.^k  ,  "*!  """^  '''^  "^^  membrane 
In  .h.  okler  and  d^n^r  portb^ft  ;«':%m«.i"<;<V/e,«  par//a/,». 
>rra.inaiiv  become  mo^oKT^hLf  °'^'"^'"«  ""embrane  tl^e  ves.sel.s 
in  orher-places  the  p^TanlK  ..  '  "'  *"  ""*'  ""^ ''"'  '•*■'»*?  fo™''*! 
affe„ion  is  con&^e  du^'  h.  7  i  '^'"''  '°  "  "r  '^^  "  '•"'^'  »''- 
i-ive^i.  and  vaTuirriiS  att^V  f^ ^bT:' VrH' 7^  '"^ 

*nil..  .lementia   Hundni^,^    "'^  '"  ^"""'  P"™'-^^''^  "'  '^e  insane, 
"^;'r'--in.appartr:aouttvtV'*""'  associated  with  at«>phy 

wi.h^'  Irchtf  thllrnS  ''^"'■-     T^I  '°«J»"'.^-  °f  pathologists  a«ee 
'ha.  in  scfr  «^   owrnTTf::,'*"  '"^T''^"'^-  ''"^-     ^'  ''  {--"i^C 

'^e  ^..  Of  tH:s;:^s:2^^e-^i;;x^r^^ts; 


li 


538 


THE  DURA 


t: 


t 


upon  the  siirfarr  of  the  dura  followed  by  inflkmrnation,  exudation,  OTpin- 
ixnlioii,  aiiil  ntemhnine  fomintkm.  AiH>ther  view  i.i  thrit  !ipiisin  ntnl 
(iiiitruititHiof  the  vrisi'ls  of  the  hrain  lewl  todimiriution  o'  'he  intr^iTuiiiul 
pn-s-iiirc  and  coiisefiiiently  hemorrhage. 

Tubarcnloiil.  TulM-rcuhMis  of  the  <hira  in  rathei  a<i  iinconitiiori 
fondiiion.  It  i.s  ustmlly  found  in  n-SMH-iation  with  inilin.  ■  tulM>rc-iili>'<H 
of  the  pJH,  Init  <Mru.'4ionnlly  is  <hie  to  the  exten.tion  of  Ixnie  tutien-iilosis. 
It  take>  various  forms,  either  u  diM-n-te  mihury  eruption  irf  tulMTi  It-., 
a  meniliranou.t  de|M>.Hit  eontHiniii);  tulM'rek's  (Hi  the  inner  siiJe  of  die 
thiru,  or  lar^-  (■u.se«)ii.s  ma.H,ses  or  lulierculomiLs. 

SypbiUl.  In  syphilis,  multiple,  small,  crlhdar  fini  or  fn'oi'niiiiiia.t, 
iN-casionally  ciiiilescing,  may  lie  formed,  in  some  ca.'^'s  env.  mg  i.i't'niUi- 
or  ^ununy  nuiterial.  Adhesions  may  take  place  lietweei  '  diini  and 
the  pia-uraehnoid.  'Hie  ctindition  is  most  a|>t  to  occi'.  .r  fie  I  isc  of 
the  iirain,  and  may  involve  the  eranitd  nerves. 

Histologically,   the   lesions  ctmsist   in  cellular  am      ,i  vasnilur 

granulation  tissue  which  tends  to  fpt  on  t«>  m-cnwls.     '1  m-ess  iisuiiliv' 

iH'gins  in  the  adventitia  «»f  the  vess«-ls  or  in  die  epineui.inii  of  the  nerves. 
The  nerve-HU'rs  may  eventually  undergo  atrophy. 


PBOORUSIVI  UniMOEPHOBU. 

Tumors.-  ( )f  the  U-nign  tumors,  the  most  important  are  the  flbroma, 
lipoma,  chondroma,  and  oitooma. 

Tibromas  an'  rare.  They  an-  found  on  any  jmrt  of  the  dura  v:  the 
form  of  hard,  lUNlidar.  .spherical  growths.  Lipomaa  an>  still  rarer. 
Small,  gtdatinous  tumors,  ecchondromaa,  are  found  iK-casionidly  ii'ar  ilie 
cliviis.  So-<-alled  osteomas  are  met  with  in  the  tentorium  and  falx. 
They  are  more  pro|M'rly  examples  of  metaplasia. 

The  primary  malignant  tumors  are  the  sarcoma  and  the  endotheliomt. 

The  .sarcomas  are  generally  spindle-i-elled,  more  rarely  rouiiil-(tlle<l, 
mixciU-clled.  or  alveolar.  \vt\  va.scular  .sarcomas,  or  angiosarcomu, 
have  iK-en  descriln-d.  In  certain  ciuses,  .small  spicides  or  no<liilar  cihi- 
cn-tions  of  mineral  matter  are  found  in  the.se  growths,  llenct".  liny  are 
called  psammosareomas.  Sari*onuis  of  the  dura  may  erode  the  Iumh'  and 
apjH'ar  externally,  'i'hey  are  si.nietimes  of  large  .size,  and  may  jinMliice 
.serious  pressure  u|»on  the  hrain. 

Endotheliomas.—  Kixlotheliomas  are  firm,  flattened,  or  no<lular  mniors, 
originating  fnim  the  endothelial  cells  covering  the  dura,  or,  ]»'-^il>ly, 
from  the  lining  memhrane  of  the  ves.sels  of  the  siilMltind  spai  >•  'IV 
growth  readily  implicates  the  pia-arachnoid,  aiul  may  finally  <  \:i  lai  to 
the  hrain,  which  it  compre.s.ses  or  invades.  Irritation  of  somt  kind 
.seems  to  lie  a  potent  factor  in  the  cassation.  We  have  twi  -^wn, 
jrtist  niorterr.  cas<'s  in  which  a  sjHir  of  Iwne  projecting  fr<>n)  !•  ■  inner 
surface  of  the  parietal  Ixine  fonne<l  the  centre  alwut  which  i  tii<!'>- 
thelioma  develope<l.  Occasionally,  these  tumors  spring  from  '.'  ■  filter 
surface  of  the  dura  and  erotle  the  calvarium,  finally  ap|)earing  <      >  nalK. 


SSDOTItF.UOMAS 

Txm.  I4a 


530 


»■»  ■■»  iif  Un  crntnii 


,-  H 


•••^''rj  „:  ,he  Koy,l  Victori.  Ho.p.uj!)  r«c,D.«d. 


(from  the  Pntholofical 


540 


The  bvRA 


Microscopically,  they    present 
and    anastomosing  bands  of 


Fia.  ISO 


Portitin  nf  an  endothplioma  itf  thp  ilunt 
mater.  nIkiwhik  t)ie  characteriHtif  whorled 
arranictrin<*tit  of  \\w  tilnntr  cplh  and  at 
a,  a  cnneentrifiilly  arranxptl  ralcurpotin 
deposit  t>r  piummoina  hitdy.    (P.  l-;rnot.) 


the    appearance    of    richly    bronrhing 
flattened   cells,  tending   to    be  spindle- 
shaped,  with   a    characteristic  coiici-n- 
tric  arrangement. 

It  is  not  infrequent  to  meet  with 
tumors  showing  histological  transitions 
fmm  the  endotheliomatous  to  the  sar- 
comatous type  (vide  vol.  i,  p.  757).  The 
commonest  form  of  pmnmomt  is  ii  slow- 
gn)wing,  relatively  benign  endothelioma, 
with  necrasis  of  the  "cell-ne.st.s'  and 
deposit  of  calcareous  salts  in  the  clusters 
of  necrosed  cells. 

Oardnoma. — Carcinoma  is  occasionally 
met  with  as  a  meta.static  growth. 

Ohordonut  is  a  curious  tumor  ori^'i- 
nating  at  the  Imse  of  the  skull  in  the 
up|H>r  termination  of  the  nottK-hord. 
It  is  .siturted  near  the  clivus  and  in- 
vades the  dura  secondarily  (s«r  vol.  i, 
p.  ()(M»). 


Fig.  151 


1^.: 


.S«M*linn  <»f  a  cliordnnia.  Tn  the  right  the  i-elh  art*  nf  llie  benign  type.  ii"l  ur.  ■  ■  i  arrange- 
ment thii»e  nf  curtilaKe;  tn  the  left,  thniugh  active  mullipliratinn  the  cells  arc  I J  '"  •»""• 
sarcnniatuus  type  and  the  gruwtb  in  becominc  malignant.     (Fiacher.) 


LEPTOMENtNQlTIS 

The  Pia-anchnoid. 


541 


riie  arachnoid  is  a  delicate,  connective-ti.s.sue  membrane,  devoid 
u  ,h  lil^TZ  ' 'iT'""^  the  brain,  and  lying  in  close  relationship 
*.tli  the  dura.  Ihe  space  between  the  two  is  known  as  the  subdural 
sp«(f  Ihe  pia  IS  also  a  delicate  connective-tis-sue  membrane,  but 
yascii  ar.  It  closely  follows  the  contour  of  the  cerebrum,  dipping  down 
mt..  the  sula  ami  semhng  prolongations,  which  cariy  bloodvesJls  and 
lynipliHtics,  into  the  cortical  substance.  The  arachnoid,  on  the  con- 
trary, passes  from  top  to  top  of  the  convolutions.  The  space  Ix-tween 
the  arachnoid  and  pia  contains  the  cer*bro.spinal  i.uid,  and  is  called  the 
subanuhnoid  space.  Pa.s.smg  from  one  membrane  to  the  other  are 
innimierable  bands  and  strands  of  connective  ti.ssue,  coveml  with  a 
continuation  of  the  endothelium  lining  the  sac. 

At  the  base,  the  pia  and  arachnoid  are  widelv  .separ-ted  fr«m  one 
another.in  certain  situations.  Thus,  in  the  intenHnluncular  space  and 
pster..,rly  between  the  posterior  surface  of  the  medulla  «n<l  the  inferi.  r 
surfm-e  of  the  t^rebel,™  ,,uite  large  mservoirs  are  fo„n«l  for  the 
cerehnxspinal  fluid.  The  chief  l,loodvessels  run  in  the  suUrachn oS 
spa,.";  the  veins  he  superficially,  the  arteries  at  the  bottom  of  the  su' 'i 

111.'  pia  mater  IS  «.ntinue<l  into  the  lateral  ventricles  through  the 
tmnsversc  fissure  in  the  form  of  the  tela  clioroidea  si,,H.rior,  and  sZ 
^  f.  ir  h  ventricle  i„  the  form  of  the  tela  chomi.lea  inferio  .  c-.^rvii  g 
».tl.  i  the  ehor.«d  plexus  of  vessels.  The  siibarachnoi.l  spac-e  is  \-Z 
niioiis  with  he  ventricular  cavities  through  the  foramen  of  Majen.l  e  n 
the  lower  end  of  the  fourth  ventricle.  »r"'"^  '" 


OIROULATORT  DI8TUEBAH0E8. 


he  circula  ory  .listiirbanc-es  affec-ting  the  pia-,ir«chnoi,l  -  ill  Ik-  more 
«...  ..nieii.ly  .hseusse,   when  treating  of  the  brain,  inasini.cn  ns  IZZ 
.<■lw.li  intimate  relationship  iK-tween  the  brain  and  its  meuib  ai  es  d.a 
t^ZT^^'""  '""'""  """'"''""'■^  "'"'  -••"""«"«••-  n..siilt     1 


raritAMMATIOKS. 


Leptomeningiti3.--Infl„nimati«n  of  the  pia-anuhnoid,  leptomenin- 
or  d,;;;;,-. :  "  '•'  ""'""•^'  "'"■*  '•"^"•^-  *^"»-''  "••^KiUs,  ma;  iH.  acule 
Acute  Upton»ningiti..-A<-,ue  leptomeningitis  is.  in  the  vast  majoritv 
i  ;     I  •  "7  '"'■•'   '  •'  '"''•'^••''TJ""ism.S  probal.lv  ,l.e  o„|v  ex?  ■    ,W 

the  I  „  •      '  ''"'■''.  ""'  •''*'  '  •^■"«*'""'  '■"'■'■'.  tlH'  H.  .iilH-lviilosis 

»^e  I),|.|,„,„.c.„s  pneiinioniie,  the  .Mening,K-,Kri,s  intracTlh.lar       an   ' 


542 


THE  PIA-ARACHNOID 


n  I'l 


The  infecting  agents  reach  the  meninges  either  through  the  l.iood 
(hematogenic  infeition),  by  extension  from  neighboring  parts,  or  from 
the  external  air.  The  hematogenic  form  is  well  illustrated  in  tliasf 
cases  which  complicate  croupous  pneumonia,  endocarditis,  acute  rheu- 
matism, pulmonary  tuljerculasis,  typhoid  fever,  scarlatina,  pleurisv, 
an«l  liwlsores.  The  sec«)nd  variety  is  due  to  the  extension  of  an  inflam- 
matory process  from  the  brain,  dura,  or  bones  of  the  skull.  Of  es|M><ial 
importance  in  this  connection  are  affections  of  the  middle  ear,  the  mastoid 
cells,  and  the  accessory  cavities  of  the  nose.  Those  arising  from  exttniai 
infection  are  the  result  of  traumatism,  such  as  fractures  and  penefratini; 
wounds  of  the  skull. 

While  in  many  cases  the  meningitis  is  due  to  the  particular  iiiiin)- 
organism  producing  the  primary  disease,  examples  of  secondary  and 
mixed  infection  are  not  uncommon. 

It  is  hanlly  possible  for  the  pia-arachnoid  to  be  inflamed  without  cor- 
responding changes  in  the  brain  sulwtance,  at  least,  in  the  su|MT(i(iai 
layers  of  the  cortex.  This  is,  in  part,  due  to  the  close  apposition  \w 
twceii  the  structures  in  question,  so  that  lesions  are  reailily  pn«lii(rd 
by  direct  extension,  but  also  in  some  metusure  to  the  di.s.seminatioii  of 
infective  agent.s  thmugh  the  bloodvessels  and  lymphatics  of  the  |)ia 
which  send  minute  branches  into  the  connective-tissue  septa  i.f  tiie 
cortex.  The  c-ells  of  the  gray  matter,  therefore,  commonlv  siitfer. 
showing  fatty  degeneration,  vacuolation,  and  changes  in  the"(  liromii- 
philic  l)0(lies.  .^Iultiple,  small  ecchymoses  are  often  to  lie  s«f  ii  in  the 
cortex.  In  well-marked  cases  the  ciindition  would  properlv  Ih'  itrineii 
acute  meningo-«ncephaUtit. 

Acute  Serous  Meningitis.— Acute  serous  mem'ngitis  (Quin<k<)  is  an 
important  atfection  of  the  pia-arachnoid,  often  of  the  cortex,  cliMrader- 
ized  by  congestive  hy[)ereniia,  onlema,  and  the  protluction  of  a  strous 
and  cellular  exudate.  It  is  met  with  most  frefjuently  in  children  at  the 
onset  or  iliiriiig  the  course  of  certain  of  the  infective  fevers.  Muh  as 
-carlatina  and  measles.  It  is  found,  however,  in  atlults  also,  a^  a  re- 
sult of  traumatism,  and  in  those  suffering  from  obstructive  canii  •  dis- 
ease, alcoholism,  uremia,  and  other  intoxications.  The  causaliv.  factors 
are  not  always  entirely  clear. 

The  anatomical  picture  is  not  constant.  In  certain  cases  th.  intiam- 
niatory  pro«lucts  are  so  .scanty  that  the  condition  is  onlv  (l»t( <  ttil  on 
micnjscopic  examinutitm.  In  the  .severer  forms,  the  piii-ariK  !iM<ii«i  is 
C()ngestetl,  (edematous,  and  the  subarachnoid  .space  contain-  a  con- 
siderable <|uantity  of  watery  exudation,  sometimes  clear,  -imtiines 
turbid  and  containing  flakes  Along  the  ve.s.sels  the  fluid  is  apt  m  l)eof 
a  yellowish  color  and  gelatinous  consistency.  The  dura  is  iisu  IK  tense 
and  injecttnl,  somewhat  moist  and  shiny  on  the  inner  surfm  •  If  the 
exudate  Ik-  at  all  extensive,  the  membranes  aredisteiide<l  and  ilir  ..iivohi- 
tions  flattened.  The  extenf  of  the  disease  varies  and  the  Icsk  are.  as 
a  .jle,  irregularly  dislribiitctl,  l)eing  most  marked  along  tin  urse  of 
the  main  vessels.  At  one  time  the  involvement  is  most  in  ir!  I  at  tbe 
base,  at  another,  over  the  sides  and  convexities.     The  araclip.      usually 


ACUTE  SEROUS  MENINGITIS  543 

pels  off  readily,  leaving  a  moist,  c-ongested,  and  cedematous  pia.  Minute 
iH-morrhag^may  abo  be  seen  .n  the  pia  and  the  superficial  layers  of  the 
crtex  (>cca.s.«nally,  the  d..sea.se  is  localized  to  one  part  of  {he  cortex 
owmg  to  the  del,m.tttt,on  of  the  exudation  by  adhesi^s.  In  addidon 
o  the  meningeal  mvolyement  the  di.sease  may  extend  to  the  liningof 
th.  ventricles  an  produce  a  considerable  accumulation  of  fluid  there 
(hydrops  ventn.'ulorum). 

We  may,  further  rec-ognize  a  »eropunde,d,  fibrimpurulent,  and  purvlent 
memngUKs,  acconhng  to  the  nature  of  the  exudate  pnxluced.'^ "K 
..ulude  the  majority  of  meningitis  cases.  The  exudate  is  more  ccliulaT 
...nsistuig  of  a  turbul  serous  fluid  containing  numerous  leukocytes  an  ' 
sometimes  flakes  of  hbrm.  or  it  may  be  entirely  purulent.  The  exudate 
.ends  to  coflect  about  the  v^sels  an.l  in  the  sulci^ut  in  sever^  c^s  the 
brain  may  be  bathed  in  exudate. 

The  .listribution  of  the  lesions  is  dependent  largely  upon  the  cause  and 
he  nature  of  the  infect  ng  agents.  Hematogenif  cau.^  Zf  aff^t  the 
base,  .he  c-onvexity,  and  prac;tically  any  part  of  the  membranes.  IW 
mansiii.  caries  of  the  petrous  lx>ne,  an.l  infec-tion  of  the  acc^.sson-  cavities 
lead  .0  a  local  lesion,  which  may,  however,  lK.,.,me  general.  .LTn  he 
crania  cavity  alone  may  Im.  involve.1.  or  the  whole  central  nervouf  s  slem 
as  in  the  case  of  epidemic  cerebrospinal  meningitis  ' 

I  he  cerebral  «.rtex.  of  c-ourse,  suffer..  It  is  onlematous,  the  vessels 
m-  ...ngestecl.  and  there  are  frec.uently  multiple  minute  h^norrhag^ 
he  ves-sel  walls  an<l  the  connec-tive-tissue  septa  are  infiltrated  S 
.  Hainmatory  pr,K  nets.  The  ganglion  c-ells  are  swollen,  vacuolatJl  and 
fa  ...v.  he  «xi.s.cylin,lei^  disintegrate,!.  In  ca.ses  where  the  procTss  has 
ex.en. Ie,l  to  the  ventricles,  the  choroid  plexus  is  «,ngestJd  Sler, 
'«'tl.e.l  in  pus.  and  infiltrate,!  with  inflamma.orv  products  The 
ependyma  and  the  uiulerlying  brain  subs.anc-e  are  aS"  ous  aiul 
M.f  e.„Hl.  .Shou!,!  the  exudate  l,e  excessive,  the  ventric-les  aHis  "enZ 
an.  the  brain  compressed.  The  gyri  are  flattened,  the  Zm^ 
fl.n.1  s  s.,ueezed  out.  and.  as  a  result,  the  meninges,  wiiich  were  dS 
vmiisly  <e<lematous.  now  In-come  drier.  P 

Ay.  rule,  purulent  meningitis  is  fatal,  but  the  milder  and  more  local- 
u  1  forms  are  .sometimes  r«.,vere,l  from.  In  such  cases  the  <nlT  tracts 
en,  „,,,,,,  „^  „  ,^vk.u\u^  of  the  pia-arachiK>i.l  wi  I  -.S 
l,UM.,ns  iH-tween  it  and  the  .liira.  Thi.s  is  due  to  abso  tion  ami 
lu'  or,M,„.a.ion  of  the  exu.late  into  fibrous  tissue,  l^.rulei  t  meninri  is 
K  .n  .n„s,  cases,  a  «>mplication  of  .lisease  elsewhere,  and   n  "  Zmv 

t  ,;■  "^"'"""".•'""'  "r  to  terminal  infection  in  s,„ne  chrome  .lisease 
;:  """  r-T""  ''^■''  l'*"  '•"«""n'"<-oec„s,  an.l  the  H.  ,.,|i  pi.  he 
le..^  n.  role,  less  ,x,mmonly  the  B.  influenzie.  B.  tvphi.'  B.  ,ii„K  er  ^^ 
"•"'liliM.  and  tlieGoiux-.K'cus.  ■  <"|""neria'. 

O..:,.ionally,  cases  crop  up.  either  spora.licaljv  or  in  epidemics,  which 
run  „  ..niewhat  chan.cter.stic  coui^e,  and  c.annot  Ik-  attribute!  to  any 

'  i    ll'"ry  and  Ko«,„berger,  Pmc.  Path.  .Xoc.  of  I'hila.,  February,  KJOS:  .52. 


i^r 


i:il 


i 

I' 


I 


U;     Si 


544 


TffiS:  PIA-ARACHNOID 


of  the  causes  just  mentiotied.  This  variety  is  called  acute  cerebroitpinal 
meningitis,  epidemic  cerebrospinal  meiiingUis,  "spotted  fever,"  and 
cerebrospinal,  fever.  Here  the  Diplucoccus  intracellularis  meninKltiilis 
(Weicliselbaum),  or  the  Pneumococcus,  is  found,  either  alone  or 
asMK-iated  with  other  pyogenic  germs.  At  one  time  it  was  delwted 
which  of  the  two  niicrodrganisms  alMive  mentioned  was  the  specIKo 
caiLse  of  the  disease.  Weichselbaum'  was  the  first  to  recognize  and 
describe  a  diplococcus  in  these  cases,  tending  to  be  intracellular,  which 
he  regardetl  as  specific  and  named  the  DiploocK-cus  intracellularis 
meningitidis.  His  observations  were  afterward  confirmed  by  HeuhneH 
in  Germany,  and  Councilman,  Alallory,  and  Wright'  in  America. 
Netter,*  however,  strongly  maintainetl  that  the  pneumococcus  was  the 
important  agent,  and  held,  though  it  now  seems  on  inconclusive 
evidence,  that  the  Weichselbaum  organism  is  merely  a  degenerate  form 
of  this  germ.  At  the  present  time  the  majority  of  authorities  coiutnle 
the  specificity  of  the  DipliK-occus  intracellularis  for  most  cases.  'I'lie 
agglutination  test  and  the  favorable  results  following  the  theniiteiitio 
use  of  a  specific  serum  (Flexner)  place  the  distinction  Iwtwwn  the 
Imcteria  mentioneil  l»ey<md  ((uestion.  The  relative  fretjuency  of  rhe 
two  microorganisms  in  the  disea.se  is  not  positively  settle*!.  Coniliincd 
infection  seems  to  \te  a  common  event,  and  it  has  been  thought  that 
where  the  pneumoctM-cus  has  been  found  alone  the  DiplcK-occus  intra- 
cellularis may  have  l>een  present  but  have  died  out,  as  its  teiiaciiv  of 
life  is  known  not  to  be  great. 

In  the  form  of  cerebrospinal  meningitis  under  discussion,  the  exudate 
is  abundant  and  found  throughout  the  whole  extent  of  the  centnd  ncrvmis 
system.  At  one  time  the  membranes  of  the  cerebrum  are  chitHv  in- 
volved, at  another,  those  of  the  cord.  .As  a  rule,  the  exudate  ttmls  to 
collect  at  the  base  of  the  brain  and  along  the  posterior  aspect  of  tin-  ( on!. 
The  exudate  is  largely  serous,  but  turbid  from  the  admixture  of  liiiko- 
cytes  and  a  small  ainoimt  of  fibrin.  On  removing  the  skull  cip,  tlie 
veins  of  the  diploe,  and  the  vessels  and  sinuses  of  the  dura  are  conyoiwl. 
The  arachnoid  is  somewhat  turbid  and  the  pinl  vessels  are  injcc'«l. 
The  exudate  is  foinid  chiefly  along  the  course  of  the  vessels,  iind  tills 
up  tiie  cisterns  at  the  base  of  the  brain,  and  may  even  extend  tcp  the 
ventricles,  which  are  often  found  to  lie  <listen<le<l.  The  pus  |>ri"lii(ed 
by  the  DiplociK'cus  pneumonia*  is  somewhat  different,  l)eing  of  ;i  (ri-.imy 
yellowish-g«>cn  color,  more  vi.scid  aixl  rarely  mixed  with  I>I(mmI.  Mi<ri>- 
.scopically,  the  vessels  of  the  cortex  are  congestetl  and  surnniihlid  l).v 
aggregations  of  leukiM-ytes.  There  are  multiple  small  heniorilii::'.  and 
large  an>as  of  necrosis.  It  is  not  uncommon  to  find  lesions  in  oiIh  i-  |)arts 
of  the   lM)dy  as  well  as  in  the   ineinnges.      Arthritis  is  corni'  '  itively 


'  CcImt  cI,  F.tii>lii(tic  dcr  iirulcn  Mcniiigilii  ('crclinwpiriMlis.  Kort^K-tir 
IHH7:Niw.  IH  hikI  lit. 

'  hint.  moil.  Wiich.,  1S!»7. 

'  .liinrn.  Hwton  Soc.  Mfl.  -S-icn..  2-  \X'i7  S-  .">.{. 

'  Hull,  ot  M^'ni.  S*.  Mi'il.  <l.  Mop.  ,1,.  I'nriu,  l.-i:  |N!>H:  4«7. 


'!.■!. 


1.  ;fe     5-Si  1^ 


TUBERCULOSIS 


M5 


runiltia »    'i'i.«.«  »    .      «««rnTO.    A  rare  complication  is  purulent  oeri- 
mat  uue  to  a  frank  Diplococcus  pneumonije  infection  is  marked  nath,*. 

as,s<Kiaie,l  with  JT        •     •  •  •  .  ^''™"'«^  leptomeningitis  is  at  times 
a.ss,KiaM  with  pachymeningitis  interna  proh'ferans 

»«.-.r  l„„"„iZ  skull*  ■  °'  ^'  ''"^'  """'"»  '""'  •I'"  •I"" 


>"■»  irt  and  Martin.  Montreal  Mcil.  Jonr.,  27-  ISOS-  1.5') 
"f  -  "TV  full  cmsideration  of  thi«  di«ea«.,  seo  Osier.   ' 


•"■''"«pinnl  Fever,  Cavendish'r^rur^.'isTO"' 
llopkum  Hospital  BuUetin,  10:  IS99:B6. 


on  the  Etiology  and  Diag- 


I  1 .1  ■ 


l^^-\ 


u 


646 


THE  PIA-ARACHNOID 


Anatomically,  two  forms  may  be  recojjnizecl,  the  diffuse  miliart'  and 
the  solitary  tubercle.  The  Krst  variety  is  due  to  the  diitMeniiiiiition  of 
considerable  numbers  of  the  specific  Imcilli  through  tiie  arterial  systfH). 
It  is  frequently,  but  by  no  means  invariably,  part  an«l  parcel  of  a  systemic 
miliary  tuberculosis.  Diffuse  tuberculous  meningitis,  or  mtiiarv  tiilier- 
culosis  of  the  pia-arachnoid,  is  characterized  l>y  the  fonnation  of  whitish 
or  grayish-white  granules,  the  size  of  a  pin-head  or  smaller,  in  tiit-  |)iu, 
which  tend  to  be  scattered  along  the  ccinrse  of  the  vessels.  'l'li«v  aiv 
usually  mast  numerous  at  the  Imse  of  the  brain,  almut  the  cliiii^i:i,  at 
the  anterior  and  posterior  perforate*!  spaces,  the  circle  of  Willis,  and 
along  the  Sylvian  fissures.  The  process  frequently  spreads  by  the  .'Sylvian 
arteries  and  its  branches  to  the  convexity  of  the  brain.  The  coiiilition 
is  usually  bilateral,  but  it  is  not  uncommon  to  fin<l  one  side  more  iiltected 
than  the  other.  Exceptionally,  one  sitle  only  is  involved.  It  niiiy,  how- 
ever, be  .still  more  restricte<l  in  extent.  We  remember  seeing;  one  cusf 
in  which  there  were  attacks  of  Jacksoniun  epilepsy  due  to  the  prtstiKr 
of  a  cluster  of  a  dozen  or  more  milia  over  a  |M)rtion  of  the  motor  an-a. 
Associated  with  the  efflore-sc-ence  of  tiil)ercle.s  is  a  more  or  less  :iliiiiidant 
exudate  of  a  .serous,  .seropnrulent,  or  fibrinopunilent  appeurancc  which 
accumulates  not  only  in  the  meshes  of  the  pia-arachnoid,  but  iiImi  in 
the  various  lymph-cisterns,  the  ventricles,  and  even  in  the  brain  suhvimre. 
On  removing  the  skull  cap,  the  dura  is  congested  and  w«H>ps  lilood. 
The  pia-arachnoid  is  congested  and  (jnleinatous,  and  along  the  course  of 
the  ve.s.sel  can  be  seen  minute  tuliercles.with  sometimes  j)eteclii;Ll  hcinor- 
rhnsres.  lie  basal  convolutions  are  often  somewhat  compressed.  Tlic 
C(  wollen  and  nwlematoiis.     The  ventricles  contain  ii  variahle 

a  at  of  fluid,  similar  to  the  exudation  elsewhere,  the  choroid  plexus  is 
thickened,  and  the  ependyma  has  a  turbid  granular  apfjeariiiKc.  In- 
ternal hydrocephalus  is  not  an  uncommon  result.  It  may  lie  due  to 
involvement  of  the  ependyma  of  the  ventricles,  or  to  obstruction  of  the 
communicating  pa.s.sage  Ix-tween  the  ventricles  and  the  suliiirachiioid 
space.  In  .some  few  ca.ses  the  amoiuit  of  exudate  may  Ik>  coiisidcrahle, 
without  obvious  tultercles,  but  these  can  usually  he  re<-()giiizcd  l>y  the 
u.se  of  a  hand-lens  or  on  microscopic  investigation.  Oceasionnlly,  the 
granulations  are  the  mo.st  marke<l  feature,  while  the  exudation  i>  ^cantv 
{dry  luherculoux  mriiingillfi). 

The  process  l)egins  by  a  specific  inflammation  of  the  walls  of  llir  -mailer 
arterioles  an«l  capillaries.  Small  collections  of  leukocytes  and  cpiihclioiil 
cells  are  formed  in  the  ve.s.sel  walls,  which  increa.se,  gradnnlly  c\icn<linjr 
into  the  lumina  and  into  the  periva.scular  lymph-spaces.  In  the  first 
stage  there  is  a  proliferation  of  the  endothelial  lining  of  the  lih' 
leading  to  more  or  less  obliteration  of  the  lumina,  but  this 
ma.sked  by  the  exudative  process.  These  changes  at  first  :ni 
to  the  pial  ves.sels  but  cpiickly  extend  to  the  suj)erficial  vc- 
cortex  lying  in  the  fibrous  tral)eculrp,  and  eventually  invjnlr 
substance  (tuhrcuhms  meinngo-cucrphalUls).  This  leads  ii 
and  degeneration  of  the  cortical  ganglia  and  nerve  filnrs. 
ner^'e-trunks  passing  out  from  the  ba.se  of  the  !)rain  may 


ilvcssels, 
(|iiickly 
11)1 1  fined 
.  of  the 
ic  nerve 
-wcilinp 
I  he  main 
-imilarlv 


SYPHILIS 


547 


involved.  The  m. ha  qu.ekly  unde^jo  central  caseation,  thus  becomini. 
more  opaque  Only  a,  extremely  chmnic  ca.ses  d„  the  KmnuKZ 
anv,jons.deral.les,ze  TuIk-Mc  Lacilli  can  be  demonstrft^  whhfn  tie 
lv..,|.h-space.s  und  in  the  Rranulation  tissue 

t..  tulK^le  bacilli  we.  obtSbvTJpllr  "'  ''^'  "^  "'^'^•'' 
should  only  a  few  bacilli  reach  the  n.eninges  through  a  sinde  arterial 
m...  we  get  a  small  cluster  of  tulx.,t.|es,  which,  in  time,  ^le£ ,«  f o™ 
bnr.-  ".Hlular  masses,  varying  in  si2e  from  that  of  a  walnu  t^hlt  of  a  hen^ 
ep:.    Ihese  are  situate*!  in  the  pia-arachnoid  but  tr^lZu  u 

up<.n  the  sul«unce  of  the  brain  o'r  ext^d  rL'S^^'^t:  feuXl 
at  or  n^r  the  motor  area,  or  in  the  part.,  connected  with  X  sZS 
se..,ses,  they  may  rema.n  latent  and  unsuspected  for  a  long  time    'Sch 

«hit    (^seous  detritus      Occasionally,  owing  to  the  infiltration  of  fluid 

-  ,..K.ncally  tumo.  „„d  pro^hic^  Z^^Z,J::^:^S: 
feren.r  with  the  circu!ati.)n  of  the  blcnnl  ,,nd  IvnmT     -n  "        f 

lead  to  the  projhiction  of  fresh  tui;.^:.'    ^     "  7dL,    'Sr""if  t 
mil.  or  to  a  disseminated  ...rebral  miliarv  infe  i  ^     Thfs  ts.  It  k 

form  dm-s  not  differ  from  the  s  nirmm^rv  '^^"•"»?«>P'™".v,  this 

;~;i......n„.,,„,,,.,j,„r::tr:z::;^^ 

in....tecai:r^^^^ 

«ui;:'';:;  i:;;:,;::::::;;:^^^;^;;^"  -'"  ^ann^s.  the  formation  of 

oth.T  iMf.rtio,,"   inZlllll         •;«XHlv;;s.sel.s.     The  gummas  resemble 

Krannhuion  fiZ    t„Sr  S^    '"^      masses  c-omposed  of  a  cellular 
Pm'vss  M.lvam^  IheSs         *' \"r«'y-f"'-'n«l   vessels.      Shoul.l   the 

Um,.H-      r;^;C«nlf '■"•'"''',  "™"*'""  "^  '^""'«'-  fil>"'"s  tissue 
i  Lv  central  necrosis.    The  gummas  are  pmduce^l  first  in 


I 


1 


548 


THE  PIA-ARACHNOID 


if' 

In 


III 


-.     :i 


a  i 


the  subatanw  of  the  pia-arachnoid  but  later  in  ita  rt)rtical  prolongatinn.^, 
and  even  in  the  nerve-substance  proper  {tneningo^ncephalitit  typhililica 
gumviosa).  The  bloodvessels  are  somewhat  peculiarly  involved.  Ail 
the  coats  of  the  vessels  are  infiltrated  with  inflammatory  products, 
which  eventually  give  plape  to  fibrous  transformation.  Ihe  striking 
feature,  however,  is  the  proliferation  of  the  endothelium,  brought  aliout 
by  division  of  its  cells,  followed  by  cellular  infiltration,  which  frequently 
results  in  marked  narrowing  or  even  obliteration  of  the  lumen.  Such  a 
state  of  things  naturally  predisposes  to  thrombosis,  and  this  is  an  impor- 
tant factor  in  producing  occlusion  of  the  vessels.  The  gummas  may  be 
single  or  multiple,  and  are  not  infrequently  localized  to  a  comparatively 
small  district.  It  is,  moreover,  not  uncommon  to  find  definite  large 
masses  or  diffuse  gummatous  infiltration.  Owing  to  growth  by  direct 
extension  or  hy  the  coalescence  of  small,  separate  foci,  nodular  nia.i.ses 
as  large  as  a  walnut  may  be  produced,  which  are  firm  in  texture  and 
on  section  present  yellowish  streaks  and  patches  due  to  degeneration. 
This  form  is  commonly  a.S8(x>iated  with  proliferation  of  fibrou.s  tissue 
forming  dense  bands  about  the  gumma,  and  nften  leading  to  adhesion 
with  the  >verlying  dura.  In  progre.s.sive  cases  this  fibrous  tissue  in  its 
turn  undergoes  necrosis.  I'he  cerebral  sulwtance,  as  one  would  e.\[)ect, 
manifest*)  marked  change.  Advancing  gummas  lead  to  compres-sion  and 
destruction  of  the  nervous  tissue,  while,  owing  to  the  vascular  changes, 
ischemic  necrosis  and  hemorrhages  are  not  uncommon. 

Aftinoi&jrCOlil. — So  far  as  is  known,  actinomynxsis  i.s  always  second- 
ary, arising  by  extension  from  the  fac-e  and  nasopharynx,  or  by  metas- 
tasis. The  meningitis  produced  is  either  localized  or  diffuse,  und  is 
accompanied  by  a  serous  or  fibrinous  exudate,  in  which  the  ".sulphur 
grains"  of  the  actinomyces  may  In*  di.scovered,  and  adhesion  of  the 
membranes.  There  seems  to  be  in  these  cases  a  tendency  to  iiivade  the 
walb  of  the  veins  and  sinuses. 


PBOaRZSSIVE  MBTAMOS^  iOSES. 


TlU&on. — These  are  chiefly  of  the  connective-tissue  type, 
found  not  only  in  the  external  pia-arachnoid,  but  also  in  the  telle  i- 
and  the  lining  membrane  of  the  ventricles. 

The  benign  forms,  fibroma,  lipoma,  myxoma,  chondroma,  and 
are  rare.  They  form  small,  no<lular  or  lobulate<l  mii,s.ses  wh 
press  the  adjacent  brain  sulxstance.  A  cystic  Ijrmphangioma 
been  described. 

A  peculiar  growth,  the  exact  nature  of  which  is  somewhat  n 
the  eholeitoatoma  (Perlgeschwulst).      This  is  found  espc(  i^' 
meninges  at  the  ba.se  of  the  brain,  aliout  the  anterior  or  posit 
verse  fissures,  and,  occasionally,  in  the  substance  of  the  brain. 
a  solitary  tumor  enclo.sed  in  a  fibrous  capside,  or  else  multiple  f  i^ 
in  the  pia  or  brain.     On  section,  it  is  .soft,  of  shining  white  ii) 
with  a  silky  sheen.     Microscopically,  it  is  compose*]  largely 


:iii(!  lire 

I  st«om*, 
i.  Ii  com- 
'iiis  also 


riire,  IS 
in  the 
'■  Iraii.s- 
1  forms 
iiodnles 
■;iranoP, 
'  craiin- 


ENDOTHELIOMA 


649 


.whI  celb  resembling  the  horny  epithelium  of  the  skin.  Most  authoritie. 
«t.m  to  think  that  .t  »  endotheLl  in  origin,  but  Ziegler  hoCha  U 
mo.^  probab  y  anses  from  the  external  germinal  la^er  or  mispUced 

Omnold  Ojrrti.-Dermoid  cysts  are  found  in  the  meninges,  but  are 

Not  uncommonly  multiple  cyrts  containing  watery  or  colloid  material 
are  met  with  m  the  choroid  plexus.  "«wrmi 

iBdothsUoiiu  -The  most  imp«,rtant  of  the  malignant  growths  found 
.n  the  piawirachnoid  is  the  endothelioma,  a  tumor  of  somfwhat  variable 
structure,  originating  in  the  endothelial  cells  lining  the  bloodvessels  and 
lymphati^  or  those  covering  the  arachnoid  and  lining  the  subarachnoid 
|pace.     Certain  o    these  growths  develop  art,und  vLels.  presumbj 

i^t-Tl?  ''IT  u  !*!".  P^"^'«<=»'"  lymphatic,  Ihe  soTlled 
P«rttt.Uomu,  though  It  should  l^  remarked  that  it'^is  not  always  easy  or 
p(Ks.ble  to  decide  whether  growths  presenting  this  particular  appearand 
onginate  in  the  advent.tia  (perithelium)  of  the  bloodvessels  oVTIh^ 
IminK  endothelium  of  the  perivascular  lymphatics.*  No  doubt  he 
majontvo   tumors  arising  in  the  pia  arachnoid  are  endotheliomas. 

Endotheliomas  form  circumscribed  or  diffuse,  superficial,  flattened 
masses,  of  firm  consistence,  an<l  of  grayish  or  grayish-iS  color  Sr^l? 
hey  are  melanotic.  In  general,  they  resemble  the  sa««mas,  alSh 
m  pla(-e.s  they  may  present  a  somewhat  carcinomatous  appearand 
\he«.  the  connection  with  the  lymphatics  or  bloodvessels  ca^'^KraS' 
Je  o,.r  ceils  competing  the  tumor  are  flattened  or  spindle-shTS' 
n^einhling  endothelial  celLs.  but  in  the  newer,  more  rapidly  gSg 
pails,  the  cells  lose  this  character  and  come  to  resemble  clLl/the  3 
mo^p  ous  cell,  of  certain  careinomas.  Solid  strands  or  mass^es  of  S 
cells  in  a  connective-tiasue  stroma  often  give  the  tumor  an  alveolar 
appearance  Not  infrequently  the  cells  are  laid  down  more  ohSs 
a^ncentncally  m  ayers,  after  the  fashion  of  whorb.  B«idL  th^ 
«K^.,hel.oma,  „rc„.„ry  types  of  sareoma  are  met  with,  m^J^ 
ujiowcoma,  «.giomyxo«««nu.    It  is  not  uncommon  to  SdTX 


'  A  « 
tenn  |h 
sonic  III 
the  iiini 
bliKxhi 
the  ril:, 
applii'ij 
speiikirii 
rtratf  il 
Sucli  :. 
"erhap 
Many  , 

thf   lil:, 

or.',,. 


H^  Jl  ,!,n  ""^''f""""""  "'"'  «""<'''""  "oy  not  be  out  of  place  here.  The 
nthrlioma.  n.ean.nR  a  tumor  derived  from  perithelium,  came  into  voRue 

1  ;"  T'^T-  ''  """  ""''"•^  '°  »  '^""'  °f  »  "Pecial  histological  tX 
:  t"!  ""l"^  ;»'t''"'"^""^  "'  ''"  "-'.v-formedTumor  cells  abou  the 
r  h  r^  '  '"''"""•  "■'"""*•  «"  ■"»'"'  »  -"mewhat  crude  comparison 
»H.nsh,p  of  th,.  ,,K.ke8  to  the  hub  of  a  wheel.  The  won!  later  cam^to  1^ 
I"  'n..ny  ,,uarte™  to  any  t.unor  haN  ing  this  peculiar  arrangement.  Strictly 
.  U  o,.  we  should  U.„„  ,;  .urnor  a  perithc'ion.a,  we  should  te  able  to  doS 

,  Ivn  i.        f  >;"'ng  membrane  tumor,  but  is  really  a  fom.  of  sarcoma. 

.Z..r.  ■  ""■  '"■'  ''""  ■•""'ri"™"-'""'"  would  be  preferable. 

'  'lfsT,f  h;i?'*'"'.''T'"u''  *'■'''  ■^""•^  ""angement  originate  f«,m 
^-.I^;;- e„i„:h':;:mr'"'  b-.nphat.cs  and  sh„u.d  be  called  .'perivascular" 


i  I 


i 


I  4 


I 


3  r 


1      I. 


li   t! 


tBO 


rfffc'  PIA-AHACHSOID 


choroul  pl«xua  small  granuliir  coiicrptioiLi,  the  <«o-called  "sand  ImnIh'<i." 
On  (Kt-aHion,  they  are  fouiMl  in  cotix'i  IfraMi*  numbem  in  tumors,  notalilv 
eiMlothrliomss  himI  surtuniRS,  Kivitig  th«'in  a  hani,  ^rittv  ohariictpr 
(pnaUMOM,  pMinimtMBOiin).  lliey  vary  in  sizt*  and  shape,  \»'\ug 
laminated,  riHindttl,  im^lar,  or  spinrMis. 

Otitl— BIM  — Carciiinmas  are  found  in  the  veiitrieles  and  ^iifrilly 
arise  fn>m  the  chori>i<l  plexus  or  from  the  epitlieh'al  layer,  more  nn. ' 
from  the  ependyma.  i'hey  fonn  soft  urowths  r()iri|>oHed  of  a  filirmii 
stroma  in  which  are  nests  of  e|>itheliid  rells .  f  cylindriral  type.  In  sume 
cases  the  stroma  is  va.<teulur  and  proliferates,  );tviiif(  to  the  tumor  a 
papillary  appearanee.    The  stroma  often  undergoes  mucinous  <lc>r<  ii- 


Via.  183 


KniJ»ilii'lii>in«  (piiammonia),     WinokrI  obj.  Nn.  .1,  without  ocul  ir.     (I  rum  tli"  <    INtinn 

o{  A.  U.  ^ic'llllU^<.) 


i   '. 


"1   :!-■■ 


eration,  so  tiiut  the  growth  presents  a  {M-ciiiiar  appearance, 
to  the  ac-cumiilation  of  the  mucin,  the  papiihe  are  not  iiifn 
converted  into  cysts.  These  are  liounded  l)y  epithelial-cell  ma>^<  - 
in  iinu'  may  form  a  new  fihn>us  stroma  sometimes  containing;  i<! 
not  uidike  the  "j)earls"  so  commonly  foimd  in  cutaneo'is  epiili< 
The  neoplasm  usually  remains  l(K>alize<l  to  the  ventricle,  pHnlii 
effects  maiidy  hy  pressure,  hut  occasionally  .secondarj-  nodules  an' 
within  the  brain  substance. 

Parasites. — Among  the  animal  parasites  may  be  menlimi 
Echinocorciui  aiitl  the  Cyntlrfrcim.  The  echinococcus  leads  to  iIh- 
tion  of  single  or  multiple  cysts  which  press  upon  lln-  brain  sul)>i  n 
result  in  its  degeneration.    The  cysticercus  is  met  with  ii  .    l:. 


( )winp 
i|iu'iiily 
,  which 

1-lll'Sl.S, 

li:iiiias. 
■iiii;  its 
rurmed 

,■,1  the 
foriHii- 
(cand 
in  the 


(EDBMA 


651 


f..rn.  of  .small  cy»t  with  a  scolex.  or  u  the  «m»II«1  cvMicereus  ««- 
masuH  llrre.  there  are  large,  bbukted.  and  generally  ..erile  vy^ 
pn^n  .ng  .ntemally  and  externally  grape-like  mw.^  of  m^ondaiJ  S 

:  1 '^ '^"^i'-  i"  K*  ""ghborfKxJ  co«nective-ti.«ue  pn.UfeS  u 
to  l<e  observed.    Such  cysts  may  become  calcified. 


m  oiBUBUM  AMD  onmuim. 

OntOULATOIT  dutubbaxoii. 

;n.e  amount  of  bloo.1  present  in  the  brain  and  its  membrane,  varies 
w..l.;lv  even  under  normu   c-ondition.,   being  dependent  on  incmJl  w 

Hyp6rwni«.-ActiT.  HypM.»l..-Active  hyperemia  occurs  patho- 
k'..ally  m  exces.„ve  action  of  the  heart  an.l  wUever  arterial  tS 
.s . hmuHshed  t  may  be  general  or  local.  Dilatation  of  th^arteS 
wul.  .ncrea.s«l  blood  supply  „,uy  be  due  to  drugs,  ,uch  hs  amyl  nhritT 
nitn)j;lycenn,  and  alcohol,  or  to  sunstroke.  ^  ' 

-.'Tlr  ■^'•«^~^*«-"«'*-^  hyperemia  of  the  brain  and  its  membranes 
H.  of  o  her  organs,  is  commonly  due  to  obstruction  to  the  free  outflow  of 
W..i  fn.,n  the  p„rt^  This  is  met  with  in  chronic  carE  ai^d  pul 
monary  .liseases  and  m  the  paresis  of  the  c-erebral  ves.sels,  which  results 
m„.  ...creased  intracranial  p,««ure.  The  condition  is  f^und  inTeath 
M.ff.H„t.onan.l  in  those  .lying  in  the  status  epilepticus.  Wl 
ims  ve  «,„ges(,„„  ,3  due  to  thn.mbosis  or  the  pres.sure  of  Tumour 
exudutes  u,K,n  the  efferent  veins  a..d  sinuses,  or,  4»in."n  s^ me  c^"  Z 
the-  r..,..„„lH.„t  position.     Owing  ,0  the  deliWv  o^he  m;,"^  a^'lh^ 

r^a  liK  ,let«ted  there  post  mortem  thun  in  the  ca.se  of  thVbrain.     In  the 

s;;:::^b^:fttrr;r^  "—'""'•  -'  -^^^^  ^ 

Anemia.  -^Anen.ia  of  the  brain  is  .lue  to  general  systemic  anemi«  or 

-v  ...use  which  interferes  with  the  p„,per  fupp™  o? S3  to   he  LT 

t:      I     \  '^P"'"?  ."^  '^^  vessels,  cardiac  lV«knes.s.^rtie  dS' 

rr;!'.;    "7k'"'  PT"""' «•"  f~n'  •••xu^late  into  the  sub^raXoTd 

'p    ;    r  TLh'""""'"'^''  ^^■'^"'P'  -"""<-"l'>n.rn,  tumor.,  all  pC 

1       ,       ■:         "',''*''•/•«•''♦'•'' «»""'«  •»«>•  l^  collateral,  due  to  an  excessive 

i,    '  ,,  * '"  '^  "^" .'"  •'•*■  *•«■''«  o^  «"  o"'inary  "faint."    LocaVanemia 

eXn.'ii:::::;:^  rp^s:;r '""^  •^'^''-'''•"  -^  ^^^  «^--'  -  ^- 

-^tlZ'u'^,^^^^^  particularly  changes  in  the  vessel 

is  m., ,  .1     "' ""'^•n»  "V.he  brain  in  cases  where  the  outpoured  plasma 
«  not  ,,„.,„p,|y  removed  by  the  lymph^^hannels.     On  secln^he  Sn 


MKROCOrv   RBOIUTION   TBT  CHART 

(ANSI  Old  ISO  TEST  CHART  No.  2) 


1.0 

■  )0 

y. 

y. 

tli 

»33 

■  2.2 

tii 

tii. 

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JjL 

Us 
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1 

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11.8 

A 


/APPLIED  \MA3E    Inc 

16i3   East    Mom    Sfeet 

Rochtstar.    Umm    York         14609        USA 

(7'6)   *«?  -  OWO  -  Phon« 

C?16)   288      5989  -  Fo« 


,1 


11 


i  = 


552 


THE  BRAIN 


is  pale,  moist,  and  shiny.  The  condition  is  brought  about  by  heart 
weakness,  obstruction  to  the  general  circulation,  thrombosis  of  the  sinuses 
of  the  dura.  Local  oedema  is  also  found  in  the  neighborhood  of  hemor- 
rhagic exudates,  tumors,  and  thrombosed  veins.  Toxic  causes,  too, 
sometimes  play  a  part,  as  in  chronic  nephritis.  (Edema  is  a  frequent 
accompaniment  of  inflammation  of  the  brain  and  meninges. 

As  a  result  of  acute  inflammation  and  passive  congestion,  it  is  not  un- 
common to  find  a  transudation  of  fluid  into  the  ventricles  {hydrops 
ventriculorum;  hydrocephalus  internus),  which  leads  to  dilatation  of  the 
ventricles  and  compression  of  the  brain. 

Microscopically,  the  glia  is  looser  and  more  reticular,  and  the  lym- 
phatic channels  are  distended  with  fluid. 

Hemorrhage. — Cerebral  hemorrhage  is  of  comparatively  frequent 
occurrence,  as  compared  with  hemorrhage  into  other  organs.  This  is 
probably  due  to  the  facts  that  (1)  the  vessels  of  the  brain  possess  scanty 
anastomoses;  (2)  they  are  given  off  from  vessels  of  much  larger  calil)er 
than  themselves,  and  are  therefore  under  higher  pressure;  (3)  the 
muscular  coat  of  the  cerebral  arterioles  is  very  slight,  so  that  tliev 
can  offer  only  a  weak  resistance  to  a  dilating  force;  and  (4)  the  brain 
substance  offers  less  support. 

Two  factors  are  chiefly  concerned  in  its  causation,  degeneration  of 
the  walls  of  the  bloodvessels,  and  increased  blood  pressure.  It  may 
take  the  form  of  hemorrhage  per  rhexin  or  per  diapedesin.  Rupture 
of  vessels  is  most  likely  to  occur  in  infancy,  owing  to  inherited  disease 
of  the  vessels,  and  after  middle  life,  when  the  vessels  are  apt  to  he 
sclerosed.  Another  potent  cause,  traumatism,  may,  of  course,  wciir  at 
any  age. 

Small  capillary  hemmrhac/es  are  met  \»ith  in  congestive  hyperemia 
and  acute  encephalitis,  as  well  as  in  certain  of  the  infective  diseases,  such 
as  malaria,  variola,  anthrax,  and  the  hemorrhagic  diatheses.  In  some 
of  the  cases  the  extravasation  of  Uoml  is  brought  about  by  fatty  de- 
generation of  the  vessel  walls  or  by  the  obstructive  and  necrotizing  aVtion 
of  bacterial  emboli,  or  even  the  blockage  of  vessels  by  simpic  emboli  of 
broken-dow  .  tissue  or  blcxKl  cells.  In  such  cases  the  hemorrha^'cs  are 
scattered  along  the  vessels.  They  vary  in  size  from  that  of  a  n)ill(  t  seed 
to  a  pea,  and  are  present  both  in  the  brain  substance  and  in  the  coitical 
prolongations  of  the  pia.  When  in  the  latter  situation,  the  hemoirlia^'es 
have  been  regarded,  but  incorrectly  so,  as  dissecting  aneurisin  ()1>- 
struction  of  vessels  by  sclerosis  may  also  lead  to  lieniorrhages.  naliv 
of  small  extent.  Hemorrhages  are  also  due  to  congestion  l>i(iiij;ht 
about  by  the  pressure  of  tumors  or  exudates,  and  to  trauma  of  \:irious 
kinds. 

Of  more  importanc-  is  sponiancous  hemorrhage  which  is  caii-rd  bv 
rupture  of  an  artery.  In  such  cases  there  is  almost  invariably  a<!  iiifcd 
degeneration  of  the  vessel  walls  caused  by  sclerosis,  calcificiii  n,  or 
inflammation.  In  the  common  condition  of  arterial  .sclerosis  tin  'rsions 
may  be  fairly  generalized,  but  in  not  a  few  cases  some  particular  'an  is 
specially  picked  out,  such  as  the  brain,  heart,  or  kidnev.     Silero      !)eing 


HEMORRHAGE 


553 


primanly  a  degenerative  process  leads  to  weakening  of  the  vessel  walls 
Ihe  proliferative  changes  in  the  intima  result  in  more  or  less  obstruction 
in  the  lumen  which  may  indeed  be  complete,  and  this  in  its  turn  con- 
tributes to  the  dilatation  of  the  other  parts  of  the  vessel.  Miliary 
aneurisms  are  therefore  rather  common,  being  present,  it  is  said,  in 
one-third  to  one-half  the  cases.  Rupture  of  the  vessel  is  precipitated  by 
increased  arterial  tension,  such  as  may  be  caused  by  excitement,  worry 
mental  or  physical  overwork— in  fact,  any  condition  which  puts  sudden 
strain  on  the  vessel.  "^ 

The  most  frequent  site  for  this  form  of  hemorrhage  is  in  the  basal 
ganglia.    One  of  the  penetrating  branches  of  the  Sylvian  artery,  usually 
the  lenticulostriate,  is  the  vessel  at  fault.    Less  commonly,  the  hemor- 
rhage takes  place  into  the  pons,  the  peduncles,  the  cerebellum,  the  white 
matter  and   m(^t  rarely,  into  the  convexity.    This  distribution  is  ac- 
counted for  by  the  fact  that  the  blood  pressure  is  greater  in  the  Sylvian 
artery  and  its  branches,  the  latter  coming  directly  off,  and  that  arterio- 
sclerosis IS  ^ually  commoner  and  more  extensive  about  the  base  of 
the  brain.    The  effects  produced  depend  on  the  extent  of  the  extrava- 
sation.    Minute  hemorrhages  lead  simply  to  pressure  upon  and  dis- 
location of  the  adjacent  brain  substance  without  much  further  disturb- 
ance, and  may  be  absorbed,  leaving  little  or  no  trace,  although  the 
clmical  symptoms  may  be  ,<.triking,  if  temporary.    When  laree  vessels 
giv^  way,  extravasations  varying  in  size  fr«m  that  of  a  pea  to  that  of  a 
walnut,  or  larger,  take  place,  leading  to  destruction  of  the  brain  tissue 
in  the  neighborhood  and  pressure  on  the  peripheral  parts.    In  the  most 
extreme  ca^es   the  whole  of  the  corpus  striatum  on  one  side  may  be 
torn  up  and  the  blood  may  dissect  its  way  through  the  white  substance 
and  <iestroy  the  greater  part  of  the  posterior  lobe,  or  the  blood  may  even 
hn.l  m  way  into  the  ventricle  or  into  the  meninges.    In  such  cases  the 
convolutions  are  compressed  and  the  lirain  substance  id  other  parts  is 
anemic.  f-,^  ,a 

In  the  early  stages  one  sees  in  the  affected  ar*a  a  variable  quantity 
of  .ark,  soft,  semifluid,  or  granulated  blood,  mixed  with  detritus  from  the 
des  roved  tissue  In  the  neighboring  brain  substance  ar«  numerous 
petechia  hemorrhages,  the  result  of  the  sudden  disturbance  of  the  vascu- 
lar eriuilibnum.    Later,  the  fibrin  separates  more  completely  and  the 

Z'."i!,Vr  — ''[''"u'*'"°^'^  ^y  '^^  lymphatics,  so  that  the  pressure 
up<m  tl  e  brain  is  to  that  extent  at  least  relieved.  The  clot  gradually 
c.  >,tn.e..s.  l,ecomes  more  granular,  and  chariges  from  a  ml  to  a  brownish 
ef.r,  owing  to  the  transformation  of  the  hemoglobin  into  hematoidin. 
1!  -■  i.ijiment  IS  gradually  diffused  into  the  neighboring  tissues,  imparting 
■■n  a  yellowish  tinge.  In  time,  the  greater  part%f  the  fibrin,  cor- 
I'l'xlo,  pigment,  and  detritus  is  transformed  and  absorbed,  so  that 
a  eavi.v  remains  containing  a  clear  or  slightly  tinged  fluid  (degenerative 
or  ai..>lectic  cyst)     Sometimes,  however,  the  tissues  collapse  to  fill  up 

.  .Nh.iency   and  in  such  cases  there  is  compensatory  enlargement 

not  ;:.!?"''•'■'  I'u'^J^^  ""l-^"™'  'P"^*"-     ^^li^"  t»>e  extravasation  is 
not  tn„  extensive  the  damage  is  made  good  by  the  formation  of  a  fibrous 


■I 


*    ..,   i  f-i 


■:    = 


B 


I 


;t. 


'.I 
^1 


554 


THE  BRAIN 


scar,  either  quite  firm,  or  enclosiii)^  the  remains  of  the  destroyed  tissue, 
together  with  pigment  and  cholesterin  crystals.  Old  cysts  eventuailv 
become  walled  in  by  fibn)us  tissue  derivetl,  it  is  believed,  from  the  pri>- 
liferation  of  the  adventitia  of  the  vessels.  We  thus  get  a  closed,  smooth, 
fibrous  sac,  more  or  less  pigmented,  containing  either  clear  fluid  or 
fluid  with  granules  of  hemosiderin,  crystals  and  amorphous  masses  of 
hematoidin.  As  a  secondary  result,  we  find  degeneration  and  atrophy 
of  the  neuraxones  belonging  to  the  affected  area. 

Encephalomalacia. — The  arteries  of  the  brain  come  largely  under 
the  category  of  "end"  arteries.  Consequently,  obstruction  of  their 
lumina,  if  at  all  marked,  is  followed  by  most  serious  results.  These 
consist  in  a  peculiar  form  of  infarct— necrosis  and  softening  (encephalo- 
malacia)— in  certain  vascular  districts,  accompanied  by  more  or  less  inter- 
ference of  function,  and  followed  often  by  death.  The  occli  sion  of  the 
vessels  is  commonly  brought  alwut  by  thrombosis  or  embolism.  Arterio- 
sclerosis, in  the  form  of  proliferating  endarteritis,  may  also  cause  it,  and 
in  any  event  would  predispose  to  the  conditions  just  mentioned.  The 
causes  of  embolism  and  thrombosis  are  the  same  here  as  elsewhere, 
Emboli  are  usually  vegetations  from  diseased  valves  of  the  heart,  di-;- 
lodge<l  portions  of  intracardiac,  venous,  or  arterial  thrombi,  disintegrating 
tissue,  or  microorganisms.  Thrombi  are  found  in  certain  infectious 
diseases,  marasmus,  or  form  in  diseased  vessels  or  upon  emboli. 

Emlwli  generally  reach  the  brain  by  the  most  direct  path.  Usually, 
ii  is  the  Sylvian  artery  or  one  of  its  branches  that  is  involved,  lea*  cnrii- 
monly,  the  anterior  cerebral,  and  less  commonly  still,  the  posterior 
cerebral.  The  left  side  of  the  brain  is  affected  slightly  more  often  than 
the  right. 

Arteriosclerosis,  when  present,  is  most  marked  in  the  circle  of  Willis 
and  the  Sylvian  arteries.  In  advanced  cases,  all  the  arterioles  of  tiie 
cortex  may  Ix-  involved  and  l(X)k  like  small,  white  threads  upon  the  pia. 
The  sdemsis  is  commonly  of  the  nodose  variety.  When  the  blood  siipidy 
of  the  brain  is  gradually  cut  off,  as  in  a  slowly  progressive  arteriosclerosis, 
we  get  simple  atrophy  of  the  brain  tissue,  with,  in  time,  a  tendem  v  to 
fibn>si.s.  This  is  well  seen  in  agwl  people.  The  more  frequent  e\  ciit  of 
sud<len  anemia,  brought  aliout  by  emlwlism  or  thrombosis,  or  tiir  cir- 
culatory disturbances  in  the  neighborhood  of  inflammatory  foci,  pn«liK('S 
local  softening  with  rapid  disintegration  of  the  brain  sulwtance. 

I'he  older  anatomists  used  to  speak  of  three  kinds  of  cerebral  siltcn- 
ing— white,  red,  and  yellow.  It  should  lie  remarket!  that  these  icriiis 
refer  projjerly  not  to  distinct  pathological  pn)cesses,  but  rather  to  -|ii(  ial 
|)efuliarities  or  different  stages  of  the  one  affection.  In  white  soIk  ning 
there  is  a  pure  anemic  necrosis,  the  tissues  Ix-ing  absolutely  cut  oil  from 
the  circulation.  In  re<l  softening,  hemorrhage  takes  place  int.  ' 
necrosed  area,  either  by  regurgitation  or  by  rupture  of  neij;lili 
vessels.  Later,  when  fatty  (legenerafion  of  the  cells  occurs,  will 
formation  of  the  blowl  and  lil)erated  blood  pigment,  we  have  the  m 
yellow  softening. 

In  the  early  stage.      tensive  softening  of  the  cerebral  substai   •  may 


the 
...ring 
;  raiis- 
.nlied 


ENCEPHALITIS  555 

Ix-  present  with  but  few  visible  signs.  The  affected  district  is  sometimes 
a  httle  c^lematous  or  turbid,  but  not  infrequently  it  do^  noTdiffe 
materially  from  the  healthy  tissue.  On  palpation,  however,  the  part  is 
fouMd  to  be  softer  than  normal  and  pulpy.*^  The  other  regions  of  the 
brum  often  show  shght  hyperemia.  In  more  advancJ  cLes  the 
softened  area  may  be  o  a  reddish  or  yellowish  color,  as  above  men'bned 
an,  .s  of  a  pulpy,  semd.qu.d  consistence.  In  some  cases  there  may  ^' 
muluple  small  foci  of  softening  in  close  juxtaposition,  givinrthTpart 
a  cribriform  appearance  (ftat  cribl^).  In  other  cases  thf  desfructloK 
tissue  s  complete  leading  to  the  formation  of  cystic  cavities  co.Sni 
fluid,  fatty  granules,  and  detritus  (one  form  of  poren^Ty  S 
mfrequent ly.  however,  the  cavity  resembles  a  spolJge.  being  tmve.^ 
by  small  bloodvessels  and  fine  strands  of  glial  tissue  iraversea 

Microscopically,  in  the  degenerated  area  we  see  what  has  been  termed 
var-cse    atrophy  of  the  protoplasmic  pn,cesses  of  the  speciScTr^ 
Cjells  and  chromatophihc  changes  in  the  ganglia,  while  the  neui^g lia  is 
d.su.tegrate<l,  presenting  numen^us  pigmented  cells.  dn,plets  ofTat  and 
myel.ii,  leukocytes,  and  corpora  amylacea 
In  murse  of  time  the  detritus  is.  to  some  extent,  absorbed,  the  fluid 
m.l,y  becoming  thinner  and  clearer,  and  there  is  an  attempt  atcicaS 
zat.,.n.     In  young  persons  and  those  with  healthy  vessels,  pmvidS  Sat 
the  lesion  ,s  small,  there  is  a  slight  amount  of  pmliferation  of  the  S 
alK,Mt  the  softened  area,  leading  to  imlumtion.     fn  Ziv  cases  however 

zone  Whei  Jic  <-.s  I,p«  near  the  surface  of  the  brain,  the  suoerficial 
bouM.larv  00  lapses,  leaving  a  .lepression  in  communi;!,,  S  the 
iXf  Th'^T'  "Y"'?  ''^  """'  "■'■•''  «'"'l  ("^""'her  form  of  p^r^n! 

The  clinical  symptoms  pnKluce.1  by  encephalomalacia  dei,end  upon 
the  localization  and  extent  of  the  lesion.  In  slowlv  developi  reuses  of 
w.e  extent,  there  is  apt  to  1.  gradual  .legra.laUon  o  Z  inXt 
M  ng  even  to  dementia.  In  the  sudden  local  lesions  we  ge  vSus 
mo  ..r  .  r  sensory  phenomena.  A  lesion  in  the  internal  caosule  wSl 
hul  ,0  hemiplegia  on  the  opposite  side;  one  in  th^  ortTcaEoV  ar^a 
cfnis  s  „,„„r  paralysis  of  the  corres,H.n,hng  muscles  Whei The  thiS 
j-ft  frontal  convolution  is  involve.!  Inotor  aphasia  results      Lesions  b 

a^.onn,:;:J:r;in^:ii'o^,:rstiS^;;:?^ 

INFLAMMATIONS. 

Encephaliti8.-Inflammation  of   the   brain  is  terme,!   encephalitis 
Be  ....  entering  on  the  discussion  of  this  subject  it  should  iTob  en S 

are  or  an  inflammatory  nature  or  not.    The  nervous  tissue  is 


n 


1   • 


u 


n  .'. 


55G 


r/ZA'  JJ«i4/Ar 


the  most  delicate  and  hijjhly  specializetl  in  the  body,  consequentlv,  it 
is  comparatively  easily  put  out  of  gear,  and,  further,  iu  repanitive 
powers  are  slight.    Extensive  lesions  may   be  produced   by  trifling 
causes,  are  often  quickly  induced,  and  are  followed  by  far-reaching 
results.    Many  conditions,  such  as  einlwlic  ii.f-^tion,  abscess,  traumat- 
ism, and  tul)erculosis,  are  frankly  inflammatory  and  present  no  special 
difficulty.    There  are  others,  however,  which  are  somewhat  similar 
in  ap{)earance,  due  to  intoxication  with  alcohol,  bacterial  or  miiural 
poisons,  to  sunstroke  and  concussion  of  the  brain,  that  are  not  (iiiite 
so  dear.    The  most  obscure  of  all  are  thosv.'  chn,  .  ic  c-onditions,  of  which 
disseminated  sclerosis,  system  degenerations,  Huntingdon's  chorea,  and 
general  paialysis  of  the  insane  may  be  cite<l  as  examples.     Some  of 
these  appear  to  be  depentlent  on  circulating  toxins,  and  are,  therefore, 
possibly  inflammatory  or  <legenerative,  while  others  are  more  probably 
manifestations  of  develop  .lental  defects.    The  difficulty  arises  from 
the  fact  that  degeneration  and  disintegration  of  the  specific  nerve  ele- 
ments are  common  to  all  these  affections  and  are  followed  by  insidious 
regeneration  of  glial  elements.     It  is  obviously,  therefore,  imjwssible, 
in  the  present  state  of  our  knowletlge,  to  make  a  satisfactory  classification. 
Any  that  we  ailopt  must  be  based  mainly  on  clinical  grounds  and  on 
convenience. 

Seyenil  forms  of  encephalitis  can  be  differentiated  according  to  their 
localization.  In  the  majority  of  ca.scs  the  cortex  and  peripheral  jx)rtion.s 
of  the  cerebrum  and  cerebellum  art  involved,  less  frequently  ilie  l)iisal 
ganglia.  In  nniny  instances  cortical  encephalitis  is  associate<l  with 
meningitis  (meningo-eneepluUtia).  When  the  gray  matter  is  chieflv 
involved  we  speak  of  poliencaplulitis.  The  medulla  may  be  atTtded 
(bulbomyelltis),  or  both  brain  and  coni  (encephalomyelitis). 

Encephalitis  may  l)e  hematogenic,  traumatic,  or  the  result  of  the 
extension  of  inflanmiation  from  contiguous  parts,  as  the  meninges  and 
cranial  Iwnes.  According  to  the  kind  of  exudation,  it  is  simple  or  sup- 
purative. 

Acute  Encephalitis.— Acute  encephalitis  of  hematogenic  origin  occurs 
as  a  complication  of  certain  infective  processes,  chief  among  wlii.h  are 
acute  endocarditis,  septicetnia,  cerebrospinal  m°ningitis.  More  nirely, 
it  has  l)een  ttiet  with  in  typhoid  fever,  acute  rheumatism,  S(:ii!;itiim, 
influenza,  ulcerative  pulmonary  tiiVrculosis.  and  rabies.  The  coii.lition 
mav  lie  due  to  the  sfiecific  germ  producing  the  primary  disease.  I.iit  is 
not  infrequently  brought  about  also  by  secondary  infection. 

The  lesions  are  most  commoidy  met  with  in  the  cerebral  coii  \.  but 
any  part  of  the  brain  may  l)e  involved.  In  the  more  strictly  I  .^  ilizeo 
form,  the  gray  matter  in  the  fl(M)r  of  the  third  ventricle  and  a  I  it  the 
aqueduct  of  Sylvius  is  often  involve<l  (superior  poliencephnlilis  ;  that 
m  the  neiglilmrhood  of  the  fourth  ventricle  (inferior  pollena  ■  I'Hisl 
The  cerel)ellum  is  rarely  involved.  The  foci  of  inflamniatioi'  av  be 
single,  midtiple,  or  evenly  scattered  throughout  the  brain. 

The  smaller  arras  of  inflammation  are  often  invisible  to  r  aiiwi 
eye  and  may  only  be  discovered  accidentally  on  making  a  in        copic 


TRAUMATIC  ENCEPHALITIS  557 

examination.  larger  ones  appar  as  tuniid  patches  of  a  diffuse  reddish 
c.lor  an.l  may  pm^nt  small  hemorrhages.  In  suppurative  casS  the 
fo,.  are  yellowsUhite  in  c^lor.  with  sofTor  liquefi£j  centre'  ' 

Microscopically,  the  vessels  are  congested,  surrounded  bv  inflammn 
tory  leukocytes,  and  here  and  there  may  be  small  extmrati^n  of  bZcT 
1  he  nerve  elements  are  softene<l  and  degener«te<l.  The  Ranglion  ceHsTre 
also  degenerate,!,  and  may  disappear.  I'he  axi.s-cvli„de^r«  swdl  u^ 
bec.,.me  nodose  and  disintegrate,  while  the  niveli,;  sheaths  are  c^^: 
verted  into  small  droplets.    The  glia  shows  also  ^trogre.ssive  chaL? 

^  ru  ZJ^  "  ^?'^''"?  '•*  ^"'^'  '^^  destroys  cells  are  to  some 
extent  absorbed  and  at  the  periphery  of  the  affected  area  there  is 
proliferation  of  the  gha.  Small  foci  may  heal  «,mpletelv,  andTven 
larger  on«  if  the  patient  survive,  with  the  fonnation  of  k  ""ie^I^ 
area  or  a  fibrous  scar.  't-ruseu 

H„eT^',h"''T"'%""-'"^**'~^'"*«  suppur-aive  encephalitis  i. 
.  nh  iJil"  T  "'  ^"'""^  P>'''«""^  rnicri6i>,anisms.  noL'Jv  e 
Staphylococcus,  streptoco<-cus,  and  Pneumoc-occus.  and  s  met  with  in 
such  cond.tio.;«  as  gangrene  of  the  lung,  infected  wounds,  and  ulcerating 
carcinomas.  The  condition  is  bn^ught  about  by  infective  emboEZ 
from  a  prima^  foc-u.s.  and  is  really  a  manifestation  of  a  genem  z« 
^pticemia.  The  lesions  are  usually  multiple,  and  are  foSndTn  the 
cerebrum  and  cerebellum,  less  commonly  in  the  basal  ganglia 
Ihe  process  begins  with  the  formation  in  the  brain  of  miniiteischemic 

f fwi'  Zt  "'^''"'"*^-  ""'^  ''^'"'"•••haK'-c  extravasation.  ¥0  JL  J 
quickly  added  suppuration.  Absc*.s.ses  are  thus  pro<luc^l.  varvin^  in 
size  from  that  of  a  hemp  s,^d  or  pea  to  that  of  a  walnut  or  hcl ''  i^ 
«,ntaming  creamy,  yellowish-white  or  yellowish-green  pus.  In  exc*£ 
tional  ca.ses  a  arge  part  of  one  hemisphere  mav  t  excavated  InX 
acme  forms  afer  the  pus  is  evacuate.!,  the  wall  of  the  abscS  is  found 
to  Ik-  covered  with  .shap  .letritus.  an.l  the  surroun.ling  tissues  are  mark- 
edb  ne..ematous  and  present  multiple  minute  hemorrhageT  The 
abscess  „,ay  extend  to  the  surface  and  indue,  meningitis,  or  S-  bu^I 

IrS'r  "'"*  '^T  ""'^  -"'-P^a<J  inflammation  is  se   up 

In  the  unlikely  evei.i  of  the  patient  surviving,  i;  is  possible  tha     he 

smaller  abscesses  may  heal  with  th.  production  Lf  scarTs  uT    I    r^er 

ones,  after  a  lengthv  period,  become  bounded  bv  a  zone  .,f  c^  n.lensa, bn 

«.mp..,se.l  of  a  rather  dense,  fibrous  capsule;  lined  wi  r^inl  ^ 

sMie.  .So  long  as  pus  is  l,eing  produced  the  a.ijacent  brain  substance 
«  -..pressed  and  undergcK-s  degeneration,  alth.ngh  in  time  h  p^ss 
ma^  .ease  to  extend  an.!  the  pus  to  some  exteni  be  ahsorbe.l^^e 

ncaiM.lation  of  the  absce.s.s  .loes  not  entirelv  obviate  the  ^ss7bilitv  of 
e  .en.,,,,  of  the  inflammation  to  neighboringparts.     iS'is^n 'en    "  it^ 

Dopri,  i,.t|.,,  lead  to  cnronic  hydrops  of  the  ventricles 

M  ,  .auite  hematogenic  enoeplmlitis  will  appiv  faiHv  well  to  the 
trau-,,  ,„c.  fonn.    Here,  however,  the  process  is  infective  or -nonSnfective 


I  I 


I       IF   ^      '    '    ' 

I 

I     ' 


■I 


558 


THE  h     'W 


III  the  simple  form,  the  pathological  manges  ure  local,  correspon.iiii.r 
as  a  nile,  to  the  point  of  injury,  and  the  resulting  inflammation  Is  cInVHv 
the  attempt  at  removal  of  the  destroyetl  tissue  ami  its  replac-ement.  lii 
the  infective  variety,  the  pnK-ess  may  extend  more  or  less  wi<lclv  iixn 
the  substance  of  the  brain  (abm-s»)  or  along  the.  meninges  (tneniiiijlti,) 
^  bMphaUtii  per  Ixtomionem.— Kncephalitis  per  extensionem  <<.iiw 
moiily  originates  in  meningitis.  As  a  matter  of  fact,  leptomeningitis, 
so-calleil.  is  practically  always  a  meningo-encephahtis.  Many  vhm-s, 
35  per  cent.,  according  to  Collins,  are  the  result  of  suppurative  niiilijie 
ear  «lisease,  which  has  led  to  ne<-n)sis  of  the  fjetrous  Imhic.  In  children 
however,  meningo-enccphalitis  may  lie  due  to  an  otitis  without  bone 
disease,  owing  to  the  fact  that  certain  Iwiiy  sutures  remain  unossifjed 


Fio.  I.W 


Kxlensive  h!,«w.  „f  the  brain.     (Fri.in  llie  PatlioioRical  DepartmenI  of  the  Mnnt,.;.l 
General  Hospital.) 

for  some  time,  thus  allowing  direct  communication  l)etweeii  the  ii  iiidie 
ear  and  the  cranial  cavity.  This  channel  of  infection  is  Mill  more 
effective  since  the  dura  fret|uently  sends  prolongations  dowinv.ml  into 
the  fissures.  In  such  cases  the  temporal  lol»e  and  the  (rrtlx  llnni  are 
most  liable  to  be  involved.  In  advanced  and  severe  caso  .li. -.cesses 
of  considerable  size  may  be  priMluced. 

Still  other  cases  originate  in  infection  from  the  nasopharvnx.  ili.  frontal 
and  ethmoidal  sinuses,  and  the  orbital  cavitv.  Certain  trminatio 
ca.ses  also  come  into  the  category  of  encephalitis  bv  extension.  In  inanv 
instances  extensive  sulMlural  collections  of  pus  are  found,  t«)L"t!i-r  with 
meningitis  and  sinus  thromljosis. 


i9MJ 


SYPHILIS 


559 


Tuberculoili.-rubercula„.,  of  the  brain  occurs  in  the  form  of  mi.I 
'•;''•  T'^TT'  RJ«n"»?'n'«  of  small  she  (milia).  and  ..s  the  Z-  ^l.w 
...  KTcle      The  .nfection  may  be  hematoKenic  ,lue  to  baeil  7umT  £ 
H...-red  the  c.rculafon  from  some  .listant  fTnus.  usually  th^ ,«'  i.r."  cSal 
.....sentene,  or  r^tmpentoneal  Iymph-no<les.     I„  mn.^y  <as4,  l„.  not  al I 
tiK.  .•ond.tmn  is  part  and  parcel  of  a  generalize,!  miliary  tul^^r^ubsr  1' 

Ml.  (see  p  545).    In  another  class  the  infection  is  lymphogenic  ori.ri 
na  ..iR  m  the  petrous  bone  or  the  nasophannx.  '?""««•'"«.""«'- 

I'l  "'*  ''Tf'"K^"i<=  type,  the  tulK-rcles  ar«  distributed  nlouir  the 
Mualier  arterioles  and  arterial  capillaries,  usually  in  the  Srtex   b^it  ,« 
s..,ne  extent  in  the  central  ganglia  also.    The  pWess  l^e^ns  ^itl   the 
onnafon  of  minute  foci  of  cellular  infiltration.  !.t  ,en  wit^^emo     „I,e 
ihese  enlarge,  undergo  necnxsis.  and  then  appear  as  snudl  ^     K 

When  but  a  small  area  of  the  brain  is  implicate.1  an.l  the  patient  lives 
or  s...ne  time,  larger  solitary  tulK.n.|es  «,!e  p,«<hu.e,l.  varf  «  ,  '^ 
fn.  n  ,ha.  of  a  pea  to  that  of  h  walnut  or  larger  Thev  form  weH..  Ih^  ^ 
Rohujar  or  n.Klular  masses,  of  firm  v^nlteJ-  l:2Ct^^^^ 
Ih-s  IS.  perhaps,  the  c.,mmonest  form  of  cen-bral^umorTo  "|  i,  n  ; 
persons  On  sec-tion.  they  are  .^mpased  of  a  large  ce^.ll  Zt.  L'  Zf 
^un.le,l  by  a  zone  o  granulation  tissue,  in  which  cm,  ^.n,!  H  X' 
re<i.gnized  small  subsidiary  tubercles  f)ccMsinn„IK  'T''"*""-^  '•*^ 
mam.  sof,c„s  or  liquefies,  so  that  .^^.scl^S  t L  sUl^^^ 
r,^H.rcul„mas  are  found  most  commonly  in  the  cer^-lK-lium  next      Ihe 

^P..i.i.ic  end„rteritrieadir„  i^^'ib^rSf  V  I    v;;er2i 

sii:!"""' '^•^'•''^'  »'-• '« '-'  "trophies.  ;o;hm:rL;::m 

deceiUTation  •  L       ,     'i*""'"''  J"""*'""  •••"""'"nlv  shows 

2ii:;;:rd;de.im.T;i  ,^z^is^.:^'ZT  '""<-•  '-- 

™o„|y  develop  in  the  me;Wnges  alnl^St  tt^^^^"  T  ^Z^ 

Silr,,;;  ^"  niembranes  oyerlying  the  gumnw!  usually  became 

of  Ih:'';.:;;;!,^''''''""'^'  "»"'*  «"'''■"»-'  ^h-splmcheta  palh^a  in  a  gumma 

Actinomycosis  -Primarj-  actinomycosis  of  the  brain  is  cxccssiyely 

'  Proc.  Path.  Soc.  of  Phila.  (\.  S),  9:  1906:  195. 


t 

if 


U 


in 

il 

S  i 


I  n  i 


M 


H 


i 


hri 


I  H 


560 


r«fi  BAit/JV 


Brises  by  mrtafltaniii,  or  the  extension  of  actinomycosis  of  the  face,  n»Hk, 
or  throat.  In  the  metastatic  form,  which  is  usually  only  one  phn.M-  of 
a  ({eneral  infection,  multiple  gelatinous-looking  or  necnitic  foci  an>  pro- 
duced. In  the  cases  due  (n  extension,  the  actinomyces  reach  the  cruniul 
cavity  throu({h  the  various  foramina  and  fissures. 

As  a  rule,  the  meninj^s  are  involved  in  a  more  or  less  diffused  suppiiru- 
tive  inflammution,  with  the  fornmtion  of  numerous  small  necrotic  (mi 
that  tend  to  invade  the  brain  substance  and  the  various  sinuses.  In  the 
more  chronic  cases  adhesion  may  take  place  between  the  membranes. 


BlTEOOSIUin  MBTIMORFHOIU. 

Atrophy.— Atrophy  of  the  brain  is  seen  particularly  well  in  old  ajje. 
The  brain,  as  a  whole,  is  diminishetl  in  size,  as  is  proved  bv  the  weijjht 
being  below  the  normal,  but  the  wasting  is  relatively  most  iimrke<!  in  the 
frontal  and  vertical  regions.  The  convolutions  ar*  small  and  the  .sulci 
wide.  In  cases  of  moderate  extent,  when  the  braiti  is  sectional,  little 
alteration  may  be  noticed  .save  that  the  gray  matter  of  the  cortex  is  sdine- 
what  thinned.  In  the  more  'dvanced  ca.ses,  however,  besides  tiii.s,  the 
periva-scular  spaces  are  enlarged,  .so  that  the  vcsm-Is  lie  in  wide  ciiamifls, 
and  small  foci  of  degeneration  are  to  be  seen  (^dtat  cribl<s).  It  is  not 
unmmmon  as  a  concomitant  of  the  loss  of  substance  to  find  enlar;;« mciit 
of  the  subarachnoid  space  and  of  the  ventricles,  which  are  filli  d  with 
fluid  (hydrops  meningew  ex  vacuo;  h.  vctitn'culorum  ex  vacvo).  'I"he 
cerebellum,  a-s  a  rule,  is  not  involved  to  uiiy  extent,  but  occasidnally 
has  been  found  to  Ite  waste<l. 

Micrascopicaliv ,  the  changes  are  referable  to  atrophy  of  the  spcf  ific 
nerve  cells,  ganglia,  and  medullated  nerve-filiers  alike.  There  is  urannlar 
disintegration  with  chromatolysis,  and  often  pigmentation  of  the  ctlls. 

Senile  atrophy  may,  with  con.siderable  certainty,  lie  attributed  to 
.several  causes,  chief  among  which  are  the  normal  tendency  to  retrojrres- 
sion  of  all  tis.sues  as  advanc'eil  life  is  approached;  impoverished  nmriiion 
of  the  IxkIv  as  a  whole;  and  the  local  effects  of  imperfect  blfMxl  Mipply, 
owing  to  sclerosis  of  the  ves.sels.  In  acconlance  with  the  general  riili  that 
the  more  highly  diiTerentiate<l  structures  are  the  most  liable  to  <li.se:i>c  and 
degeneration,  it  is  that  portion  of  the  brain  containing  the  in(ell((tiial 
centres  which  chiefly  suffers. 

Other  causes  of  atrophy  are  prolonged  wasting  disea.ses,  nldil.olism, 
and  chronic  lead-poisoning. 

Fatty  degeneimtion  of  the  specific  nerve-cells,  fngmentation  of  tin  mvclin 
sheaths,  diaintegntion  of  the  rilnrs,  necroiis,  and  Uqnefaetion  nre  IV.  ;  imtly 
met  with  in  connection  with  injuries,  inflammation,  and  cir  Litorj- 
disturbances.    They  need  not  l)e  more  specially  dealt  with  liei' 

We  come  now  to  discu.ss  certain  affections  of  the  brain,  which  ..dealt 
with  here  largely  as  a  matter  of  convenience,  since  their  etii  !  irv  is 
ob-scure.  In  these  cases  the  most  striking  feature  is  atrop!'  f  the 
brain  substance.    The  difficulty  lies  in  determining  whether  tlii       ophy 


rri  f 


amsKAi.  fAHALrm  or  ns  rnsAne  5,,, 

numbers  of  the  same  famil^  .m^Jl  .    I      ? P"**""'  »"''  '"  ■■^^•••™l 
......nalie,  of  develpmem  of  Z'V^J^"'  "'H'"'  P-"''«""-  «' 

.....tributory,  if  not  i  S„J  Id/^r     """T  ''""'.'"••"•^  may  play  a 

f«ilu.*torei;hanaom™lS«  on  ^^"'L"'^  "'''  '"'l''>'. ""«'  •^•'■^  ■>• 
of  v.,.tative  fo.«..  ■-  ^£^'^0' ^7- X?^ 
imtt  the  demamls  made  unon  them  or  ll  .  .  ""*  """'''"  '° 

.iel-teriou.  influence,,  mnherwe'  ale  t.^T"  ""/'S  ■'"«*?'"•'«•  "> 
Ihi.ijrs  as  a  disease  in  itself  or  7,  Z    i  i^*^""'  """  «>nd'«'"n  of 

..nnisse.,  must  aTp^^TlL Tefror'^r''''T"'^  '"  '"'^'^  '""'»'"' 
m.MinK  under  this^^teRory  a^^ml  ™^if  ""1' i."^'^''"*  «''*^"«"« 
don's  chorea,  and  di  JmSaS  S.^'r'*"''  "'  ""^  '"^"^'  """''"K" 

itfeftion  of  th™Ss*  system  tth™rrV'  i**"  •'^T*'  "  "  ^'•^"'^ 
ize,l  .linicallv  by  a  wellXfinS  i^t  T      T'^  P«"P^"»1.  character. 
mav  Ih.  mentioned   n^  ll  .1^77-    '  ''^"/P'T"'  ^'''•^'  '""'"'K  w^ioh 
inHl..t.  .IHuIns'of  a  ';Ldr£irrd;^^^^^^^^    disturbancef  of  the 
Iff-nors  and  weakness    S  fme,  lil         t  K™"*^*'"'">'  '""^ular 
ami  ArKvlWloberteormmrw^h  r    ^'"'•.t'i"'^''""'  «f  "P«^h, 
(•ha„«,.s  i„  theS  J    TK^»°         •'^'"'  '^"''"^^  referawTto 
who  have  led  thestis  ^'0^^  If  ""r"^  '"^^  '^''''  i"  '^ase 
m...„al  .s,«.ss  and  woS^TJ  In'v  .7  7k      t*'*'  tf"  '"^J^'«^  ^°  «•*«' 
ha.l  svphilis.     It  is  S  me^k^nfte  V""  ?^'l  "'™^«'''^''  °'-  ^ave 
an.l  af  ,-r  trauma     Men  a^  mlv  r»  ^'« '"'^^''''  '"^eterate  epilepsy, 

=.;-  of  thirty  and  fitv  vea«  A^^  "  Tp'.  r"""*"?  ^'^^"  ">« 
•v.i.a  is  an  Vxhaustiv^  dTeSe  X^Se'l^'^^'^^^r-''  TT 
owin«  to  mental  strain,  sho'  or  worrv  L 1  k  ^''V  '"  '^'""'''' 
m.)>^  s,.vi.rely  affected  A  Zl^\u  "^^^^"^  '"  primarilv  and 
-nav  l„.  remarkThat  Wa  m  ^  °"  "'^  '*'°'»K.^  "^  '''e  condition  it 
••H;vfi-a-as?tTs;n,yph3is.  P'^'P''«f'on  test  is  positive  in 

Tht' lesions  found  are  somewhat  strikino.     tu    j       •     . 
•"  fh.' .alvarium.  and  there  may  S  an  intemalT^^     ?  's.often  adherent 
S'tH.    The  pia  is  turbid  and  thirll»7  hemorrhagic  pac  hymenin- 

an.lisofr..„  Llyl^tJei^o  K  rffc;SEb  ••'"  *V""*"'  "«'°"' 
>ng  K.  remove  it  portions  of  thp  HaT  """' ""  *''*' ""  attempt- 

Pia  is  ...netimes  K  adhlnt  ielT  "^  !T  "^■"•^•-    '^^''^  "P'""' 
f  H';«<s  i..  the  pos^eriorTl^lCrntorir  V:-   ''^."'r '^ 

'"•-  -.■  mi^^SZaS^i^ed  •'"'?;?•■'••     The  frontal  an.l  parietal 


Ihi 


1  !  i 
I 


■i  ' 


ill 


n 


562 


rffe  BAi4/v 


proliferation  of  the  ronnertive-ti»ue  tmbeculn  penetrating  the  Sniin. 
The  specific  nerve-celLs  are  swollen,  cloudy^  or  gra  nil  hi  r,  often  vucuoL.tnl. 
atrophic,  and  pigmented.  The  neuraxone-  are  ultentl  in  size  niiil 
shape  and  the  deniirites  are  wasted.  The  myelin  sheaths  are  ulisciit 
wholly  or  in  part.  The  nuclei  stain  badly.  The  glia  is  greatly  incrciisiNt 
and  the  vessel  walls  are  thickened.  To  the  lesions  in  the  brain  arc  nfitii 
added  thase  of  tabes  donah's  or  combined  sclerosis.  The  grnniilntion 
of  the  ependyma  is  due  to  the  subepithelial  proliferation  of  the  gliii. 

DiiMiniiikted  8el«roiif  (Mnltlpl*  or  uioUr  Sderoiii;  Sclerose 
en  PlAqnei). — The  lesions  in  this  disease  are  found  scatteretl  irr'i'- 
ularlv  throughout  the  central  nervous  system.  At  one  time  the  ti >rtl  k 
chiefly  affecte<l;  at  another,  the  cerebrum.  Occasionally,  single  fiK-i  art- 
found  in  the  brain  which  are  probably  of  the  same  nature.  'I'he  ksloiis 
consist,  as  the  name  implies,  in  the  formation  of  islets  or'  sclt-nisis, 
varying  in  size  from  that  of  a  pin-'n  ad  to  patches  two  or  thn-e  iridu's 
across.  The  larger  lesions  are  apt  to  be  found  in  the  neighborlnNKl  of 
the  ventricles  and  in  the  pons  ana  medulla.  When  the  fin-i  are  sitiiiitcd 
in  the  cortex  or  have  extended  through  to  the  surface  of  the  liraiii,  s|i<;|it|v 
elevated  o<iules  are  to  he  seen,  to  which  the  pia  may  or  may  not  Im- 
adherent.  ')n  section,  the  patches  are  rounded  or  irregular  in  simp*', 
of  a  grayish-white  or  reddish-gray  color,  distinctly  firmer  than  the  iioniial 
brain  siibstunce.  They  can  often  be  localized  better  by  the  sctis*-  of 
touch  than  by  their  appearance.  When  marked  degeneration  is  piinj; 
on,  the  areas  appear  somewhat  variegated.  In  the  cord,  the  cerviciil  iind 
lumbar  enlargements  are  mast  likely  to  be  involved. 

Microscopically,  the  sclerotic  areas  are  found  to  consist  in  the  imiiii 
of  proliferated  glia  cells  and  connective  tissue,  in  which  cun  1k'  sccii 
remnants  of  degenerateil  nerve-ceUs  and  fibers.  The  iixoncs  slmw 
loss  of  their  medullary  sheaths,  or  may  be  entirely  disiiitegraltd.  often 
leaving  only  a  space  to  show  where  they  were  formerly  pn'scni.  At 
the  periphery,  these  changes  are  mast  marked,  and  there  may  !).■  t'onml 
drops  of  myelin  and  fat,  ;,Tanule  cells,  and  amyloid  Ixxlies.  'I'ln'  vas- 
cular changes  are  not  constant,  but  there  are  usually  thi«'kfiiiri':  and 
hyaline  ilegeneration  of  the  vessel  walls,  with  distension  of  the  |)frivas(u- 
lar  lymphatic?.    Ribbert  has  described  a  new  formation  of  vcs^i  U. 

The  causes  of  the  disease  are  (|iiite  obscure.  Some  cases  sn m  to  Ix' 
de|)en(lpnt  on  previous  infection  or  toxic  influences,  and  ore  pniliaKly 
due  to  a  primary  degeneration  of  the  specific  nervous  element>,  iniifllier 
with  an  attempt  at  repair  on  th'  pn-t  of  the  glial  cells. 

In  other  cases  where  the  <lis'  vgins  in  early  life,  or  tlifif 
tinctly  familial  taint,  it  is  prolwibiy  due  to  defective  embrvona 
ment.  The  symptoms  vary  according  to  the  distribution  of  tl 
There  is  usually  some  impairment  of  emotional  control  with  .iM;i(k>  i>f 
giddiness.  Later,  we  get  spasticity  of  the  lower  extremities,  u}  I'liri""^- 
.scanning  speech,  extension  tremor,  and  partial  optic  atrophy. 

Hontingdon's  Ohorea  (Chronic  DegeneratiTe  Ohoreai. 
don's  chorea  is  a  curious  and  rare  affection,  characterized  li\ 
movements,  disturbance  of  speech,  and  dementia.     It 


I-  a  (lis- 
ivfloj)- 

!('siipn>. 


Hiiiitinp- 

irn'>;nlar 

usii:ill  ■  occurs 


rr.1,  jKs 


603 


U(.-  Ill  lilr  unil  »  nouMy  •  hmily  and  koiil  iliVa,i.     Tfci  i   . 
iiHir|ihc*iKi™l  dtvinfiom  from  ih.  „„,r.i  k     i  7      ">    uil.v»lii«r 


riOORKSBIYI  MITAM0KPB08U. 

;  nr,..,,.pt  at  .^generation  of  ih.n.^i^i^r^'tlit^^^^^^ 
'l''s<n[.lM.n.  an<l  authorities  aw-  not  aBre«l  on  .h»  :  .         .    ^  "''*""'•■'' 
a|>KannK...s.     Proliferation  of  the  neZjlia  J    L   ^f'""'""""  "'  '''- 
''»'liNni..twithehie.''valK,nf  nil   ;.fl        *^.    <"  m  iHi   more  mmnion. 

-~.-.»^„raZi;j'.;zr;,^-;^srr"::;ir,~ 

a'lol.-^.. ■„,.,.  Im  r,  not  .n  f«^"ently  met  with  i„  ,hil,|h,M.,|  .....l 

.       "n.initis  not  uncommon  after  adult  lif»»     'n.„  ...    i    ••      • 
1^  in  til.'  licrnisphcres  iust  lienH«»l,  ^jl     •  ,         "'"'"'  ""«'"•»"•" 

the  „.r,„„  callosum  til  Tin  P'f'  ''"*  "'""•  ••<™-^'«>nailv.  in 
"f  'he  -lavarimlTtrpre^n^  ^ft^f  cerel.lh.n,.  (,„  renlovHl 
f"ritl..l...visiW;exterTanv  A  n,  »  K  '  "'"^"fF'*^'''"'.  ''>r  it  is  rare 
I'^'^^il.lv.  .Iisc.,lom'ron  ^f   L  „ffL?f  •  *'r'*  r-^'  ''^  ■"'■>'"  f"'"'-'*^  with, 

»»'!  <iei:.  .,.mt  1      t'!^"'^''."!  ^'■""'.  ".  "•«•«•'.>•  J»y  a  zone  of  softe.n-ne 
uostance  accord.,, g  to  circumstam-es.     I„  appearance  it 


II  ' 


:  ;i 


I     i 

i 


!i 


il 


111:1. 


h         :i 


<       i    i 


564 


THE  BRAIN 


is  jjrayish,  j^rayish-while,  or  retldish,  somewhut  translucent,  an<l  olicn 
strcaktHl  with  reddish-yellow  or  opaque,  white  bunds  and  patches. 
The  tumor  is  vascular,  an<l  it  is  not  uncommon  for  hemorrhap'  to  tiikt- 
place  into  its  substance.  This  may  Ik"  so  extensive  as  to  mask  tlic 
true  nature  of  the  growth  and  give  it  the  ap|)earance  of  an  a|H>pl<'('ti(' 
focus.  Owing  to  hemorrhage  or  colli(|uative  necrosis  tlie  tumor  iiiny  In- 
ctmverted  into  a  series  of  cysts  containing  turbid-whitish  or  l>r(>\Miis|i 
fluid.  In  some  instances  it  is  extremely  ditKcult  to  distingiiisli  tlie 
mass  fnnn  the  brain  substance,  save  that  it  is  a  little  redder  or  ))alfr 
than  the  normal  structures,  li  is  probable  that  some,  at  least,  of  the 
ca-ses  of  hypertrophy  of  the  brain  descril)ed  by  the  older  writers  were 
more  pn»perly  gliomas.  This  tiunor  d(H's  not  involve  the  mcmliraiies 
or  the  bone. 

As  its  name  implies,  the  glioma  originates  in  the  proliferation  of  tlie 
glial  cells.  Microscopically,  we  have  a  more  or  less  cellular-lookiiii,' 
growth,  consisting  of  glial  cells  of  the  ordinary  type  which  jxtssess  loiif; 
branching  and  interlacing  processes.  The  cell  IkkHcs  vary  consideralily 
in  size  and  contain  large,  deeply-staining  iniclei.  The  cells  themselves 
are  evenly  (listribiite<l  or  aggregated  into  gnnips.  The  fibrils  funii  a 
sort  of  meshwork,  which  at  times  is  dense  and  at  others  rather  loose, 
containing  spaces  which  give  the  tumor  somewhat  the  a|>|iearan('e  of 
a  myxoma  (mi/xoglioma).  The  structure  is  in  some  cases  not  unlike 
a  round-celled  sarcoma,  but  its  true  nature  <'an  «)ften  lie  delenniiieil 
by  teasing  out  a  bit  of  the  fresh  tumor  and  discovering  the  bniiicliiiii; 
cells.  The  use  of  a  special  stain  for  glia,  such  as  Weigert's,  gives  imieli 
assistance.  The  bloodvessels  and  sinuses  are  often  niiineroiis  and 
may  he  so  large  and  abimdant  as  to  warrant  the  designation  of  glioma 
telangiectatieum.  Hemorrhages  are  frecjuent.  The  wails  of  the 
bloodvessels  often  present  hyaliiic  degeneration  and  the  advei.iiiia  may 
proliferate,  so  that  the  vessels  are  surroundetl  by  a  zone  of  ceiliil.ir  or 
fibrocellular  appearance. 

In  certain  ca.ses,  a  glioma  of  the  structure  just  descriljcd  contains 
cells,  sometimes  possessing  more  than  one  nucleus,  which  n-einlile 
closely  the  ganglion  cells  of  the  brain  and  conl.  These  aiv  evenly 
.scatterc<i  throughout  tlie  section  or  are  mas.sed  into  groups,  l-olated 
mtHliiUated  nerve  fil)ers  can  also  l>e  made  out.  To  this  variety  /.iei;ler 
gives  the  name  of  neuroglioma  gangflionare.  Many  authorities,  however, 
<lo  not  admit  that  in  these  ca.ses  there  is  a  true  new-fonnatioii  of  L:aii;.'lii>n 
cells,  or,  more  accurately,  reganl  them  as  an  overgrowth  of  mnuenital 
origin  developing  from  a  "  cj'll-rest." 

At  the  periphery  of  a  glioma  the  brain  structure  |)resei, 
grades  of  degeneration  and  necrosis,  although  it  is  n'markni'l' 
it  may  l)e  preserved  in  .some  ca.ses.     Not  iiifre(|uently,  the  nl 
out  ]>n>longations  which  gradually  infiltrate  and  surroiiii<l 
the  brain  substance. 

When  a  glioma  is  rapidly  growing  and  .so  cellular  that  it  i 
sarcoma,  it  has  Im'cii  customary  to  sjwak  of  it  as  a  gliosarcoma . 
be  remarked,  however,  in  this  coimcction,  that,  inasmuch  :> 


-  \arioiis 

how  well 

'■iia  senil> 

MlliollS   (if 


.  inhles  a 
Il  diiiiili! 
ii('im>;.'liii 


GLIOMA 


565 


is  cpiblastic  in  origin,  it  is  a  mistake  to  reeard  tumors  devplnn.n„  t 
It  as  sarcomatous,  that  is  to  say,  mesoblS  '"("^" j'^Yf'^P'ng  f«>m 
s".  I.  «  thing  exist,  would  ..  a  n/xelTt™  '^nsiftini  i„fc  '' 

an.l  u.  part  of  sarcoma  derivcl  f«,m  the  al^S  pSSiontt^ 
«.n.u-ct.ve  tissue  fonning  the  a.lveutitia  of  the  vessels      K?Lr 

.K...a.sionaip.s'inc.ofga„;Sci[rs'h  tsrg;^"^  tfr^^^^^^^ 

ment.  such  as  embryonic  "cell-i^sts."  may  S  2  work  ThL  •'"'''^ 
.su|,,K.rt«l  by  the  observation  of  Stro^be  '  Jho  f« nnTin'  r  ""^"^  '^ 
eavi.i..s  .in.l  with  cylindrical  epitheliu^Tn.     Tl^ZLVl£r::& 


Kio.  154 


♦I,-       II  -        ""'*^'  ""J-  •>»».  0,  without  OCIlInt- 

the  ,  ..llect.un  uf  Dr   A.  CJ.  .\ich.,IN.)  ' 


(Fmm 


-5SES*iS?Ss=s 


"f  Hlnr.  in  which  are  ce  111;      t  ^'''"l  "  ^•»mp«-''«l  mainlv 

''^'"'<vi.s   as  th  V  hnl  l  •'*^'"'*   "(  processes.     X„w  the  glia  cells,  or 

-11^  •■•-'•..•.llsS     rl.;  /t  V  Sis  "^^^^^     r.'"'^'''^  cliL,.ntiate,l 
^ariu,,^  ..(ages.  1^)11,  eml)ryo.nc  and  adult.     Flexner' 

-I  '.>.o.n„U.s.«.    Jour,  of  Nervous  „,k1  .M,,,;,,  uiLse,  .May,  Ism. 


;l 


'  t 


i 

■ 

V  '■ 

;m       1 

'TTTi 

i  - 

i 
■ 

iiii 


iHl 


?  I 

.! 

i! 

.3  i 


H    :l 


566 


THE  BflX/AT 


has  described  a  glioma  composed  of  ependyma-like  cells.  The  cellular 
or  sarconuUoid  gliomas  (medullary  gliomas  of  Ziegler)  possibly  oriniiuiio 
ill  the  intermeiliate  cells  (astroblasts),  which  might  readily  persist  In 
a  latent  form  into  adult  life.  The  gliomas  composed  of  branching  iunl 
"spider"  cells  suggest  a  derivation  from  the  primitive  astrocytes,  wliilf 
the  denser,  more  fibrous  growths  resemble  the  adult  glia. 

Suconu. — Sarcoma  of  the  brain  originates  in  the  conne<tivt'  tissue 
forming  the  intracerebral  prolongations  of  the  pia  or  adventitia  of  the 
vessels.  It  takes  the  fonn  of  single  or  multiple  growths  of  irrejjularlv 
globular  shape,  which  are  fairly  well  defined  from  the  brain  substance 
or  even  encapsulated.  In  many  cases,  owing  to  the  degenenitiim  of 
the  structures  at  the  periphery  of  the  tumor,  it  -an  be  shflKd  out. 
The  favorite  site  is  in  the  cortex,  where  it  forms  a  projecting  noilular 
growth.  On  section  the  mass  is  of  a  grayish  or  yellowish  appearaim  ami 
presents  numerous  hemorrhages  and  foci  of  degeneration.  .Micro- 
scopically, the  most  common  variety  is  the  round  or  mixed-celled  sar- 
coma, but  spindle-celled  forms  are  also  found.  In  some  cases  the 
sarcoma  is  highly  vascular,  and  seems  to  originate  from  the  adventitia  of 
the  vessels.  The  tumor  then  consists  of  a  series  of  whorls  of  si)iii(lle 
cells  arranged  radially  and  apparently  continuous  with  the  vessel  walls 
(angiosarcoma;  perithelioma).  We  have  seen  tumors  of  this  type  lH)tli  in 
the  it)rtex  and  in  the  corpus  callosum. 

Occasionally,  there  is  a  deposit  of  calcareous  matter  in  the  i;rowth 
(psammosarcoma).  The  pia  over  the  sarcoma  is  inflamed  or  inliltrateil. 
wiiile  the  adjacent  brain  substance  is  softened  and  degeneraitil.  The 
ventricles  may  l)e  dilated.  Secondary  nodules  may  be  found  in  various 
parts  of  the  central  nervous  system. 

Angioma. — Of  the  primary  benign  tumors,  the  so-called  anj;ionia  is 
not  infre(|uent.  This  presents  the  appearance  not  of  a  tumor,  i)nt  of  a 
diffusely  reddened  patch,  not  unlike  a  congested  area  of  inflainniation. 
Micn)scopically,  it  consists  mainly  of  dilated  bloodvessels  ami  simises, 
alK)ut  which  the  brain  substance  is  softened  and  degenerated.  .\(ror(lint,' 
to  Virchow,  angiomas  are  congenital,  and  are  probably  to  !«•  dassed 
with  the  vascular  nevi. 

The  fibroma  is  a  rare  tumor,  taking  the  form  of  nninded  iiodiilis. 

\i\  osteoma  of  the  corpus  striatum  has  been  recorded  In    liidiler.' 

Lipomas  are  rare. 

The  peculiar  tumor,  consisting  of  flattened  epithelial  cells  ananued  in 
lamina',  called  cholesteatoma,  has  l)een  met  with  in  the  brain,  alllionjrh 
more  common  in  the  meninges. 

Dermoid  cysts  are  decidedly  rare.  A  few  examples  have  bcci i  >  li^-  ved 
in  the  cerel)elhiin. 

The  secondary  tumors  are  sarcomas  and  carcinomas.  Tli-  >  arise  \<}' 
<lirect  extension  from  the  meninges,  choroid  plexus,  cranial  I  "ins,  tvm- 
panum,  and  orbit,  and  also  by  metastasis. 

'  Vireh.  Arehiv,  88:1882. 


CONTUSIOXS  ASD  LACERATIONS  5^7 

Parasites.— The  Echinococcw  and  Cyaticercua  ceUuloaa  have  been 
met  with.  Ihe  resulting  cysts  are  single  and  multiple.  They  are 
sifuafed  usually  v:  the  membranes,  but  may  be  found  in  the  brain 


TBAVMAnO  DISTUKBANOIB. 

Injuries  to  the  brain  are  produced  in  a  great  variety  of  ways  Ordi- 
nanly  they  are  caused  by  great  external  violence,  for  the  brain  is 
parfeularly  well  protected,  not  only  by  the  bony  cranium,  but  by  its 
several  membranes,  and.  moreover,  is  surrounded  by  fluid.  The  most 
iiniK,rtant  mjunes  are  eoneuiion,  eompreiiion,  eontaHon,  and  Uceration 
ll.e  results  are  often  .erious.  and  depend  upon  the  nature  and  extent 
of  the  trauma  and  its  localization.       '^  ^  "=  «"a  «^x'^nt 

OoiicU88ion.-Concussion  of  the  brain  is  brought  about  by  falls  or 
I.I0WS  upon  the  head.  Partial  or  complete  loss  of  consciousness  results 
w..h  muscular  taxation.  The  condition  may  be  a  transient  one  «; 
en.l  ...  death.  Ihe  exact  nature  of  the  lesion  is  somewhat  obscure 
In  some  cases,  although  by  no  means  invariably,  multiple  small  hemor- 
rhages have  been  noted  m  the  brain  substance.  In  some  others,  c-ertain 
of  the  ganghon  cells  have  been  calcified.  It  is  probable,  therefore,  that 
the  injury  leads  to  rupture  of  the  finer  capillaries,  solution  of  the  con- 
"r 'ir  "*""'"  "^'"''^  ^^^'  ""'^  degenerative  changes  in  the  fibers  and 

Coinpre88ion.-Compression  of  the  brain  is  usually  due  to  intra- 
cranial growths,  hemorrhage,  or  excess  of  the  cerebrospinal  fluid  Ud 
to  a  eertam  point  the  brain  is  able  to  accomnio,late  itself  to  the  abnormal 
cm.  .turn  of  things  largely  by  the  extrusion  of  a  corresponding  amoun 
of  the  cerebrospma  fluid.  It  is  often  surprising  whaVan  amount  o 
pn-sMire  the  brain  will  bear  without  the  production  of  structural  changes 
or  .hsor^lered  function.  Should,  however,  the  compression  exS The 
nnit.  or  be  rapidly  brought  about,  we  get  flattening  of  the  gvri  inter! 
m..,<;e  with  the  free  circulation  of  blood  and  lymph.Lultingi'n  mated 

ContuZn'^'^H"?""'"^         degeneration  of  the  brain  substance. 

ContusiOM  and  Lacerations.-Contusions  and  lacerations  of  various 
k  ■  s  are  produced  by  fractures,  gunshot  wounds,  and  cutting  or 
stal.lm,g  injurie^.  Here  the  effects  are  mainly  local.  The  slighter 
mjunes  lead  to  local  softening;  the  more  severe  present,  in  add  ion  to 
«.nn.ssu.n.  s.gns^of  disintegration  of  the  brain  substance.  The  rem  ti 
JM  hs  depend,  of  course,  upon  the  extent  and  localization  of  the  in^.i  I 
'  >ne  of  the  important  centres  are  involved,  provided  that  the  site  of 
n,,„ry  remain  aseptic  and  the  patient  sur^■ive,  the  lesion,  aimtomic- 
;      speaking  IS  not  unlike  those  met  with  in  anemia  and  hemon-hT^. 

th  h"  it^^S.'^t"^^^  "  ^'^''"''"-^  disintegrated  and  absorl.'d 
1  nerv^  fibrillae  and  ganglia  present  various  forms  of  degenera- 
t  ,  1  a,K>„t  the  periphery  we  find  reactive  inflammation  wifh  pii 
l>h„„„  of  connective  tissue,  which  is  most  noticeable  along  the  coSrse 
of  the  vessels.     In  time  the  granulation  tissue  may  be  converted  in^^ 


i 


568 


THE  BRAIN 


fibrous  connective  tissue.  In  the  case  of  trivial  injuries,  healing  may 
take  place  with  the  replacement  of  the  dead  material  by  a  scar,  com- 
posed mainly  of  fibrous  tissue  and  bloodvessels,  but  ako  to  a  limited 
extent  of  newly-formed  glia.  In  the  more  extensive  injuries,  degenera- 
tion is  more  widespread  and  persistent. 

When  infection  of  the  wound  has  taken  place,  acute  inflammation 
is  set  up  (traumatic  encephalitit),  with  sometimes  the  formation  of  an 
ab.scess.    The  meninges  are  apt  to  be  involved  in  such  cases. 


fi,* 


CHAPTER    XXVII. 

THE  SPINAL  C^RD. 

In  order  to  obtain  a  correct  idea  of  the  spinal  cord  and  the  diseases 
to  wliich  it  is  subject,  it  b  well  to  bear  in  mind  certain  peculiarities  of 
structure  and  of  function.  Owing  to  its  position  within  a  bony  canal  on 
the  dorsal  aspect  of  the  body,  it  is  rather  liable  to  suffer  from  accidents 
and  injuries  of  various  kinds,  and  to  be  involved  in  pathological  processes 
orijjinating  in  the  vertebral  column.  Its  va«^-ularity  and  the  delicacy 
of  the  vessels  make  it  particularly  susceptible  to  circulatory  disturbances 
ami  to  the  action  of  various  toxins.  It  is  curious  to  note,  in  tl^  con- 
nection, how  certain  parts  may  be  picked  out.  Thus,  in  poisoniii  «ith 
lead  and  other  metallic  substances,  and  in  acute  poliomyelitis,  the  ganglion 
cells  of  the  anterior  horns  are  specially  involved.  In  chronic  ei^tism 
and  in  locomotor  ataxia,  which,  in  a  large  proportion  of  cases  follows 
sypliilis,  the  posterior  columns,  and  in  pernicious  anemia  the  posterior 
ami  lateral  columns,  are  attacked.  The  explanation  of  this  is  not  clear. 
Finally,  the  cord  contains  bundles  of  :  terve  fibera,  which  serve  to  con- 
duct iinpubes  from  the  cerebrum  and  cerebellum,  on  the  one  hand,  and, 
on  the  other,  from  the  peripheral  nerves  and  posterior  spinal  ganglia. 
In  this  way  lesions  of  certain  tracts  occur  which  are  to  be  regarded  as 
secondary  to  disease  of  some  distant  part.  Thus,  cerebral  apoplexy, 
evsts,  or  injuries,  involving  the  motor  cortex  of  the  brain,  are  in  time 
foiimved  by  degeneration  in  the  pyramidal  tracts  of  the  cord,  and  in 
multiple  peripheral  neuritis  lesions  may  be  n.duced  in  the  posterior 
cohiinns. 


^'  Wi 


THE  SrINAL  MENIN0E8. 

Inasmuch  as,  anatomically  and  functionally,  the  spinal  membranes 
do  not  (liffer  materially  from  those  of  the  brain,  the  discussion  ot  the 
lesions  affectmg  them  will  be  somewhat  sketchy,  emphasis  l)eing  lai<l 
only  on  such  points  as  are  of  special  interest. 

The  fipinal  Dora  Bbter. 

lilt-  dura  mater  spinalis  is  a  tough  connective-tissue  menihrane 
contiiMious  with  that  covering  the  brain,  completelv  enveloping  the 
COM,  and  separated  from  the  external  vertebral  column  by  what  is 
known  .IS  the  epidural  space. 

It  forms  a  loose  sheath  about  the  cord,  i.s  adherent  to  the  circumference 
Of  tlu  tc.rainen  magnum  and  to  the  posterior  common  ligament  in  the 


u*- 


If 


n 


570 


THE  SPINAL  DURA  MATER 


extrt'ine  upper  cervical  region,  and  in  the  lower  end  of  the  spinal  cHual. 
Below  the  level  of  tiie  third  piece  of  the  sacrum  it  becomes  ini|H'i  .ions, 
but  continues  down  us  a  slender  thread  to  the  buck  of  the  coccyx,  .vlitre 
it  blends  with  the  periosteum.  The  space  between  it  and  the  Imiiic  is 
filled  with  loose,  areolar  tissue  and  a  plexus  of  veins.  On  each  side, 
op|M>site  the  iiitervertebrai  foramina,  it  has  two  openings,  givin;;  exit 
to  the  sen  dfv  and  motor  roots  respectively  of  the  corresponding  spin,.. 
nerve.  I'rolongutions  of  dura  surrouiul  the  roots  until  it  is  lost  in  ihcir 
sheatlis. 

'I'he  piu-anichnoid  of  the  cord  is  similur  to  that  of  the  brain  The 
two  ineinliruiies  enclose  Iwtween  them  <he  subarachnoid  space,  which 
contains  cerebrospinal  fluid.  The  outei-  layer,  the  urachnoid,  is  not 
norinully  adherent  to  the  d.ira,  except  |)erhaps  in  the  cervical  n-;;ion. 
The  pia  covers  the  entire  surface  of  the  cord,  to  which  it  is  iiiti-  'ttiv 
adherent,  and  sends  a  process  down  into  its  anterior  nuHJiaii  livsiire. 
It  also  invests  the  spinal  roots  in  their  exit  from  the  c-onl. 


5' 


ontouiJiToaT  dutukbanoes. 

Hemorrhage. — Hemorrhage  into  the  dura  of  the  con!  may  arise  from 
injury.  It  is  met  with  sometimes  in  infants  who  have  Ikimi  (itliv.td 
by  instruments.  It  occurs  also  in  asphyxia  and  tetanus.  Ahnnte 
petechial  extravasations  of  blood  are  foinid  in  cases  of  nieiiiiijfiti^. 


rarLlBIMATIOlfS. 

Pach3nneiUIlgitis. — .\cute  inflammation — pachymeningitis-  is  most 
frequently  due  to  the  extension  of  diseu.se  from  the  neiglilnjiin;;  |i;irls, 
the  pia-urachtioid  and  vertebrae,  or  to  trauma.  TLe  dura  bein;;  raihtr 
den.se,  the  resulting  exudate,  which  may  lie  cellular  or  fibrinous,  is  jipi 
to  collect  on  either  the  outer  (pachymeningitis  eztenia)  or  inner  simI'ikc 
(pachymeningitis  interna)  of  the  membrane.  In  the  severer  rornis. 
what  are  practically  abscesses  are  produced,  and  may  lead  :<<  loni- 
pression  and  destruction  of  the  cord  at  *hat  sjjot.  Where  heidiiii;  tends 
to  take  place,  orga'iization  of  the  exudate  is  gradually  bn)iif;hi  ;d«Mit, 
with  the  formation  of  'elicate  va.scular  fibrous  atlhesions  between  the 
dura  and  adjacent  structure's. 

-V  modified  form  of  internal  pachymeningitis  is  that  known  as 
pachymeningitis  interna  hemorrhagica,  analogous  to  the  diseuM  of  tiie 
same  name  occurring  in  the  cerebral  dura.  Its  etiolo^'v  i-  nithcr 
obscure,  .save  that  it  is  apt  to  be  found  resulting  from  syi)liiliii('  or 
tuberculous  disease  of  the  vertebral  bones  or  pia.  In  the  seveivi  forms 
adhesions  are  liable  to  take  place  between  the  dura  and  pia-ar  i  iiiioid 
which  result  in  degeneration  in  the  cord. 

f^harcot  and  .loffroy  have  describe*!  a  chronic  hypertruphic  cernc»I 
pachymeningitis,  which  leads  to  compression  and  degenerati":i  of  the 


PARASITES 


671 


ntrve-roots  and  cord  in  the  cervical  region.  The  condition  eventually 
involves  the  pia-arachnoid  and  the  peripheral  zone  of  the  curd,  with 
rcsiiltinR  fibrosis.  Complete  transverse  softening  of  the  cord,  from 
ocrlusion  of  the  vessels,  may  occur.  Most  cases  seem  to  be  due  to 
•  piiilis. 

Tuberculosis. — Tnln-rculosis  of  the  dura  is  almost  invariably  sec- 
ondary to  I*  ill's  disease  of  the  spine,  less  commonly  to  tuberculosis  of 
the  pia-arachnoid  and  cord.     In  the  -nrlier  cases,  scattered  granular 

Tia.  1&5 


I'ac  liymeningitis  hypcrtrophioa  cerviciilis  nf  syphilitic  origin.     Secondary  degeneration  of 
the  cord  is  well  shown.     (From  the  collection  of  Dr.  Colin  K.  Kuiuel.) 

tiilMTclcs  may  form  on  the  outer  surface  of  the  dura.  These  mav 
coiil.scf,  so  that  large  cuseating  masses  of  granulation  tissue  are 
produced,  which  lead  to  compression  and  degenfratioii  of  the  cord. 
<  liiiically,  then,  we  get  the  features  of  a  transverse  mvelitis.  Delicate 
iMlliiMiinatory  membranes  may  in  some  cases  be  found  on  the  inner 
siirlace  of  the  dura.  Or  tubercles  may  make  their  appearance  here, 
iiiirl  (  veiitually  extensive  tuberculous  granulation. 

Syphilis.— Syphilitic  granulation  may  be  primary,  but  is  usually 
Ml  i.iMliiry  to  syphilis  of  the  pia-arachnoid,  less  often  of  the  bone.  It 
Itiiils  to  dense  cicatricial  adhesion. 

Parasites.— The  Echinococcus  and  the  Cysticrrcn-  uelluloace  have  been 
toiiiHl  both  in  the  epidural  and  subdural  spaces.  These  affections  are 
iHiir.liy  secondary. 


i  t 


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II'            i 

fi73 


rffi?  SPttfAL  DURA  MATEH 


PKOOBIMITI  MITAMOBPBOIia. 

*'™®"'— '!''•«  primary  tumors  of  the  dura  spinalis  are  the  ureoma 
pMmmoiiu,  Upoflu,  flbroma,  myzoiu,  and  ehondroiu.  They  are  till 
rare.  ' 

Oueinomft  is  met  with  in  metastasis  fnun  cartinoina  elsewluri' 
usually  in  the  mamma.  ' 

The  SpiiuJ  Pia-arechnoi<L 

OIROULATORT  DUTURBAHOU. 

Hemorrhagea.— Hemorrhages  into  the  meninges  are  due  usiihIIv 
to  trauma.  Petechial  spotn  are  sometimes  to  be  noted  in  infectioiw 
diseases  and  the  hemorrhagic  diatheses. 


nrrLAMMATIONS. 

Leptomeningitis.— Inflammation  of  the  pia-arachnoi.Iea  sniiialis- 
leptomeningitis— is  hematogenic,  derived  by  extension  from  adji.c.nt 
parts,  or  traumatic.    According  to  the  character  of  the  exudate,  w.-  iiiav 
recognize  a  purulent,  a  seropurulent,  a  fibrinopurulent,  and  a  <iis,.,.iis 
form.     Ihe  inflammation  may  be  localized  to  a  particular  district 
may  extend  along  the  dorsal  or  ventral  aspects  of  the  cord  or  iriiiv 
involve  the  whole  length  of  the  cord.     In  not  a  few  cases  it  is  coiirl.iii.;i 
with  inflammation  of  the  cerebral  pia-araclinoid  (cerebrnnpinal  m,;,i„. 
(jitm).     It  is  common  for  the  process  to  extend  bv  the  fissiin-  iiixi 
along  the  perivascular  lymphatics  to  the  conl,  where  small  li.inor- 
rhages  and  infiltrations  with  round  cells  are  not  infreciuent  in  the 
cortical   portion  {meningomyelith).      The   nerve-roots   niav  nU,  l«. 
infiltrated  (neuritis).     As  examples  of  hematogenic  infectiiiii  iiiav  l«. 
cited  the  so-called  idiopathic  or  sporadic  spinal  meningitis,  and'  the 
epidemic  cerebrospinal  meningitis  (see  p.  544). 

Traumatic  meningitis  is  due  to  infective  agents,  usuallv  the  pus- 
producing  cocci,  which  are  introduced  into  the  spinal  canal  at  the 
time  of  injury,  or  invade  the  wound  subsequently. 

Should  the  meningitis  heal,  it  is  not  uncommon  to  find  circtiins.  liM 
areas  of  fibrous  thickening,  of  a  pearly  white  appearance,  on  the  num- 
branes,  or  the  formation  of  more  or  less  extensive  adhesions  l>.  t,ucn 
the  neighl)oriiig  structures.  When  the  nerve-roots  are  inv.)h.,|  in 
a  cicatricial  process  we  get  secondary  degenerations  of  the  '  l.crs. 
In  meningomyelitis  the  peripheral  portions  of  the  cord  niav  .how 
atrophy  anrl  sclerosis. 

Tuberculous  Spinal   Meningitis.- Tuberculous  spinal  meniii 
occasionally  hematogenic,  but  in  the  great  majority  of  ca 


•|>    IS 

ii'iscs 


TUMORS 


673 


liy  extension  of  tiil)errul<iu.s  disease  fnim  the  cerebral  meninf{es, 
vertebral  bones,  or  spinal  winl.  The  most  common  is  the  cervical 
li|)tomeningitis  that  so  often  accompanies  tuberculosis  of  the  cerebral 
iiifinbranes;  next,  the  form  resulting  from  Pott's  disease  of  the  spine. 
In  the  latter  ease  the  infecticin  probably  extends  inwar«l  from  the 
liiira.  In  the  milder  or  less  advanced  con<litions,  one  sees  small, 
isolated,  tuberculous  ncnlules,  arranged  chiefly  along  the  vessels! 
In  more  severe  cases,  however,  there  is  a  more  widespread  inflamma- 
tion, with  the  production  of  a  seropurulent  or  fibrinopurulent  exudate, 
of  v«'ll«wish-white  color,  sometimes  mixed  with  bloo*!. 

The  process  may  extend  to  the  cord  and  nerve-r<M»ts,so  that  a  tuber- 
( iilous  meningoniyelitis  or  neuritis  is  produced.  This  leads  to  more 
or  Ifss  widespread  degeneration  of  the  nerve  elements. 

SyphUitie  Spiiua  Maningitii.— Syphilitic  spinal  meningitis  is  rather 
rare.  It  takes  the  form  of  a  circumscribed  or  flattened,  diffuse,  and 
sii|Hrficial  infiltration,  which  may  extend  to  the  cord,  on  the  one 
liatid,  or  to  the  dura,  on  the  other.  Occasionally,  the  prooeM  begins  in 
the  lK)ne  or  dura  and  extends  to  the  pia-arachnoid  secondaiily.  The 
process  in  time  leatls  to  inflammatory  induration  and  thickening  of  the 
pia-arachnoid,  with  the  formation  of  adhesions  between  the  various 
striKtiires.  In  the  central  portions  of  the  infiltrations,  necmsis  or 
):iiiriMiatous  degeneration  is  frecjuently  olxserved.  The  sequelie  are 
in  all  respects  similar  to  thase  in  the  tuberculous  form. 


PBOORS88IVS  METIMOKPH'^SKS. 

Tumors.— Small,  flattened  plates  of  bone  are  not  infre«juently 
foMiHJ  in  the  arachnoid,  which  are  supposed  to  be  due  to  degenerative 
(hanjies  in  the  connective  tissue.  They  are  supplie«l  with  vessels 
from  the  dura.  It  is  questionable  whether  they  belong  to  the  cate- 
;.'nry  of  true  oiteonu.  OutiUginoni  plaques  are  also  found  in  the 
aniclinoid. 

\'aricose  dilatations  of  the  veins  of  the  pia,  which  occasionally  assume 
tlif  form  of  cavemoas  angiomas,  are  sometimes  met  with.  Thev  cause 
more  or  less  extensive  compression  of  the  cord  and  nerve  root.s. 

Of  i>rimary  tumors  proper,  the  sareoma,  flbronu,  myxoma,  Upoma, 
angioma,  psammoms,  and  cholesteatoma  should  lie  mentioned.  It 
iiiav  l,e  remarkefl  that  all  tumors  of  the  cord  and  its  membranes  tend 
i(.  |i-.snuie  a  flattened,  elongated  form,  owing  to  the  contracted  and  un- 
vKl.linj;  lK)undaries  within  which  thev  lie.  The  sarcomas  form  circum- 
X  rilM.l  orflattenefl  diffuse  growths,  which  tend  to  invade  the  neighboring 
stni,  fiires.  The  alveolar  endothelioma  is  the  most  important  variety! 
•>\vinv'  to  the  abundant  formation  of  bloodvessels  in  certain  tumors, 
«<  limy  (iisfinguLsh  angiomas  and  angiosarcomas.  Mvxomatous  degen- 
'■!•:!>..>.)  IS  not  uncommon  in  these  rases,  and  iivaline  clianges  mav  l)c 
so  marked  as  to  warrant  us  in  calling  the  growth'a  cylindroma. 

Fibromas  are  roundel  or  flattentnl,  firmish  growths,  of  pale  color  an<l 
'ii:">tli  surfacf,  which  originate  commonly  from  the  p«'rineurium  of 


11"; 


r  :i  ^>'r    ■  ill 


]   '■ 


I 


n,-' . 


i\ 


.;  I 


r.74 


rffff  SPISAL  PIA-ARACHSOin 


t\w  iM>n«'.m(i«s.  They  arr  ofh-n  niiiltipli',  and,  as  wo  Imvi-  (Wfii  in  on. 
fusi',  iniiy  Ifuil  t»»  imtnlili'  conmressioii  of  the  «)nl. 

Lipomu  an-  found,  romnionly  in  association  witli  spina  \nM». 

S'fondury  tumors  «»f  \\w  spinal  meningrs  are  tlie  Mitiaomt,  lareoiiu, 
and  Bjraloiitt.  As  a  rule,  the  vertebral  column,  nerve-n)o».s,  and  iIh' 
<<>nl  itwlf  an>  involved  as  well,  and  the  symptoms  of  eonipnssion  myeliiis 
are  pr.MhHiMl,  ro.)t  \w\m,  spastic  paralysis,  iiKn-ast-d  knee-jerks',  an<l 
I  >ladder  symptoms. 


THE  SPINAL  OOED  AMD  MIDULLA  OBLONGATA. 


OnOULATORT  DIBTURBAHOU. 

Hyperemia.— AeU?«  Hyperemia.- Active  hypen-mia  i.  «>nnn..iilv 
met  with  in  the  acute  inflammations  of  the  cord  or  meninjjes.  In  >m,  ii 
(•as«\s  tiie  white  matter  pre.si>nts  a  delicate,  rosy  flasli,  and  the  grav  niiiin  r 
is  somewhat  brownish. 

Pusive  Hyperemia.— Passive  hypj-n-mia  is  f«>und  in  chronic  ciir.liiu 
and  pulmonary  affections,  and  in  those  who  have  iHt-n  iH-ilriddcii  l.ir 
pn>lonj;eti  periiKls. 

Hemonhages.  Hemorrlmj,w  into  the  sulwtani-e  of  the  cord  :irc 
cither  puiH-tate  or  massive.  Tiiis  condition  is  distirictiv  less  fr<.|ii.  iii 
than  cerebral  luiuorrhup-.  The  causes  are,  however,  nuich  the  siiinc  in 
lioth  ca.ses.  Fatty,  hyaline,  or  calcan-ous  defeneration  of  tlic  v, ,.,  N, 
thromliosis,  endM)lism.  sudden  alterations  in  bliKxl  pressure,  and  triiii:iiii- 
tisni,  play  ihe  leading;  role.  With  the  exception  of  the  trauuiatic  loriiis, 
the  lesions  an-  mon-  apt  to  k-  found  in  the  medulla  ami  up|HT  |.;iit  ..f 
(lie  con!  than  els«>when-.  IIcmorrhaj;e  into  the  nu-dulla  is  the  niiiin  i  ;iii-c 
of  the  disease  known  as  »co»e  bnlbu  paralysis. 

Tht  jninute,  punctate,  )r  capillary  hemorrhages  an-  conunmilv  ;,>mh 
ciated  with  the  infections  and  intoxications,  and  an-  met  with  in  mkIi 
conditions  as  active  and  passive  hyjK-remia,  inflanunations.  i.i..nii>, 
hydrophobia,  strv-chnine  iKiisoninjr  degenerative  softening  ati.l  ( on- 
cussion  of  the  spine.  They  are  often  met  with,  also,  iu  the  so.  illnl 
"  caisson  disease." 

The  hcmorrliajies  ap|K-ar,  on  cros.s-sc<-tion  of  the  cord,  as  niii.nif, 


n-ddisli  dots,  siattt.i-d  irrc^nilarly  thn)U>,'h  tli<-  substance.     In  tr, 
cases  the  Icsioas  are  j;eiierally  found  in  the  gniy  matte.,  an<l  i 
in  the  dorsal  horns. 

In  the  mon-  extensive  extravasations,  the  effust-d  blcKnl  p-mnilh  t 
the  line  of  least  resistance.     The  whole  thickness  of  the  cord  •; 
involv«-d,  local  collections  may  Ik-  formttl,  or  the  bloo<l  mav  .Ii- 
way  ahmg  the  filx-rs  up  and  down  the  cord.     SuKsequentlv.  .1. 
tion  of  the  ner\<-sui>stanc«-  takes  phur,  with  the  formation  "of  .v 
cavities   in   the  coni   (linnatomi/riopnrc),  Van   Cicson).     ().<:]- 
the  blood  may  cs.ajH-  into  the  central  canal,  which  thenupt.n  I 


■l.lllC 

u.illv 


i-ni- 
i-ivc 
ally, 
■mes 


ACUTE  HEMATOdENiC  Af    KUTIS 


57S 


(lilatf<l  (hrmntnmydiii),  or  into  Hm-  nw-mhrarM-s.  Sliouhl  tlw-  tmiwnt 
siirviv...  Jhe  .sulwHiuent  thaiiKi's  in  the  .l..,sfn.v,.l  nn>a  arc  .similar  to 
thos.-  «J«'.scri»>e«l  in  the  caw  of  oerrhral  hcmiirrhap-. 

^•™^;- -^'"'"•'n.  or.  p«'rha|w,  more  corrffliv.  in  th«.  majoritv  of 
iriMarurs.  Uch«ma.  w  nc.f  infrinpient,  and  is  .Jur  to  a  variHv  of  rnums. 
riir  arteries  of  the  eorl  are  prnctically  all  en.l-art.ries.  so  that  their 
.K. hision  hv  cmlarterifis,  throtnkxsis.  or  enilK>lisn.  is  foliow„l  l,v  Lnal 
ar-as of  aneinia.  softening,  an.l  ne<-r.«i.s.  Tlie  imssnr..  of  inHarn.natorv 
(•..I  .•.  tious  effuswi  |,|,xkI.  ..r  tumors  on  the  e..nl  is  foliowwl  bv  Lsehemir' 

llie  eonl  IS  also  ischeinie  in  ta.s«-s  of  ,).rni.ious  and  other  systemic 
aiii'tiHii.s. 

IHn.AMMATI0H8. 

MyeUtto.--MveIitw  in  the  stricter  s,.n.s...  or  inflammation  of  the 
^|.^.al  eonl,  is  Hue  to  hematop-nic  caUMs,  to  the  extension  o/  inflamma- 
i..rv  i,r,Kr.ss..s  fmm  the  meninges  or  ven-t.-hral  column,  lew  eommonlv 
from  the  centnil  canal,  and  to  traumatism.  Acct.nlinK  a.s  the  pr.K-e.^s 
affe.ts  the  gray  or  the  white  matter,  writers  luive  Ik^h  accu.stom«l  to 
.litrmntiate  a  jxAumyHiiii,  an«l  a  leukomyrlUh.  Several  terms  also 
an>^nsed  to  designate  certain  l(Kalization.s  of  the  inflammation,  which' 
^iifhruiitly  e.xplain  themselves.  Such  are  d!s»emi„aUd,  diffme  fra„„. 
irnr.  villi  ml,  and  annular  myeti'tin. 

Til.'  earlier  stages  of  the  |>ro<rss  ar.-  not  precMv  ^^Ildel^.to«Ml.  It  is 
[.n.l.al,!e  how,.ver,  that  many  .-a-scs  iM-gin  with  degeneration  or  ohstruc- 
iu.n  ..f  the  yessels.  follow^l  l,y  the  ,>r,Mluction  of  minute  lieTn-rrhaites 
an.  tl,..  „r.i..mry  inanifesfations  «,f  inflammation.  These  chunycs  ninv 
1h'  l.mi.^rh,  alKHit  l.y  bacterial  or  other  toxins,  su.-h  as  ergot,  lead  or 
ars..r,i.'  „r  by  the  actual  I.Kalization  of  bacteria  in  the  eonl.  The  aw-nts 
part..ularly  mnct-rned  are  the  pyogenic  cm-ci.  the  Pneumocoec-us,  the 
iul..n_l.'  Imcillus.  and  the  toxi,.  prcKlucts  of  rabies,  tetanus,  leprosy,  an.l 

<"iM.i.lent  with  this,  or  following  hani  upon  it.  an-  well-mark.-.l 
.  j:.M,ra  .vc  .hanges  in  the  nen-e-filH-rs  an.l  ,vlls.  brought  alniut,  proln 
jiN} . I,v  the  combined  action  of  the  toxin,  the  interf<.r,.nce  with  the  .ircu- 
laii.iu,  aiKl  the  pressure  of  the  inflammatory  poxlucts 

Acute  ^Jeuutogenic  Myelitis.-Acute  hematogenic-  mvelitis  arises 
-aMunaily  in  the  c<jup,e  of  such  affc-tions  as  rabies,  t^phoi.l   f.-v.-r 

l-Mt.ry  influenza,  riieumatism.  fmsillitis.  pneumonia. and  gonorrhcea 
h  M.M,..  f,>w  casc^,  .t  apiH-ars  to  In-  due  to  infective  emimli  that  lutv,'- 

3  m  'rT  •  ™™  ""'  I™"''"'"  '■"'""'•  ""'  ^™™  suppurative  or  oth.-r 
ntl.  .„„  ,,t,  ry  foci  in  some  distant  part  of  the  IkkIv.  Omisionallv.  cas,.s 
■  n>''  w|,„l,  are  on  analogy  infective  an.l  hematogenic-,  vet  a  d.-finitc 
'•au<.-.,uiii.)tl)e  made  out.  '    '  "  """""^ 

N..  iMrticuiar  rule  is  followed  with  regar.1  to  the  distribution  of  the 
wi on  ft''  "'T  "^^  *"  '"^  multiple,  and  may  Ik-  cnfim-d  to  one  small 
m,o„  ,.  ,h,.  ,.ord.  or  may  involve  s.-veral  segments.     In  some  c-ases  cer- 

c..r !  *"*  '"      ''  ""*  """^  '•''^  '^''"'"''"  *"":•■  *'^'^-"''  '•«P"»v  "lo%' 


i  i 

i 


■^'l 


ill 


67« 


THE  SPINAL  CORD 


i  ! 


M-' . 


;l- 


;t! 


Ai-c-cmling  to  the  naJiire  of  the  invaiiiriK  nii<'nHir|(niiUm,  wi    inav 
«li.Htiii);uLsh  »imf}lf  an<i  suppurative  fomw  «)f  inyelilU. 

When  n'tnuvc-il  fnim  the  h«Iy,  the  spinal  coitJ  in  thesi-  easeji  will  pn-. 
wnt  a  variable  jtii-tiire  arrnniin)<  to  the  severity  ami  extent  of  the  |>nNi-H.i. 
The  crrebronpinal  flui«l  may  In*  inrreawl.  'ITie  pia  w  c-onunonlv  \,^ 
jecte*!,  espeeially  over  the  alT«ite«l  areas.  When  palpatnl,  tin-  mv. litic 
tix-i  ean  readily  Ito  ileti>rte<l  by  their  soft,  pnltaeeoiu  roasi.slen(T,  (|iiiti> 
unlike  the  firm,  resilient  f«>el  of  the  normal  eonl.  On  seetion,  in  ail- 
vniM-«l  eases,  these  sp<»ts  are  semiliquiil  and  the  distinctive  sJniriurp 
of  the  c-ord  can  no  lonjp-r  be  ma«le  out.  In  c-olor,  the  destroyetl  snlwtaiin' 
is  rwldish  or  reiliHsh-brown  (red  softeninjf).  In  the  later  staj^  it  may  Ik« 
more  yellowish  (yellow  softening).  In  milder  forms,  however,  the  ninl 
may  .«ow  only  s<>attere<l  |>atches  of  con^^fion,  and  the  inflamnialorv 
nature  of  the  lesioas  Is  first  detected  on  raakinjf  a  microscopic  exniriina- 
tion. 

\ye  may  now  refer  more  in  detail  to  the  leading  fonrn  of  acute  heniato- 
gcnic  myelitis 

Aeut*  Antwior  PoUomyalitii.— Acute  anterior  poliomyelitis,  ,c  ///. 
fnntilr  ptihy  of  clinicians.  Is  a  discas(>  of  the  con!  in  wli.  'i  the 
pin^lion  <-ell3  of  the  anterior  horns,  the  axones  proceeding  from  tlifin. 
and  the  mascles  supplied,  are  the  parts  chiefly  affected.  It  is  p-ncrally 
|)elieyed  now  that  this  affection  is  due  to  some  hematogenic  infwlion  c 
intoxication.  It  is  found  almost  exclusively  in  young  children.  iKca- 
sionnlly  assuming  an  epidemic  character.  It  follows  exposure  to  cold. 
and  is  an  occasional  sequel  of  certain  of  the  infectious  fevers,  sncii  as 
measles  and  scarlatina.  It  -eems  proliable  that  the  caasativo  apnt 
octs  first  u|>on  the  blood  .essels  and  suKsequently  on  the  ganglia,  (•(>ntrar\- 
to  what  used  to  lie  thought.  Clinically,  the  disease  is  cliararttTiznl  hv 
11  finccid  paralysis  of  one  .  :  more  extremities,  followrtl  by  iurophy  of 
•  f-rtain  groups  of  muscles  and  eventually  contractions  and'  dcfortniiiis. 
Tlic  reflexes  are  aksent.     Sensation  is  not  impaire<l. 

Post  mortem,  the  cord  presents  congestion  of  the  gray  mnttiT.  piirtkii- 
larly  of  the  ventnd  horas,  which  are  often  the  seat  of  n-d  softenin;;.  Tlie 
pia  is  inje(te«l,  especially  in  its  anterior  portion,  and  the  cereliro^pinal 
fluid  may  be  increase<l.  With  low  magnification  it  can  gdicnilly  In? 
maile  out  that  one  horn  is  affected  more  than  the  other. 

Microscopically,  the  most  market!  changes  are  to  Ik-  fouml  in  flie 
antero-exterior  part  of  the  ventral  horn.  Occasionally  the  Mincrior 
lateral  tracts  of  the  white  sukstancc  are  involved,  rarely  the  posterior 
columns.  The  ve.s.sels  of  the  affected  region  are  conp'sfed,  iin.l  tlicre 
may  Ih'  small  hemorrhages,  while  the  perivascular  lynipii->|!,i.,s  are 
distended  with  inflammatory  leukocytes.  The  glia  isddeiiniinii,  and 
infilfratcfl  in  places  with  round  cells.  The  ganglion  cells  varv  in  appar- 
ance  according  to  the  age  and  intensity  of  the  prtx-css.  'lii. y  uiiy  Ite 
swollen,  turbid,  and  stain  Iwdly.  The  chromatin  granules  arc  iinrimj 
in  im-gular  clumps,  the  nucleus  stains  diffusely,  the  nucleolus  i-  \a(iiii- 
Uxtvil,  and  the  protoplasmic  proces.ses  are  irregular.  Later.  l!i'  micl  " 
have  <lisapix'are<l,  the  cells  arc  shrunken,  deformed,  and  il 


oroto- 


ACUTE  TRASSVKHSE  MYELITIS  577 

pla.tnk-  pr,M-,^s,^  have  .IwippeamJ,  leavinK  onlv  «   thHk..,MHl    .xU 

;.anKlm  .l..sa,.p..«r.  The  filK-p.  in  .he  anterior  roo<rir?L.«u.l 
fn.r„p  of  nene  .JeK..ner«.ion.  the  myelin  ,he«.h  L^ZakinK  Zn 
ll.!?'  'S,:''r'"''"  r'  '"*•  ""^  "'■•^•Mi.Klm  are  .swollen  u.hI  «;. 
ll  o„.r.S  i^r™"""  ""y '•«'«'nJ  ««'>«»  •h*'  l-erij.heral  ner>e..  a,J| 
!::::;S1^^^^^^  -m.pon.li„g  .^.le  ,ro„p«'    '/he  «lia  U  asuall, 


Fio.  IM 


-is  f! 
iiumlH  r. 

filXTS    nf 

infiliriiii( 

37 


m  ,1  ih  r'f  "•'•  J''"  «""«"""  '•*""^  «"■  <Jinn-nish«l  in 
•ml  timse  hat  remain  show  evidences  of  degt-.u-ration.     Certain 

H.e  anterior  roots  have  also  .lisappeare.l  The  perivascular 
'..  w.th  round  c^lls  is  still  n.tic^ab  i.  and  eom,Lur^anuIar 


5: 


578 


THE  SPINAL  CORD 


11 

s " 

!| 

' 

ill 

; 
,   i 

Nil 

it ! 

I 


ct'lls  may  be  found  in  fair  niinil)ers.  Years  after,  when  the  <Iisoa.se  lias 
eiiinpletely  .sultsitleil,  that  portion  of  theeoni  eom-sponding  totliesitc  of 
the  lesion  is  distinctly  atrophieil,  and  its  contour  is  thereby  aUered.  ( )ii 
stH"tion,  one  or  l)oth  of  the  ventral  horns  is  niarke<lly  atrophied.  As  a 
rul«-,  one  horn  only  is  noticeably  involved,  while  the  other  is  -Mmnal  or  iait 
slifthtly  affected.  Occasionally,  the  horn  is  alx>ut  normal  size,  alfhoii^'h  the 
normal  structure  is  last,  owin^  to  what  appears  to  be  a  colloid  dejrciicra- 
tion  of  the  neuro^rlia.  In  certain  parts  the  ganglia  have  entirely  dis- 
appeannl.  Those  that  remain  are  usually  normal.  The  blofxlvesscls  art' 
large  and  their  walls  thickened.  'I'he  glia  is  considerably  increased,  and 
ap|H'ars  as  a  delicate  meshwork  containing  abundant  nuclei.  I )<it(Ts' 
cells,  or  astrocytes,  may  lie  fuuml  in  considerable  numbers.  The  iiicihil- 
lattnl  fil)ers  of  the  anterior  ro«»ts  have  more  or  less  degenerated,  iiiul  ilic 
nerve-trunk  looks  thin  and  atrophic.  Occasionally,  a  few  filnTs  in  the 
pyramitlal  tracts,  in  the  immediate  neighlK)rho<Ml  of  the  priinarv  Icsidii, 
may  Ir-  degenerate*!,  but  this  is  only  trifling. 

The  nmscles  innervated  from  the  affcctwl  region  of  the  cord  inpiilh 
atmphy,  the  filjers  waste  and  disappear,  the  connective  tissue  is  iiuTeasril 
and  may  Ik-  infiltrated  witli  fat.  In  children,  not  only  the  nnisclcs,  lait 
the  lM)nes  and  vessels  are  markii'V  involved,  and  the  lind)  may  rtniaiii 
stunted  or  lag  behind  in  its  development. 

Acute  Transverse  Myelitis. — Acute  transverse  myelitis  is  occasioiiallv 
met  with  in  infectious  diseases,  but  stmietimes  without  very  evichiit  ( aiisc 

In  the  early  stages,  the  whole  thickness  of  the  c-ord  is  swollen  and  soft- 
ened for  a  short  distance.  On  section,  the  affected  part  is  reddened, 
(wlematous,  and  may  present  hemorrhages.  The  cut  surface  assumes 
a  convex  form.  Microscopically,  the  vessels  arc  congested  and  an 
surrounded  by  clumps  of  leukocytes,  chiefly  of  the  [Milymorplu)iin<lear 
variety.  The  interstitial  substance  is  (cdt-matous.  Tlic  glia  ctlh  are 
swollen  and  incri'ased  in  numlH-rs.  The  axis-cylinders  are  -.wollen, 
fraginenf*-*!,  or  atrophiwl,  and  the  myelin  .sheaths  are  degeiier.itiMi:. 
The  ganglion  cells  stain  irregularly,  their  nuelei  are  dislocated,  and  iIk 
protoplasmic  processes  are  varicose*!  or  fragmented.  Later,  imiMlieis 
of  granular  ceils  are  found,  which  are  |)robably  eomiective-lisMii  eni- 
puscles  containing  the  debris  of  the  broken-down  tissue.     "AniNlnid" 

bodies  may  also  Ik'  seen.     This  stage  may  1k<  reganled  as  oi (  red 

softening.  It  .s<K)n  gives  place  to  yellow  .softening.  The  cord  i-  (inie- 
wliat  swollen,  and  of  a  yelh)wisii  color.  The  gray  matter  is  di^iiiidly 
wa.sted.  The  microscopic  apjH'arances  are  similar  to  those  just  dr  rilied, 
save  that  tli^  neuroglia  is  more  swollen  and  l(Kiser,  e()iis((|M. ndv,  in 
texture,  the  glia  cells  In-gin  to  show  degeneration,  graruilar  cell 
more  numerous,  and  the  |)arenchymatr)us  changes  are  more  i 
The  ganglion  cells  are  swoll«-n,  irregular,  and  vacuolated,  n 
they  may  l)e  shnmken,  stain  badly,  and  contain  no  niuli  i 
may  be  n-presenled  by  a  protoplasmic  sac  containing  brow: 
ment,  and  .some  have  totally  disapfM-ared,  as  is  proved  ii\  ■ 
that  the  numlM-r  of  ganglia  is  reduced.  In  very  severe  cases,  i' 
eration  Is  .so  extreme  that  the  affected  |M>rtion  of  the  cord  is  i. 


llllV, 
;.I,'  still 
iiirked. 
lijaiii. 
Some 
■!.  |>ii:- 
,■  fait 
dejren- 
i.rd  to 


LANDHY'S  PARALYSIS  579 

a  puhaccous  mass  composed  of  fat  globules,  granular  cells  and  defrih.c 
no.. or  cases,  wher«  the  process  L  son^eS^t  M^^d^^^^ 
n-pura  .ve  changes  make  their  appearance.  The  ganglia  aid  S 
hlK.rs  have  largely  disappeared,  the  granular  cells  are  less  numerous  and 
ar^  f<...nd  mamly  about  the  bloodvessels,  while  the  glia  showTpSera 
t.on  and  .s  mor«  abundant.  Secondary  degeneration  may  appear  7, 
ttrta.n  tracts  above  and  lielow  the  inflamed  area  ^'^ 

Mv.-i.fc  processes  heal.  wi.e,.  they  .lo  so,  with  the  replacement  of  the 
,.s.rny,.l  ner^•e^h.ments  by  dense  scar  tissue,  giving  the  cTrd  at  t le 
afr...-..-,.  part  a  .shrunkc...  grayish  appearance  and  f  somewhat  h.H 
.•ons,s„.,.c..  lh.s  ,s,  .„  part,  d.,e  to  hyjK^rplasia  of  the  glial  cells  In 
II!  TJ  f^  Prohh-ruthn  of  the  ^nn^ctive  tissue  deiv,3frm 
tlK  sh..atl.s  o   the  blo«<  vesses  an.l  the  prolongations  of  the  pia 

mv   ll'i '    f"ll      r'""-'  ''''^"'  •'"  '^'  P"^'*'""  "f  'he  lesion.     Transverse 
V         .      the   hoi-acK-  conl  gives  rise  to  spastic  paraplegia  of  tl  c  lowe^ 
,.  .r......  .OS  without  atrophy,  paralysis  of  the  abdoninal  muscls   par 

alvs,s  „f  the  bladder  a,.d  ...testines.  and  anesthesia  Ix-low  thT levd  ofT 
es,on.    A  les,onof  the  lower  cervical  region  causes  flaccid  parab^s  of 
.h<-  arms  w.th  atrophy,  spasmic  paralysis  of  the  legs,  lo.ss  of^ilaLn 
...   I..-  an„s  a„,l  Ih-Iow  the  level  of  the  second  riirpupmarvXnLes 
a...i  n.s,,.ratory  emUrrass.nent.     W.en  the  hnnba    rogC  ^  [„vK 

Acute   Suppurative  MyeUtis. -Acute   suppurative   nnelitis     when    ,.f 
on,a  o,..„K.  „r,g,u.    is   rare.     It   .K-c-asiouallv   is   found   Sondarv 
^...•l...-.ja..s.  ..ppura^on  i„  the  ge„it.M.ri,^ary  tm.-t.  l.^' Wr  ^ 
al.M-...  of  the  hyer.     The  suppuration  mav  Ik-  somewhat  diffuse    fol 
;w.M,     ..hue  of  the  bl,H,dvosscls.  or  smallabsccsscs  mav  1.1  SmJ  ' 
II'"  I'M  hologieal  ,.hanges  ,lo  not  differ  materiallv  fmm-those    „       ,  ; 
;;"•;  -'  a.-te  myelit  s.  e.xc..pt  that  the  process  ismon  1,"^.     W 
tl.'  al.Mrsscs  are  small  and  isolatcl,  the  .legenerative  chanires  aro  o    , 
"">■  -  «l"-  .".."«liate  neighborho,.l,  while  the  intenSg  L     'i 
(•i>iii|),initivfiy  or  entirely  free.  ••toimng  iissue  is 

Acute  myeUtis,  arising  by  extension,  can  iisuallv  1k«  trace,l  to  inflnn 

M>.  Ims  of  central  origin  is  generally  clue  to  abscesses  or  sunnuritive 
m^. mn.  ,..,.  somewhere  in  the  ventricles,  the  i„fe,.,iv..  agenTs  fZ  w  lich 

«  m    ■  '         '"'^'T'  "^-'''''f  '""'  •"^'■"'''.'^••'''i""  of  the  cells  in  tl  c  "fa; 

ai.;  ::::;■;.:  th;t;;s;':^.t:^::'"'' "-'  '-•'  "--•  »"•'  •--- 

iMdry  s  Paralysis.   -Apart  fi-om  tulH-rculosi.s  an.l  svphilis  of  the  conl 
'  ^  '"  ' •'^••"'•*"'  '"•'-'"f'*"-.  IxThaps  the  most  important  affectkll; 


1: 


"11 


■  1    J I 


n 


580 


THE  SPINAL  CORD 


coming  under  this  category  is  aenU  ueending  panlyiit  (I^ndry'.s  |)jir- 
alysis).  This  affection,  as  its  name  implies,  is  an  acute  one,  character- 
ized clinically  by  the  occurrence  of  paralysis,  usually  extending  from 
below  upward,  and  ending  quickly  in  death,  owing  to  involvement  of 
the  bulbar  nuclei.  Sensory  symptoms  are  in  abeyance,  and  the  aff<rted 
muscles  preserve  their  faradic  irritability.  The  spleen  is  cniurj;ed, 
sometimes  also  the  various  lymph-nodes,  and  the  kidneys  show  dejiener- 
ative  changes.  This  would  suggest  a  general  systemic  infection  us  tlie 
cause,  although  the  nature  of  it  is  quite  obscure.  Proljably  a  variety 
of  agents  may  cause  it.  Judging  from  clinical  features,  the  lesions 
may  be  primary  in  the  cord  and  medulla,  or  may  extend  to  it  from  the 
peripheral  nerves. 

The  histological  features  of  the  disease  have  lieen  much  (lel)ati'il. 
Landry  did  not  find  changes  in  the  central  or  peripheral  nervous  s_v. -it  ni. 
Others  l)elieve  the  cord  to  be  extensively  involved,  while  the  majority 
regard  the  disease  as  primary  in  the  peripheral  motor  neurones.  The 
lesions  apparently  vary.  In  vj  case,  they  are  practically  those  of  an 
acute  poliomyelitis.  In  another,  there  is  an  acute  exudative  iiiHainnia- 
tion  of  the  connective  tissue  of  the  peripheral  nerves,  whith  may  W 
simple,  hemorrhagic,  or  suppurative,  leading  to  extensive  degeneration 
of  the  nerve-elements. 

Tnumatic  Myelitis. — ^IVaumatic  myelitis  includes  all  those  forms  which 
result  from  injuries,  such  as  gunshots,  cutting  or  .stabbing,  contusions, 
fractures,  and  dislocations  of  the  vertebrae.  These  injuries  lead  to 
more  or  less  laceration  and  compression  of  the  cord,  or  even  to  solution 
of  continuity  or  complete  destruction  of  the  cord  at  the  afTet-tiHl  refjion. 
The  amount  of  inflammation,  of  course,  depends  on  the  nature  and  extent 
of  the  injury.  The  injury  leads  to  the  rupture  and  disiiitejrralion  of 
certain  of  the  nerve-fil)ers  and  ganglia,  and  this  leads  to  sccondarv 
degeneration  in  the  tracts  functionally  connec-te<l  with  the  dcNiroycd 
structures.  The  glia  and  connective  tissue  mav  also  Ih"  involved.  In 
severe  ca.ses  the  section  of  the  cord  affected  may  soften  anil  liecoine 
li(iuefie<l.  Should  there  l»c  but  little  l)loo<l,  we  get  the  wt  ll-known 
"white"  softening.  \Miere  blood  is  effti.se«l,  wc  have  "red"  ,iiid  later 
"yellow"  softening.  Interference  with  the  free  flow  of  bliHMJ  en-  lymph 
in  the  vessels  may  lead  to  foci  of  softening  in  <listricts  n-niotc  tinni  the 
injury.  If  infection  with  pyog«'nic  microorganisms  take  place, 
have  aKscess  of  the  cord  with  extension  of  purulent  inflaniniaiii 
Tneriingi'M.  In  the  milder  forms,  healing  may  take  place  l>\ 
or  replacement  of  the  destroywl  tissue  by  proliferatwi  glia  > 
the  severer  cases,  esj>ecially  where  the  membranes  are  involvii! 
coiHUK'tive-tissue  .scar  may  Iw  pnxluctHl. 

Tuberculosis. — ^TulH>nulosis  of  the  con!  is  ran-ly  priiimn 
has  met  with  one  case  of  tul)crculous  myelitis  in  which 
tuberculous  lesion  was  detected  in  the  IkmIv.     As  a  rule,  li>'" 


wv  may 
>ii  to  the 
-c  liTosis, 
ilk  in 
,  ;i  di'iw 


( 'ollins' 
IP  other 

v!-.  thvTV 


'  American  Text-book  of  Put  liologj',  W.  U.  iNiunders  &  Co.,  PhiLi. 
lUOl :  567. 


I.imtlon, 


RETROGRESSIVE  METAMORPHOSES 


581 


is  tiiJwrcuIosis  elsewhere.  The  disease  takes  three  forms— multiple 
mihnry  granulomas,  larger  single  or  multiple  nodules,  and  meninao. 
myclihs.  " 

In  the  first  mentione<l  form,  numerous  small  tubercles,  often  of  micro- 
scopic size,  are  found  l)oth  in  the  gray  and  the  white  substance,  usually 
alK)iit  the  vessels,  indicati/^  a  hematogenic  mode  of  infection  The 
ohsfruction  to  the  circulation  thus  caused  and  the  consequent  lack  of 
nutrition  leads  to  areas  of  ischemic  softening,  and  there  may  even  be 
socoiKlary  degeneration  of  the  fibers  near  by. 

1.1  the  second  variety  granulomas  sometimes  as  laree  as  a  hazelnut 
miiv  l)e  found,  which  present  extensive  central  caseation  or  even  lique- 
faction. The  tubercles  may  extend  to  the  meninges  or  l.reak  into  the 
central  canal,  so  that  more  widespread  infection  may  take  place  In  some 
ca.s,.s  the  continuity  of  the  cord  is  practically  entirely  interrupted. 
biwiKiary  degeneration  of  neighboring  fibers  occurs. 

The  most  common  form  is  the  tul)erculous  meningorayelitis.  Here  the 
.nf.rtion  sprea,'  from  the  meninges  by  means  of  the  intraspinal  prolonga- 
ti-iiis  of  the  pia,  through  the  perivascular  lymphatics.  Small  tubercles 
arc  found  ai)out  the  vessels,  which  may  in  time  reach  a  fair  size,  caseate, 
and  lead  to  considerable  destruction  of  the  nerve-substance 

SyphlU8.-Some  writers  are  inclined  to  believe  in  the  existence  of 
a  simple  acute  myelitis  occurring  in  the  eariier  years  of  syphilis,  which 
IS  not  unlike  the  non-specific  forms  of  diffuse  mvelitis  before  referred 
to  1  here  IS  the  same  degeneration  of  the  specific  nerve-elements  with 
cellular  inh  tration  of  the  connective  tissue.  The  bloodvessels  appear 
to  h;  specially  implicated.  They  show  endarteritis,  may  be  thrombosed 
an,i  1.1  their  vicinity  small  hemorrhages  may  be  seen.  I^ss  questionable. 
Iiowever,  y^  syphilitic  meningomyelitis.  This  is  most  common  in  the 
nmca!  and  dorsal  regions  of  the  cord.  The  main  characteristic  is 
he  thickening  or  degeneration  of  the  vessels  with,  sometimes,  the  forma- 
tion of  small  gummas  along  their  course.  This  leads  to  degeneraf!..,, 
of  the  nerve-fibers  and  ganglia.  Secondary  degeneration  is  comm-,;.. 
lluw  IS  a  small-ceiled  infiltration  about  the  vessels,  and  the  glia  is 
increased.  " 

Leprosy.-In  a  I.  w  cases  we  find  merely  atrophy  and  .legeneration 
of  tlie  nerve-elements  particulariy  the  ganglia.  As  a  rule,  however. 
h,n.  a  e  areas  of  softening  and  hemorrhagic  extravasation.  Micnn 
Z"  .  ■«  "  "!"■•"  •'*"'?'".'^''  a"^  degenerate<l.  and  the  connective  tissue 
h     s  ,„f|,„nma  ory  exudation  and  hemorrhage.    The  lepra  bacilli  have 

siil.sta."'e      '"  '^""'^''^'^  "■'^^"t''  '"'"'  "f  the  gr.->y  and  the  white 

RBTROORESSIVK  BUTIMORPHOSU. 

tin!  i,!'wl :"."  ?r  '".'"f  "^^''l*^  I?"""^  forms  of  atrophy  an.l  dcgenera- 
;      .  uhich  the  spinal  cord  is  liable.    We  have  to  premise,  however, 

1    n     r^-lf  !r^^  '""'  ^^  difficulties.    As  has  been  In^fore 
"i-iik.  I  (p.  .jofi),  the  nervous  tissue  is  the  most  delicate  and  highly 


l!H 


Til  I  ■ 


I 
1     = 

' 

"" 

) 

1    - 

f 

1          '      1 

- 

!■  1 


It  M    »HWB 


582 


THE  SPINAL  CORD 


specialized  structure  in  the  Ixxly.  It  Is,  consequently,  particularlv 
susceptible  to  the  action  of  all  kinjls  of  deteriorating;  agencies,  while 
its  recuperative  jwwers  are  slight.  This  cx|)li!ins  why  it  is  that  disinte- 
gration and  degeneration  are  the  most  constant  and  striking  path()ii)};i(al 
changes  which  meet  the  investigator.  These  retrogressive  phenonutia 
are  produced  by  tlie  most  diverse  causes,  and  it  is  not  always  possihlc, 
in  any  given  case,  to  determine  the  etiological  factor  chiefly  or  eiitirch  to 
blame.  Thus,  the  distinction  between  intliitnmatory  and  pure  degenera- 
tions cannot  always  In*  made.  Nevertheless,  it  is  the  custom  iiiuoni; 
clinicians  to  apply  the  generic  term  iiiiifllti'n,  or  iiiHammatioii  of  the  cim' 
to  all  forms  of  dcgeiier..lion,  irresp«H"tive  of  the  cause,  inasmucli  iis  iliev 
are  characterised  by  fairly  definite  and  constant  symptoms,  dcpeiidinj; 
<m  the  localization  of  the  lesion.  Tiie  term  "myelitis,"  in  tin's  wide 
sense,  is  a  convenient  one  and  thoroughly  establisluHl  by  ciistdin.  Imt 
shouhl  be  use<l  with  a  certain  mental  reservation. 

In  order  to  get  a  clear  uiulcrstaiHling  of  degcnenition  of  iMivc-ii^^iic 
and  its  results,  it  is  important  to  In'ar  certain  facts  in  mind. 

According  to  the  "neurone"  -•oncept  of  the  histological  striicnirc  of 
the  nervous  .system,  commonly  hehl  at  the  present  day,  the  l)r:iiii  atul 
spinal  cortl,  with  their  prolongations,  the  peripiieral  mrves,  are  lo  lie 
r«>gardcd  in  the  main  as  a  pwuliar  aggregation  of  highly  spcciaJi/t  il  (ells. 
consisting  of  a  large  cell-lMMly  with  protoplasmic  pnxesscs  (the  pmiilion 
cell)  from  which  pr<x-eeds  a  single  long  and  atteiuiated  thread  ta\i«- 
cyliiider  or  neuraxone).  The  whole  constitutes  the  ncuninc.  Kadi 
neurone  is,  so  to  speak,  self-<-ontain»'d,  and  has  no  coiminiiiicaiidii  wiili 
adjacent  neurones,  save  by  contiguity. 

The  varioas  constituents  of  the  neurone  may  act  differeiiih  wiuii 
subjectiKl  to  abnormal  conditions.  In  general,  it  may  Ix'  said  tln't  a 
niTve-fiU'r  or  neura.xone  when  .severed  from  any  cause  from  lis  r  .iriiiit 
centre,  the  ganglion  cell,  will  degenerate.  The  process  iM;:in>  at  llie 
distal  extremity  and  extends  gradually  Inckward  to  the  site  of  ihi  lesjon. 
In  .some  ca.ses  the  degeneration  is  prliiKiri/:  that  is  to  .say.  it  i^  due  to 
•some  cause  acting  Kxally  and  directly  <;ii  a  filx-r  or  bundle  nf  lilKr>. 
The  lesion  may  Ix-  chiefly  or  entirely  confine<l  to  one  ])liysii)l(i-i(  :d  trait 
of  the  cord,  and  we  then  .speak  of  a  primary  "nynlrm"  ili.siax' .  <  >r  more 
than  one  tract  may  Ix-  involved  anil  we  have  a  rowliliial  ■- o/'w" 
(li-sras  In  other  cases,  and  probably  the  majority,  the  depm  ration 
may  1k>  refern-d  to  .some  lesion  at  a  distance,  such  as  de-irn.  lion  of 
the  ganglion  cells  nourishing  the  filx'rs,  or  anything  wliic  li  iiiirferes 
with  the  conducting  jM>wer  of  the  fibers.  This  is  callfd  •mhwi 
degeneration. 

In  primary  de-'cneration  certain  tracts  appear  to  Ix-  spetTii:  pickiti 
out.  These  are  the  ncnsonj  nciirofir.i  of  the  cord,  which  ma;  <  traitil 
from  the  posterior  nervc-r<M)ts  into  tin-  coliunn  of  Hurdadi.  t'  me  into 
the  coliinm  of  (ioll,  to  end  finally  in  the  medulla  in  the  iiur'  i  "f  (ioll 
and  Burdach;  the  crnfrul  motor  neurones,  starting  in  the  pyrar..  la!  layer 
of  the  !m>tor  cortex,  and  passing  through  the  int»'rnal  caii-u!. 
mids,  into  the  pyramidal  tracts;  the  peripheral  motor  neuran. 


]f  jivra- 
.•iiinirij; 


RETROGRESSl  VE  MET  A  MOliP  HOSES 


583 


in  the  jjHiij^lia  of  the  veiitntl  h«irrw,  and  exteiidiiiK  throiKjh  the  anterior 
roors  to  the  muscles. 

S't-ondary  depi«neratioii  is  divid,^!  into  uxceiuliny  and  descetulhm 
according  to  the  direction  it  takes  in  the  cord.  A-scending  degeneraticin' 
is  generally  found  in  the  posterior  columns,  the  direct  cerebellar  tract 
and  the  untcrdateral  trad  of  Gowers.  It  mav  Ix-  a.s.sociate<l  with  lesions 
of  111.'  gungh'a  in  Clarke's  «)lunins.  The  prtJcess  terminates  in  the  resti- 
foriii  bodies  of  the  me<hilla.  Descending  degeneration  tnainlv  affects 
the  purawnlat  tracts.  Thus,  in  the  case  of  a  unilateral  lesion  alK)ve 
tlie  decussation,  say,  in  the  motor  cortex,  we  find  degeneration  in  the 
anterior  pyrami.lal  tract  on  the  same  side  and  in  the  lateral  or  crossed 
pvraiiiidal  tnu-t  on  the  opp.x^it,.  side.  .\  few  motor  filn-rs  appear  not  to 
.leciissate  and  pass  down  tin  iiijh  the  lateral  columns.  In  long-stamling 
eases,  atrophy  of  the  ganglion  c,  lis  of  the  ventral  horns  has  In-en  observe<l 
l).M-eii.liiigdeg.-neration  has  at  times  Ihtii  noted  in  the  p(.sterior  columns' 
111  the  up|HT  part  of  the  cor.l  it  affects  two  small  tracts  passing  outwanj 
aiMJ  Laekward  fn>m  a  point  slightly  hchind  the  grav  commissur*-  (c-o'iima- 
.l.p  neration  of  Schultze).  Lower  down  the  fiher;^  api>roach  the  posterior 
colli   iissiire,  where  they  form  the  oval  field  of  Fleclisl.,'. 

.S.ondary  degeneration  is  apt  to  be  of  consideriibfe  extent,  siiiec  the 
iitrye  paths  are  so  elongated  and  their  correlation  is  close. 

Tlie  (aiiscs  of  n,'r%e  degeneration  are  luiinerous.  Chief  amon<'  them 
may  !.,■  mentioned  mechanical  trauma;  circulaforv  disturbances  siicli 
a,  anemia,  embolism,  thrombosis,  endarteritis,  and  hemorrhage-  and 
Kixiiis  of  bacterial,  mineral,  or  vegetable  origin.  In  some  <'ases  'tlu-rc 
may  l.c  a  combination  of  factors  at  work. 

CoMsidt-rable  difficulty  is  experienced  when  one  attempts  to  .|,H-ide 
ii|Mm  a  ogical  classification  of  the  degenerative  affections  of  the  spinal 
< onl.  We  have  referred  above  to  " primarv"  and  " secondarv"  degencra- 
tionx  .Many  authorities  speak  of  "primary  .system  diseasV,"  meaninj; 
h}  hat  a  disease  in  which  the  lesions  are  confined  to  a  definite  "svstem" 
"1  ii.rve-tract,  involving  a  greater  or  less  extent  of  its  course,  whiel-  can- 
not he  referred  etiologically  to  any  obvioas  or  gross  external  anatomical 
•  lianj;..  lliis  IS  certainly  a  convenient  clinical  genei  llzation,  but  it 
mav  wej  be  tlouiited.  from  the  point  of  view  of  the  p  l„,ri,.a|  histol- 
0-1  I,  whether  the  lesions  in  (|uestion  ever  are  rcstri.  one  i.hvsio- 

op.Ml  nervi-tntct.     .Vgain.  in  many  ca.ses,  opinions  livided  as  to 

'lie  l>iopnety  of  the  term  "primary,"  inasmuch  as  our  k„uwletlge  ..f  the 
orifiiii  aii.l  course  of  the  pathological  change,  is  still  impcrfi-ct,  while 
jmiiiaiy  and  secondary  manifestation  are  often  so  intimatelv  asswiated 
't  eniMs...  where  it  is  po.ssibIe,  our  classifications  of  rliseasc  should  Ik- 
«>e'l  M|M,n  pathogeny  and  morbid  anatomv,  and  it  should  be  our  aim 
t"  >li-^N  th,.  harmony  Ix-tween  these  and  the  clinical  features.  In  manv 
eases,  hmvevcr  as  here,  we  mast  to  a  large  extent  Iw  guided  bv  exp.-di. 
••>'<y.  It  luis  l)een  dwrn.^l  wiser  here,  therefore,  not  to  draw  Un;  fine 
'li^iiii'  iiuMs   but  to  adopt  a  mainly  "regional"  classification. 

Alii,,,.::  the  commonest  forms  of  spinal  c<.rd  degeneration  is  that  due 
'u  p'VMiie,  the  so-called  "comprtMion  myeUtis."    .Vs  a  rule,  the  lesion 


1  ; 


i  ' 

'«   I 
it   i 


.'iS4 


THE  SPI\AL  CORD 


is  a  tranavenie  iino,  iitrcctiiiK  till  tin-  cliMiiiMits  of  tlio  c«»r<l  in  ii  «t>ni|>iira- 
tivfly  rcstrii-tiNl  un-u.  It  nmy  lie  c-iiiLsttl  Uy  trui'inHti.sni, sufh  an  fnuiiirc 
of  the  vortohral  coliitiiii  witli  |m\s.siirp  of  ii  luiniim  ii|M)Ii  t!ie  t-onl,  hut  is 
often  also  tliie  to  tiilM>nMilous  t-arics  of  the  spine,  tiiln'reulosLs  of  the 
nu-iiinp's,  an«l  primary  or  stM-ondary  tumors  in  tlie  vertebral  canal  or 
in  the  eon!  itself.     Central  degeneration  may  l)e  eause<l  by  the  aceuiiiii- 


Fio.  157 


Coinprcs^iuii  myelitis.    (Vrviral  curd.      (Krora  the  collection  of  Dr.  Colin  K.  l!n--i  I 

Fia.  158 


riimpre.i>i.in  myelitis.     Dorsal  cord.     Degeneration  in  the  posterior  and  lat«T:il 
(From  the  collection  of  Dr.  Colin  K.  Kus.<el.) 

lation  of  I)I(mmI  or  fluid  in  the  central  canal.    Any  of  these  c.ii.l 
cause  marked  destruction  of  the  ner\e-element.s  at  the-  site  of  li 
with  widespread  ascending;  and  desccndirij;dej;eneration  in  tin- .. 
tracts.     The  locnl  effects  pnKhicetl  may  Ite  referrcii  in  part  U' 
influence  of  the  pressure,  but  much  more  to  the  disturbaiuf  "t 
and  lymph-circulation.     The  degeneration  is  first   niiinif.  - 


•-will 
il  ~i(lll. 

i.llK»i 

:,   till' 


MULTIPLE  on  mSSKMIXATKn  SrLERO!iL<< 


iM 


whit.-  siilxstaiHi-,  th«'  fiU-rs  of  which  swell  up  and  di.sinU'Krut.-,  much 
as  has  l»een  (IcscriUHl  in  the  rase  of  tmiisverse  se<tioii  of  the  n.rves. 
'I'hc  iixis-eyhnders  swell  and  Ui-onu'  varieosi-d,  and  tin;  nivelin  sheaths 
l.riak  down  into  fat.  Tlie  fjanjjlion  wlls  are  soinewlmt  more  resistant, 
hilt  ultimately  undergo  vacuolation  an<l  ehn)mafolvsis.  (irannlar  cells 
ii|>|H-ar  early  and  in  eonsi.lerahle  mim!K,rs.  hi  theVourse  of  a  few  davs 
the  (h'jjenerative  ehanj,'es  may  Ih<  trawl  to  the  extremities  of  the  neurones. 
r«if.r,  Inith  the  HIhts  and  their  sheaths  will  have  almost  entirely  dis- 
a|.|)<are<l.  although  degenerate.1  atid  varicosed   filn-rs   mav  here  and 


Fio.  159 


(■..nipre-Hon  inyelili^.     I.iinilmr  cord.     (Frum  the  .■.,llcLli..n  of  Dr.  Coli,,  K    n,„.^.|  ) 

tlurc  i)e  seen,  the  numlHT  of  fiU-rs  remaiiiiii};  iH-ing,  of  course  de- 
[HiKi.iit  (m  the  extent  of  the  original  lesi.m.  'I'he  place  of  the  degener- 
at.d  filters  is  taken  up  hy  newly-formed  glial  tissue,  wliicii  cveiituallv 
l«ai|>  t(.  contraction  and  sclerosis  of  the  cord.  The  cord  as  a  whole 
shniiks,  JKTomes  firmer,  and  assumes  a  grayish  color. 

It  -lioiiid.  jH-rhaps,  Ih-  remarked  that  in  cases  su<h  as  tulnTciilosis  of 
th.'  iiuiiinges  the  msulting  lesions  in  the  cord  mav,  in  some  instances, 
not  1...  .Mitirely  due  to  pressure  and  circuIatorv'disturl)anccs,  hut  to 
inll,iiiini;;tion  as  well. 

Multiple  or  Disseminated   Sclerosis.-Multiple  or  disseminatcl 

xl.n,,,,  ,see  p.  M2)  is  a  disease  which  affects  th<-  nervous  svst<Tn  as 
a  «l„,|,..  Xot  only  may  the  spinal  cord  l.e  involvc.l,  l.ut  the  llrain  and 
[KriplMtal  nerves.     The  lesions  iirv  irregularlv  (li>trihute(i.  apparcntlv 

'"" '  ""'^•'»  '••'yme  or  nnison,  and  mav  Ik-  cliieHv  IcMalize.l  ii,  .he 

liniiM.  ur,  again,  in  the  cord. 

Ill  i!ir  case  of  the  cord,  one  Hnds  multiple,  gravish  foci,  gcnerallv  in 
Hi-'  -.:('■  suhstance,  hut  also  to  some  extent  in  tlie  gray  matter,  which 


•   I 


I  i 

II 


i    t 


'  I 


I' 


jM^ 


586 


r//fc'  SPIXAL  CORD 


may  lie  tho  .si/A>  of  u  |>iii-li«>a<l  «»r  smiilU'r,  «r  may  involvt-  iM-urly  t\w  w  Imli. 
traii-sverse  thickness  of  the  conl.  Tlics*-  fiK-i  vary  .soincwliut'in  a|>|Hiir- 
aiK-e,  Ix'ing  at  one  time  ratlior  soft  and  p-latino'us-looking,  of  j;ravi>||. 
white  c-olor,  ratlier  badly  (k'fincd  fnwn  the  normal  tissues;  at  aiioilur, 
fairly  firm,  of  a  uniform  gray  fok)r,  and  sliarply  ditferentiatiHl.  ( ). ra- 
sionally,  the  lesions  are  to  lie  found  in  n>lation  with  various  blotxivj^s,  N. 
Mifrosoopically,  in  these  areas  t)ne  firiils  droplets  of  myelin  ami  fat, 
fattily  degenerated  crlls,  granule  crlls.  and  detritus.  The  vessels  rom- 
nionly  present  hyaline  thiekening  of  their  walls,  and  there  nun  U' 
aceuinulations  of  round  crlls  in  the  |N-rivaseular  lymph-spacer.  111,. 
glia  invariahly  shows  prolifenition,  which  niiiy  Im-  extensive,  ainoiititini' 
to  <lefinite  sclerosis. 

Kio.  Ill) 


•^■niinaU'il  «lfr«)sis.     The  curd  i-howB  irregularly  distributed  patihes  of  di-ip'ij.r.iu  n 
(Kn>m  the  cullecUon  of  Dr.  I'oliu  K.  Itusael.) 

The  etiology  of  the  disease  is  oKscure.  The  affection  of  the  vr-^N 
might  suggest  a  vascular  origin,  such  as  a  circulating  toxin  or  int. .  liun. 
or,  again,  an  ischemic  necrosis.  From  the  histological  apiMar.in.r  of 
the  lesions.  Ziegler  would  recogni/e  two  varieties,  scroiiiliiri/  rjtljl 
.icleraiia,  which  results  fron»  a  previous  focal  degeneration  or  iriii.iiiuiia- 
tion.  jind  prlmm/  miilliiJe  sdrroiiU,  due  to  a  pathological  1iv|m  ^lasia 
of  the  glia,  akin  to  what  occurs  in  syringomyelia,  and  prohalilv  1. 1,  raUi 

to  some  error  in  development.     The  latter' type  affects  clii.li.\  n  .  ] 

ferior  columns  and  the  neiglihorluMxl  of  the  ventricles,  and  is  < !  ■::,<  K  r- 
ized  by  a  jH-culiarly  dcn^e  overgrowth  of  the  glial  subsfaiicc.  :  uhidi 
may  Ik-  found  scatteretl  nerve  filn'rs  that  present  little  or  no  liti;.       iiiuii. 

Chronic  Anterior  Poliomyelitis.— In  .some  instances  the  gan.'  i  <  tH> 
of  the  ventral  cornua,  together  with  the  peripheral  mot.pr  •  ,r..ne>. 
undergo  degeneration.  Chronic  anterior  poliomvelitis  mav  h.  !.tii  a.^ 
the  type. 

This  disease  is  similar  in  its  clinical  features  to  the  twm-  ttrior 
poliomyelitis  dcscrilHtl  More  (p.  j7»i),  save  that  it  Iwgins  in-i.i;     -iyami 


LATERAL  SCLEROSIS 


M7 


runs  a  chronic  or  siilichronie  course.  Some  cases  are  l)clievi><l  to  huve 
an  inflammatory  liasis,  ami  the  histological  app<>aranccs  are  stricily 
coinnarahle  to  those  found  in  the  acute  form.  In  other  ca.ses  the  afl'ec- 
lioii  seems  to  l»e  a  pun-  (h>^-tienition,  the  lesions  \mi\g  atrophy  of  the 
cills  of  the  ventral  horns,  witii  siijjht  interstitial  changes  in  tin?  white 
siiltstiince,  degeneration  of  the  peripheral  motor  neurones,  and  wasting 
of  the  n>ib.^les  supplied  by  tiieni. 

Progressive  Bulbar  Paralysis.— Analogous  to  this  in  all  ns|M«ts 
is  ilie  progn'ssive  hulUir  paralysis,  or  giossolahioiaryngeal  pandysis,  in 
wliicli  the  motor  nuclei  of  th«'  medulla,  usually  the  nuclei  of  the"  hv|M)- 
j;|(issal,  vagus,  acce,s,siirius,  facial,  and  glossopharyngeal  nerves,  an- 
inv(>lve<l.  There  may  or  may  not  Im'  degemratioii  of  (he  pyramidal 
tracts.  When  degeneration  in  this  situation  is  presi-nt  m-  havi-  Vcallv  an 
aiMyiitropliic  lateral  sclenisis.  The  nature  of  the  disease  is  oliscun-. 
Soniclimes  it  shows  a  familial  distribution.  It  is  most  prolmhlv  an 
aliiiitrophic  condition. 

Progressive  Spinal  Muscular  Atrophy. Closely  resembling  chrome 

anterior  |)oliomyelitis,  clinically  as  well  as  anatomically,  is  the  disease 
known  as  progn-ssive  spinal  muscular  atrophy  of  the  .\ran-l)ll(•lM•llIl(• 
f,v|H•.  Here,  also,  there  is  atrophy  of  the  ganglion  c-ells  of  the  ventral 
li:)rns,  with  degeneration  of  the  |MTipheral  motor  ncrvc-fiUrs  and 
ihf  corresponding  muscles.  There  are,  Imwcver,  in  aildition.  more 
or  l(s>  niarkeil  changes  in  the  wiiiti-  substance  of  the  cord,  notablv  the 
p. rann'dal  tracts  and  the  anterolateral  ground-bundle.  The  puiglia 
arc  found  in  various  stages  of  atn>phy,  or  may  have  disap|)cared.  The 
anterior  horns,  as  a  whole,  do  not  setin  to  shririk,  as  is  the  case  in  chronic 
poliomyelitis,  but  an-  transformed  into  a  fine  reticulum,  containing 
lar;;c  nuintxTS  of  spindh'-yV  .^H^^\  cells.  The  anterior  nx)ts  are  wastcfL 
and  niiiiiy  of  tlie  KIkts  forming  the  [x-ripheral  ncrve-trimk.s  arc  partiailv 
or  coiripletcly  degenerated.  According  to  Gowcrs,  the  pyramiilal  tracts 
arc  invariably  involved  to  some  extent.  In  the  most  s.-verc  cases  the 
•Icpncration  can  lie  'raced  upward  as  far  as  the  mr)for  cortex. 

TIk  atftrtcil  muscles  show  simple  atrophy,  or  fatty  or  vitreous  degener- 
ation. The  muscle  miclei  are  often  increast-d,  and  there  mav  k-  increase 
of  tlic  interstitial  c-onncctive  tissue. 

Tlif  pnKt'ss  tn-gins  in  the  cervical  region.  The  muscles  affecti-<i 
arc  first  those  of  the  thenar  and  hyj)othenar  eminences,  the  lumbricales 
and  intcrossci,  later  those  of  the  forearm  an<l  shoulder.  Hcsidcs  this, 
the  more  usual  Aran-Duchenne  tvfx-,  then-  arc  r.tlier  forms,  notablv 
one  111  wliich  the  wasting  Ix-gins  in  the  lower  extremities. 

riic  cause  of  the  disease  is  obscure.  From  the  now  wcll-ncogni/cl 
fa'i  that  certain  mineral  substances,  such  as  leail,  and  bacterial  toxins, 
like  tliiit  of  diphtheria,  are  occasionally  productive  of  degenerative  .liangcs 
in  III,  motor  nuclei  and  fx^ripheral  nenes,  it  may  U-  inf.rrcd  that  < ircu- 
l3ti!,;r  jw>|sons,  either  exogenous  or,  perhaps,  of  "a  melat«jlic  nature,  an- 
at  wnrk. 

Lateral  Sclerosis.— Degenc-aiion  iti  the  laliral  or  pymmi/tnl  tracts  is 
'■°" "'b  known  as  lateral  acleronk.    It  may  Ix.-  a  descending  dcgcnera- 


J 


i--     ■   I  I  I  (    ■ 


St 


5X8 


THE  SPIS'AL  CORD 


turn,  soroiHlarv  to  «Ii.«-aw  of  thv  Kaii);lioii  evils  «>f  the  motor  rortex  of  iIip 
Ijruin  or  in  anv  part  of  tin-  up|>»T  motor  rMiiniiM-  hImivi-  the  sit.  „( 
III.'  lesion,  or  jnay  U-  primary  in  the  ia(i>ral  traits  of  t\w  conl.  '||„. 
symptoms  an-  i-ntin'ly  moU»r.  coasistinj?  in  panwU  or  jmraivsis  of  rli<- 
miwlc-s,  liyiH-rtonns,  aiui  inrn>aiK>ii  kntH-jrrks  (^pantlr  iip!nal'ixiriil,,.v.it 
I  Ih-H'  is  no  muscular  wasting.  Somewhat  similar  phenomena  an-  ii.>t.  .j 
in  the  .so-iall«l"e.)mnrp.ssion"  myelitLs,  tran.«verse  myelitis,  and  iiriairi 
raws  of  (liss«.niinat»'«l  .s<len)sis,  liut  here  s«-n.sorv  symptoms  arc  nirn- 
monly  ohsenwl.  although  less  mark»sl  than  the  "mo'tor  ones.  I'rimnrv 
s<-lerosis  of  the  lateral  troc-ts  is  (|uite  rare. 

Post«rior  Sdwoiil.-  I'osterior  sclerosis  (lucmmiior  ataxia:  Utlwn 
(liirmliii)  is.  anatomically  .s|K'akin>r.  a  defeneration  of  th,.  s<.|is.irv 
neurones  of  the  pcxsferior  nwts  and  j)osterior  columns  of  the  cord,  wirii 
less  constant  ehauKes  in  the  spinal  piufflia  and  jHTipheral  iwm-s.  II,,. 
disease  proeess  is  not  c-«infined  to  the  spinal  ner\-ous  UHshaiiisin,  l,iit 
iuy<.|yes  the  hrain  as  well,  'i'lu-  sc-nsory  nuclei  and  filnrs  in  ih, 
medulla  an-  not  infre(|Uently  atlackcsl.  and  dep-neration  of  i\u-  ink  lei 
of  (he  iMiilomotor  nerves  and  of  the  optie  nem-s  niav  „(un  U' 
ohscrved. 

The  symptoms  in  the  first,  or  what  is  known  as  the  preHtji\i<'  >ia;-r. 
are  chiefly  lancinating  pains  in  various  parts,  usually  the  lower  cxtivnii- 
lics;  loss  of  the  ki!«-e-j«-rk;  Argyll-KolH-rtscm  pupil;  cxrasioiiallv,.li|)|.i|.ia, 
niy<.sis  and  a  -jrirdle"  sensation.  Later,  we  get.  in  addilioii.  iihim  ular 
iiHoonhnation  (ataxic  stage),  diminution  of  sciisihility  to  t(iu(  h.  pain, 
heat,  and  cold,  sometinu-s  atrophy  of  the  optie  ncr\e,  and,  fiimllv,  < oiii- 
pli'tc  di.sid)ility  (paralytic  stage). 

'I'o  ohtain  a  |)roper  conec-ption  of  the  pathological  changes  i|i,,i  iK.iir 
111  laU's,  it  is  necessary  to  U-ar  in  mind  c-ertain  {M-culiariii.s  in  |||,. 
<'nil)rvological  dc-velopment  of  the  cord. 

The  posterior  columns  are  formed  at  a  ditferent  fK-ricnl  from  th,  ,.  m  ..f 
the  cord,  and  are  develo|Hil  fnim  the  (M>sterior  iierve-r<H>ls,  iiihi  tliof 
from  the  spinal  ganglia.  The  pcxsterior  columns  nnist,  tliintwr.',  Ir 
regarded  as  iiign)Wtlis  into  the  cord  of  fiU-rs  of  exogenous  orij.'iii  lli,rf 
an-.  howcvcT.  sonu-  fc-w  fiU'rs  of  endogenous  nature  derivi.l  fn.m  irlls 
sidiatcd  ill  the  gray  matter  of  the  cord. 

It  is  now  well  known  that  the  filR-rs  conijKxsing  certain  tract-  <>t  mrvi' 
liiiiidjcs,  that  arc  apparently  honiolopins,  li«rome  niedullat.d  at  .!iin  rent 
stages  of  enil.ryonic-  development.  On  this  hasis  Flcclisii:  ,ih.|  oilurs 
would  divide  the  posterior  columns  info  the  following  cnihi.Mn.nls: 
( I )  .\ii  anterior  or  ventral  r<K>t-zoiie.  next  the  posterior  coimiii 
gray  matter;  (L>!  a  middle  root-zone,  consisting  of  two  sort-  ■ 
known  as  the  »jl)crs  of  the  first  system  and  the  tiln-rs  of  the  >.r... 
of  the  inidille  rcH>t-zoiie;  (.{)  a  middle  zone,  next  the  postcrim  I 
distinct  from  tliecoliiinnof  <ioll;aiid  (4)  a  posterior  zone,  liciii-  ■ 
portion  of  (he  posterior  colmnn,  dividc-d  into  a  niedian  pan  a:  ! 
part,  the  zone  of  I.issaiicr.  The  onler  in  which  tlic-se  varioi! 
niedullaled  is  »s  follows:  (1)  The  anterior  rcK)t-zoiie.  ari.l 
this  (he  middle  zone  and  the  first  system  of  the  middle  m.  ■ 


-in-  unci 
rt  (IIhts, 
<'  -y.-,tt'm 
I'v  anil 
■inr«al 
Li'.tTal 
!ts  are 
;  aflcr 


PtiSTKmoH  SCLKKOSIS 


:m 


the  rolumn  «if  (JoII,  tht-  postero-inlrrnal  root-znru>,  ami  the  MTntHi  nvHtcin 
of  tlif  muldle  root-zone,  ull  appn>xitnutely  nlwut  the  .same  lime. 

Kaih  fiber  derived  from  the  |)osterior  root  divides  uttvr  «ei»erin>;  the 
lord  into  two  parts,  a  long,  aseeiHliiig  bran<h  and  a  short,  des< ciidinj; 
l.niiKh.  Ea<+  wh  (fives  off  <o|laterals  which  lieip  to  make  up  tlie 
ixislirior  eolui  a.  The  HIkts  entering;  the  lower  s«'nmeiits  of  tlie  vopI 
pas,t  into  the  internal  jwrts  of  the  jMHterior  columns  to  form  eventually 
the  columns  of  (JoII.  They  tenninate  in  the  meilulla  in  arlM»ri/.uti«);' 
uImiuI  the  nucleus  of  ( Joll's  column.  The  nwt  fiU-rs  that  enter  the  dorsal 
ami  (i-rvical  regioas  of  the  cord  run  in  the  other  purtu  of  th«-  jiostcrior 
(•(.jumns  and  form  their  tennimd  arlwriaitions  alniut  the  nuclei  in  the 
jH)st  rior  horns.  The  anterior  n»ot-zone  contains  fil>ers  derived  iJir«Mtlv 
fn)ni  the  posterior  rcMits,  and  commissural  WIhts  which  unite  the  jjrav 
siil)>riince  at  different  h-vels.  The  first  system  of  the  middle  root-zone 
is  ciiinjMisecl  of  fiU-rs  from  the  posterior  roots,  which  run  for  a  short 
distance  i..  the  [Kisterior  coiunMi  and  then  enter  Clarke's  column.  The 
swond  system  of  the  middle  niot-xone  coi:.-ists  of  filKTs  from  the  [Mwte- 
rior  r«H>t-zone  which  'onn  the  column  of  ( ioll  hijrhcr  up.  The  formation 
(if  ll.chsi>;'s  iniddle  zom-  is  not  yet  setth-d.     The  poslero-«'.\ternal  nnjt 

z f  Khnhsij;  (column  of  Lissauer)  i«  compos«-d  of  delicate,  closelv 

pack.  <l  filH-rs,  pn)l)al(ly  j'ollaterals  frcmi  the  jMisterior  roots,  which,  after 
niiiiiiiij,'  for  some  distance  in  the  cord,  enter  the  substantia  fr»'latino>a. 

Thf  fnacros<-opic  changes   in   the  cord   in   l(Kotnotor  ataxia   vurv 

according  to  the  extent  of  the  disease-.     'I'l uHicst  stage  is,  of  cours.". 

ninly  seen,  except  in  those  ca.s<vs  assiK-iated  with  general  paresis.  Htn' 
ill.'  ( ..rd  j)resent3  little  or  no  deviation  from  the  normal  save  on  micr.>- 
scopic  examination.  In  a  moderately  advance*!  case  the  |M>sterior 
|H)rii.iii  of  the  cord  is  distinctly  shrunken,  firm,  and  of  a  gravish-wliiic 
(•..l.ir.  The  posterior  roots,  as  a  rule,  seem  to  Ik;  somewhat  wastcl, 
altli..ii;.'li  not  invariably  so.     The  other  parts  of  the  cord  an-  normal. 

ai 

,     .  ,  .-.- id 

iiiav  he  increase<l. 

W  li.ii  sfaini-*!  by  the  Pal-Wcigert  or  other  mcth.xl  for  mv.lin  staining, 
mark.  .1  abnormalities  can  readily  b«-  observed  in  the  post.'-rior  columns! 
riio.  vary  sotnewhat  in  the  ditferj-nt  regions  of  the  cord.  In  cervical 
talx>,  wractically  the  whole  of  the  posterior  columns  rriav  Ite  involved. 
.Vs  a  ml.-,  liowever,  the  c-olumns  of  doll  are  atfecnd.  particular! v  in  the 
|HiM.ii..r  portion,  or  there  may  Ik-  two  narrow  bands  just  external  to  tlie 
'"liiiiin>  of  (  oil  and  Lissauer.     In  the  dorsal  region  there  are  usuallv  two 


.imi..iii;ii  nin  iiniinuuiy  so.  i  ne  Oilier  parts  of  tlie  cord  an-  noniial 
Tin  i>ia-araclinoid  is  somewhat  thickened  and  opacpie  over  the  dor>a 
as|),ri  of  the  cord.     The  dura  is  unalten-d.     The  cerebnwpinal  fhii< 


sir.  mIs.  ..f  dc^ciK-ration  in  Hurdach's  columas,  an<l  tlu-  jinK-ess  aj.iiarcntlv 
t<ii<K  I.,  involve  those  filxrs  nearer  the  mc-dian  line.  In  the  lumbar 
iiinl.  rli.-  degeneration  coi.nionly  affects  iiion-  or  less  conipi<t<-lv  tlie 
tra.f,  .,f  Lissauer.  The  fact  that  a  portion  of  the  LissaiK-r's  tract  lies 
y.iitnilly  to  the  fHjsterior  nwts  has  given  ri.s«-  to  the  erroneous  view  that 
"1  tal"  s  III.,  lateral  tracts  are  involved  as  w.-ll  as  the  [Mjsterior  ones,  and 
that,  i!;i  nfore,  the  disease  is  a  combined  sd.  rosis.  Lmbrvologi.allv  and 
'""" '"y.  however,  the  external  portion  of  Lissaucr's  tract  Ix-longs 


'I 

I'    ! 


T^f 

1  - 

\ 
1 

j 

. 

;, 

[1 

},'                          ' 

it 

'Mi 

i'-f 

1  *'  1 

1 

III 

It' 


an) 


THE  SPISAL  COHD 


t'rr\ii'»l  t:ilw.  ,|i.r»nli».      Hrrtiim  Ihrnuch  Iho  prrvnal 
•■"fil.     ( I  mm  iIm-  iiilliTiion  of  I)r.  I'olin  K.  Kuwrl.) 

Fir,    Ifl2 


li»  the  p(M(«>riur  rolumn.  Not  infrrqurntly  the  vrntrol  portion  i.r  tli« 
ptMtrrior  mluiana,  or  the  antrrior  n)ot-y.oiM>!i  of  Fl<><'li.si)(,  fwtt|)p.  ( jning 
(o  pniliffnition  of  the  epeniiymn,  the  rrntral  cHiml  m  often  ol)|if|.rii»n|. 
I<4>.sule<i  tlie  chun{(es  juat  «lescTil)e«l,  there  are  others,  less  i-onstant  arKJ 
ini|M>rtant,  in  other  parts,  such  as  tlie  ({ray  sulwiamv  of  the  dorsal  hihI 

ventral  hortw,  ami  the  nil 
*'"'•'  eohimn    of    Clark.-.      lli,. 

trlls  here  show  eeeenlrit  irv 
of  the  inielei  nml  more  or 
less  <  lironiutoly.sis. 

'I'lu-  tlefi^enenitive  cliiiiip's 
an-  much    the  same  ns  in 
.s4'<'(>iKlaryile);enenili<iii<'lM'- 
when-.    The  myelin  sImjiIIh 
hn>ak  down,  the  axis-»vlin- 
•lerx  swell  up,  become  in\\:- 
merited,     and      (lisi|>|Har. 
To   replace   thew  (he  jjljn 
proliferates,  and  tliirc  U  nn 
increase  of  connective  li^Mic. 
dcrivj^l  from  the  (niUi  tilji' 
of   the   pia    cxjenijini;  inici 
thcconl.    The  fillers  \\\\n\\ 
riitcr  tin- >;ray  maltci   In.ni 
the   |>o,sterior  coliitiin^   an- 
iH'casioiially      dcpiu  niinl. 
The    vascular    lc>ioii>    nw 
never  extreme.     The  vc^mIs 
in  ccriaiii  ny'<,  is  rii.iv  [pn 
sent   some  fihroiis  tliii  km- 
in>;,  esp4'cially  of  rlic  .nlvrn 
titia,  or  may  show   li\,ilim 
(lcj;cnenitioii.     Tli,i,     mav 
l>e  an  accunmiatidii  ni  -ran 
ular  cells  in  the  ail<.  mitia. 
The  pia   may   slim',    m.iiu 
lliickcninn  and  lilpn-i-. 
'i'lic  clianjjes  (Kcin'inL'iii 
■  nut 
viiml 


r«li«'^  ilurMiili^. 


Kiirwil  ninl.     (From  Ihp  ci>llci'li<in  of 
Or.  ('..lin  K.  Iluwl.) 


Till 


l.iliiiliar  cnril.     (Frmn  the 
Or.  liiliii  K.  Uui-wl.) 


the  .spinal  ^an);lia 
yet  iHH'nestahlislir 
cavil.  It  may  Ik- 
events,  that  tliev  a 
extreme  an<l  do  not  acc«)unt  for  the  extensive  lesions  foun.l  in 
terior  columns.  StriH-lM-  found  the  cells  of  the  Ranglia  to  U-  - 
irrejjular  in  outline,  many  of  them  vacuolated  and  markedly  \--. 
In  advanced  talies,  the  ^aufrlion  cells  had  largelv  disappared,  • 
capsular  .spa<e  was  distended,  and  flu;  cells  of  the  capsule  wc  n 
atin^'.  The  interstitial  suhslaiicc  showed  hyiHTplasia.  Tli. 
roots  external  to  the  conl  were  markedly  degenerated. 


I  at  all 
larcly 

I-    IMIS- 

iikcn. 

iiiter- 
nlifrr- 
-tcniT 


IttSTKHIOH  SCLKKIKHIS 


501 


I'Im'  ilwrim>s  ill  liir  |N>ri|ilH>nil  imtvm  an-  iiHtiiLseHiit  uihI  h«vi>  Ufn 
viiii.MisU'  iiit«-q)ni<-.l.  rin-  <littiiii|iy  i<«  to  <lc<ii|i>  whrtlMr  (Im-  <l«|{|.|ieru- 
lioii  that  Is  stunciitiM's  |»n«i«>iit  in  iiriiimry  or  ^w^-omlurv.  The  .'«iiiull, 
I  iiiiirifoiis  lu-nt  s  an-  tlii>  oiu-s  usually  ytxkM  out.  'riu-'invfliii  Hliratlis 
an'  .lisiiKixmUNi,  tlic  axisi  yliiMlcrs  art-  swollni.  aiui  ihiTf  is  some  iii<r«-a.sf 
.tf  iIh-  iiitiTJilitial  coiiiH-jtivr  lissm-.  Tlii'  cnniial  m-nx's,  partir-ularlv 
III.  Diitii'.  iiriii  Jill'  sym|>ntlnli<-  HIhts  arr  similarly  iiivolvwi. 

.\(ii>|)hy  of  tin-  «-«l!s  ill  ilii-  motor  cortrx  of  tli«>  I'lniin  is  -Miiiirtiinps  inpt 
wiili. 

Tlic  iiilcqiri'lntioii  of  ilif  liisiolo^ical  finilin^s  is,  as  oiip  ran  mulilv 
iin.l.  rMaiMJ.  fniu);lit  willi  ^n-at  iliffi.ulty.  ami  iiiiuli  <|<-l>at<-  has  taki-ii 
pliiir  MS  lo  wliat  coiisiiiiitrs  flu-  primary  lesion,  ft  may,  first  of  all, 
!«•  liikni  us  (•••rtain  that  tin-  licp-ncrativi-  jinH'css  is  essential  to  the  nerve' 
HU  rs  iiikI  is  not  lo  Im-  repinUil  as  siM-on.iarv  to  the  inereaJM-il  foniiation 
of  >;liii.  Nor  is  tin'n-  any  evi.len<e  of  a  |>  irv  iiiHaiiitnatorv  ilistiirl)- 
.111. r.  The  main  views  an-  ( I )  that  lo<  .t.'ir  ataxia  is  a  primary' 
M  l.r..Ms  of  the  posterior  coluins  of  the  <-onl,  anil  (2)  that  the  ehan^es  in 
ill.  ...nl  an-  siion.lary  to  ilep'iieration  of  the  posterior  nM)ts.  The 
lati.r  i<i  the  one  .sii|>|>orte«l  l>y  the  );n-atest  amount  of  eviilenee,  and  is 
air.|)t.sl  liy  the  majority  of  neiiropatholojfists  at  the  pn-wnt  time. 

Dij.riMe  would  HikI  the  esM-ntial  eaiisi'  in  endarteritis  of  the  ves.s«>ls 
Mi|i|)l.viiijj  the  intramedullary  jMirtions  of  the  |)osterior  nnits  with  eon- 
s.riiiiv.-  Hhrosis.     In  n-futation  of  this  opinion,  it  niav  W  remarked 
tlut  III.'  vasiulardisturhanees  found  in  taln-s  are  similar  Xo  those  found  in 
..ih.r  .l.'t'enenitive  diseases  of  the  cord,  and  are  never  a  striking  feature 
111  ill.    histolopeal  picture,     'i'he  vascular  <liaii>;es,  monniver,  are  not 
iiiiifornily  distributed,  aiul  could   hardly  account   for  such  a  inarkitl 
••^\^l.  111"  sclerosis.     'I'he  prepon.lerance"  of  evidence  ){o«.s  to  show  that 
ill.'  .hs.'iis.'  priK'ess  iH'nins  in  the  extramcl'illnrv  |M>rtion  of  the  jxisterior 
r.H.i>.    .Some  have  ilescrilK-d  intain  iiiiHl.)mi<'al  con.litions  that  midit 
II"  "Mill  for  this.     Udllich  and  OlH-rsteiner  found  a  thickening  of  the 
|>i:i  iiii.l  .l.ns..  sclerosis  of  the  jM-ripheral  zoius  of  the  neuroglia,  which, 
111  I  i.ir  ..|M   i.m,  lead  to  the  dcgeneralion  in  «|,icstion  liv  compression 
"f  iIh-  |..i~    nor  r.M)ts  at   the  poi.  t  where  tliev  enter  tlu'  conl.     The 
m.'.lulLirv  >i,,.aths  are  much  thinner  here  than  at  anv  .ither  part  of  the 
hlHT,  will,!,  makes  it  prohahly  the  least  resistant  point."    This  meningitis 
It  II.'.'. I  hardly  Ik-  said,  is  11..1  always  present  in  taU-s,  and,  coiiverselv' 
w.'  .In  not  hii.l  the  anatomical  lesions  of  talies  in  ea.se.s  of  meningitis  aiicj 
in.'luii;;((liiye!itis. 

It  i-  11..I  iin|M>ssil)le,  either,  that  toxins  circulating  in  the  cerebrospinal 
tl'ii.l  mi-ht  affivt  <lcleteriou.sly  the  nerve  rcnits  during  their  iiitraiiu  n-:  ,-,..,1 
'"Ml-  lesions  in  the  cord,  somewhat  similar  to  tli.ise  in  ^alu'  ,  ;,ave 
Ixt'ii  .J.xrilKsl  III  coniHH'tion  with  rhnm!,-  irqolhm  an.l  in  /x'/.'.-yM 
a  .li,  :,„■  lately  shown  to  U-  diu-  t.>  a  variety  of  aspergilliis.  M  crg.it 
l)|'i-,.K;:i-,  thi'  iM),tei'ior  roofs  are  iiegeiienite.1,  and  also  the  columns  of 
»ni'.|;„  I.  Ml  the  cord.  The  columns  of  (Jojl  an-  not  primarilv  atfecid 
"'1'  "iv  1m.  secondarily  involved  in  advaiice.1  casi's.  Th'e  anterior 
r.«.t-  ,„„..  (la-  median^portion  of  the  middle  zone,  and  F.issaiier's  tract 


Mi 


Hi 


li'ii- 


1     fa 

}j 


'i<V> 


T/it:  SPINAL  CORD 


cscjijM-.  Ill  |M-lla^rn,  tho  jMxsterior  roots  are  not  iiivolvwl,  and  M.iiic, 
on  this  a«Toiiiit,  rejiards  it  as  an  eiulogenoiis  clisi-asf  of  the  eonl.  it  is, 
in  fact,  a  primary  cicxfiieration  of  toxie  ori>,iii. 

( )pjM'nlieiin  U'heves  that  the  toxic  af?ent  at  work  in  tain's  (iorsalis  has 
a  selective  action  on  tiie  jM)stcrior  spinal  ganglia  and  their  hoinol(ij;ii(s, 
the  (lasserian  and  jujjuiar  f;anj;lia,  etc.  This  toxin  is  just  powerful 
enoiigli  to  cause  atrophy  of  the  distal  ])ortion  of  the  neurone  in  tlicjxw- 
terior  columns  of  the  cord  and  in  the  peripheral  nerves. 

Marie  considers  that  the  disease  is  due  to  a  syphilitic  lesion  invoiviiij; 
the  lymphatic  channels  of  the  posterior  columns  and  of  the  corr(s|)iiii(i- 
iiij;  pia-arachnoid,  inasmuch  as  he  has,  in  many  cases,  foun<l  a  clouijiiicss 
and  thickening  of  the  pia-arachnoid  on  the  dorsal  asinrt  of  the  cord. 

When  such  divergent  vi<'\vs  arc  expressc<l  as  to  the  exact  ineaniiii;  of 
the  anatomical  changes  in  tabes,  it  is  not  suq)rising  that  the  cdoloirv 
of  the  disease  is  not  altogether  clear.  It  se«'ms  fairly  certain  that  taluvs 
is  not  a  disease  of  the  cord  alone,  hut  of  the  whole  nervous  svstem,  involv- 
ing the  sensory  neurones,  and,  prohahly,  of  exogenous  origin.  \\V  must 
iR'ar  this  in  mind,  then-fore,  wln-n  searching  for  the  cause,  (liiiiciaiis 
usually  attribute  the  disease  to  syphilis,  overwork,  traumatism,  cx|)osun' 

cold,  or  sexual  excess.     It  is  a  fact,  as  Krb  and  many  others  have 

-intcd  out,  that  the  majority  of  talx-tic  patients  (from  ')()  to  (M)  per  ( cmi.) 
,ive  a  history  or  present  signs  of  previous  syphilis.  Hecentlv,  Wasser- 
inanii  has  shown  that  his  precipitation  test,  which  is  positive-  in  adivc 
syphilis,  is  also  positive  in  tabes  dorsalis.  This  is  highly  si;;riiliiaut. 
It  cannot  1h-  denitHl,  liowever,  that  the  atfwtion  (H-curs  in  those  wlm 
have  never  luxl  syphilis.  Tabes,  moreover,  ran-ly  comes  on  (luiiuj; 
flic  active  stages  of  syphilis,  In-ing  usually  found  from  five  to  ten  (U-  litleeii 
y(-ars,  or  cv(-n  longer,  after  iiifi-ction.  It  is  a  matter  of  common  observa- 
tion, too,  that  antisypliilitic  remedies  have  little  or  no  effect  on  the  (nurse 
of  tlu-  disease.  If.  then,  we  admit  the  importance  of  syphilis,  as  we 
ii(-cds  must,  we  have  to  regard  tabes  as  a  parasyphilitic  airt-clion,  rather 
than  as  due  din-ctly  to  the  infcctivt-  ag(-nt  of  syphilis.  We  nl^^t  IkiIiI, 
flu-rcforc,  with  OlK-rsteiner,  who  assumes  a  iniiltiplc  causation  for  talus, 
ill  which  sy|)liilis  is  the  most  fn-(|U(-iit  and  important  siiii;lc  cau^( . 

Perhaps,  the  view  thai  fits  in  most  [H-rfc<-tly  with  tlu-  oliserved  fai  ts  is 
that  of  Kdinger,'  tin-  so-called  "exhaiisticm  th(-ory."  This  is  Im^cd  on 
the  well-known  idea  of  W<ijrert  iind  Uoiix,  that  the  coiistitueiii  tissues 
of  an  organ  are  normally  in  a  stalt-  of  (-(|iiilibrium,  so  corn-lateil  one  to 
another  that  no  cell  can  disappear  without  its  plact-  beiii^'  iik.-u  liy 
liy|)crpl,tsia  of  the  surrounding  tissue, and  when  one  constitiieiii  l.roiiics 
weaker  or  less  resistant,  the  energy  of  jirowth  of  its  iieighiMuv  '.mis  to 
n-prcss  it  still  farther.  According  to  this  conc(-|>li(«n,  cirrlio  '-  of  the 
liver  is  primarily  a  degciuTation  of  the  parenchymatous  <<  1!  with  a 
secindary  overgrowth  of  tlu-  interstitial  tissue.  The  gliosis  ili  '  Kiurs 
in  the  spinal  cord  of  an  old  hcmiplegic  case  ciin  be  explain"!  in  the 
same  way,  and  when  a  cell  or  fii)cr,  or  even  a  whole  nenroiM    'rromes 

'  Dent.  ine.l.  Wocli.,  l'J()l:  KiH.t,  ISOl),  ami  1921 ;  1905:  i  aiil  i     . 


bi^ii 


d 


Wm 


POSTERIOR  SCLEROSIS  r,93 

sc  weak  that  it  is  unable  to  hold  in  check  the  proluomtive  capacity  of  the 
n.iKhl)onnK  tissue,  we  nrnst  expect  to  find  the  same  process  eoing  on 

l-.irfher,  function  involves  breaking  down  of  the  active  tissue     Nor- 
mally, the  destructive  proces.s  is  compensated  by  a  sufficient  supply 
of  nnlrition.  so  that  the  pnnJuction  of  living  substance  is  constant. 
If  (l.is  does  not  take  place,  the  no.   ..^I  r-i.n'librium  of  the  parts  is  dis- 
tjirlH.,!  and  a  progn-ssive  deg  -i  ration  is  f!,e   rsult.     Edinger  applies 
tlHY"  the  ne^^•ous  system.     \  -  assum^vs  d-at  u  .he  supply  of  nutrition 
Um  ..fH-ient  or  if,  though  it  Ik  ...nai.l,  oxcssi.e  function  Ik-  demande«l 
of  (1.0  cell,  that  IS  to  say,  ,f  the  ...rn  •!  rr!„ion  tn-tween  combastion  and 
ri-pair  Ik-  disturbed  either  by  relative  or  i,^  ...solute  suprafunction,  the 
.ner^-y  of  growth  of  the  n-sting  ti.ssue  will  lead  to  a  degeneration  of  the 
...ss  n-sistant  active  parts,  a  result  that  will  occur  the  more  easily  if  both 
factors  lM>  at  work      As  examples  of  this.  Edinger  cites  the  hammer 
palsy  of  smiths  and  the  atrophic  paralysis  of  the  forearm  mu.scles  in 
.Iruinmor  l)oys,  which   according  to  him,  occur  most  frequently  or  only 
111  hadly-nourished  subjects.  *  ^ 

To  apply  this  to  taln-s.     The  reparative  proce.s.ses  in  the  spec-ific 
(-.lis  are  unpaired,  as  a  result  of  some  to.xin  circulating  in  th.-  system 
this  to.xin  in  most  ca.ses  In-ing  syphilitic-  in  origin.    The  neurones'which 
are  noriTia  |y  most  active,  or  are  most  constantly  at  work,  are  tho.se  which 
siiff.r.     Ihese  are  the  .scasory  nerves  from  the  muscles  which  plav  an 
important  role  in  the  regulation  of  mu.scular  contraction,  and  are  Von- 
stan  ly  submitting  tho.se  stimuli  by  which  we  become  aware  of  the 
(■-.njlition  of  our  mu.scular  .system  and  the  position  of  our  limbs.     Clin- 
lealiy,  this  defect  i.s  manifested  in  the  lo.ss  of  muscular  tone  ami  the  sen.se 
of  posit,,,.,,  and  the  eon.spquent  ata.xia.    Secondly,  the  purely  .sensory 
mnvs  which  are  constantly  submitting  .sensations  f«,m  the  skin  and 
>m....iis  membranes  would  Ik.  likely  to  suffer  and  give  rise  to  sensorv 
.^^.'nrl.an<-e.s.    Thiixlly.  the  eyes  woiil.l  .suffer,  and Tmlill  the  coil 
s.rH„r  o    the  ins.  .so  constantly  active  in  the  n-flex  contraction  of  the 
>  o  ,,1.    «^,eh  must  iK.  almost  constantly  at  work  in  comparison 
l.h    rfle.x  for  accjommodation      In  this  way  the  Argyll-KolH-rtson 
I  '.  n  be  explained.     1  he  paralysis  of  the  external  .Kular  mu.scles 
■  '1-l.le   disturbance,  the  occasional  atmphic  muscular  palsies,  ma^ 
«ll  he  explained  in  terms  of  this  theory  ' 

The  p,.riph..ral  motor  neurones,  which  are  normally  capable  of  re- 
J.n  in,  to  two  .sets  of  stimuli,  th.xse>  from  the  upiH-r"  mot'  re  L  7 
«hi,  I,  are  relatively  .seldom  at  work,  and  tho.se  from  the  ,H-ripl,eral  Zrv 
neuron,-,  k,...p,ng  up  the  tone  of  the  mu.sc-les,  have  the  p  ,  rt.nity  o 
J  pair  wl„.n  they  are  not  at  the  .ser^-ice  of  voluntary  iin  X.      Se 

nuiro  „>.     VMien.  too,  the  sensory  neurones  have  deirencrated  and  fho'v 

">^  i>  IMobably  ,„  part  counterbalant-..,!  bv  the  exct-ssive  e.u-rL     Zf 
an  a,nM.  patient  puts  into  any  voluntary  niovcnu'nt  ^^  *^"' 

iH-^ .,  T    ""•'.  :     "^"^  "^""^'^  "'^'  <\\V-mm,i  of  iH-lieving  that  every 
IHrson  l.n,i,g  .aln-s  must  be  .sj-philitic.     On  tins  ,-onception  Tv.7So 


r' 


f  • 


■■ipffwwfr 


if.  'I 


594 


THE  SPINAL  CORD 


Jiow  trauma,  oxpo-siirt'  to  cold  and  wet,  and  t-xcessos  of  various  kinds 
may  act  as  prttlispcxsinj;  t-aiist-s  in  hrin^in^;  al)out  <leprec-iation  of  die 
none  unit.  Tlie  fact  that  taliws  is  more  common  in  men  than  in  women 
lM'C(»mcs  exphiinahle,  also,  men  Ix'injj  more  expose*!  to  those  delettriuiis 
influencvs  which  Edinpcr  brings  into  the  etiolojty  of  the  disease. 

Besides  (he  dcftenenitive  diseases  of  the  coni  hitherto  de.scriJH'd,  wlijeli 
affect  the  nene  elements  of  single  tracts,  there  are  others  in  whidi  several 
neurone  grou|>s  of  differing  function  are  involvwl.  These  are  rlie  so- 
calltHi  "comi)ine<l  system  tliseases,"  of  which  posterolateral  sclerosis, 
Friwireich's  ataxia,  and  amyotrophic  lateral  sclerosis  are  the  most  |)roni- 
inent  mcmlx-rs. 

Posterolateral  Sclerosis. — Posterolateral  sclen)sis,  or  mmhliiiil  .«•/(- 
ro.ii.s,  the  ataxic  paraplegia  of  the  clinicians,  is  characterized  hy  sclerusis 
of  the  postt-rior  and  lateral  tracts.  In  the  posterior  tracts,  tiii'  |)osteri)- 
internal  and  the  dorsal  {M)rtion  of  the  postero-external  columns  nre  the 
regions  sjHH-ially  picked  out.  In  the  lateral  tracts  it  is  iisuiiliv  the 
crosseil  pyramidal  tracts,  hut  not  infre(piently  the  din-ct  cerehellar  tr.K  is, 
the  columns  of  (iowers,  and  the  lateral  limiting  layers,  ("olljns  has 
n-corded  also  degeneration  of  the  cells  of  Clarke's  colinnn  and  of  ilir 
fine,  white  fibers  of  the  anterior  horns. 

The  disease  apjH'ars  to  In-  a  primary  one,  hut  the  exact  p;iiiioi:env 
is  not  known.  Slany  consider  it  a  true  combined  "system"  (lipase. 
Others  think  that  the  parts  affected,  owing  to  their  comparativi  |v  jHMir 
hl(MKl  supply,  are  less  able  than  other  parts  to  withstand  the  iltli  icrioiis 
action  of  the  morbific  agent. 

The  disease  (K'casioiially  follows  exposun-  to  cold.  Syphilis  |il;ivs  an 
unim|K)rtant  role  iti  the  etiology.  The  main  clinical  features  aic  iitaxia, 
muscular  weakness,  hypcrtonus,  and  gradually  incrcasinj;  riiriditv. 
.S'usory  symptoms  arc  rare  and  trifling.  In  advanced  cases,  owin;;  to 
cerebral  iiivolvcinent,  the  disease  may  resemble  general  paresis. 

Friedreich's  Ataxia. — Friedreich's  ataxia,  or  hereditary  at;i\ia.  is  a 
curious  disease  first  (lescril)e<l  hy  Friedreich'  in  1S(»I.  It  is  ili-ijiuily 
a  familial  disease,  but  may  or  m.-iy  not  Im-  hcn-ditary.  The  f,'rf.ii  iiiajority 
of  the  cases  arc  met  with  in  childri'U  In'fore  the  age  of  piilii'ii\. 

Clinically,  the  affwtion  is  characterized  by  ataxia  of  a  N'.\,:vini:  nr 
staggering  character  involving  all  four  extremities,  nystagmic,   ■  aiinin 
spetvh,  and  muscular  contractions,  giving  rise  to  scoliosis  inid  talijH's 
equinus.    The  km-e-jcrks  are  usually  absent. 

The  cord  is  found  to  1h'  of  less  than  normal  thickness,  a  cit;  liiioii  of 
things  which  is  most  marked  in  the  cervical  and  upptr  dni  ,  I  rei,'ioii. 
Microscopically,  the  lesions  are  found  cliieHy  in  the  posterior  ,  ■  .1  latenil 
colinnns.  The  columns  of  (loll,  the  pyramidal  trai-ls,  an  i  *  iarke's 
colutnns  are  i-xtensively  involved,  less  so  Hurdach's  and  do.',  ■-'  tracts 
and  the  dir«'<t  pyramidal  tracts.  Tiiere  may,  in  .some  cases.  ' .  atropln 
of  the  posterior  r<K)ts  and  peripheral  nerves.  The  lesion-  'iisist  in 
degeneration  and  atrophy  of  the  ner\-e  filn-rs  and  their  niyi  '.'.    -heailis. 

'  Virch.  -\rchiv,  70,  1S77:  HO. 


HEREDITARY  CEREBELLAR  ATAXIA  595 

loflither  with  increase  of  the  neuroj;lia.  The  piu  is  somewhat  tliiekened 
e.s,...<mily  over  tlie  p.>  terior  aspect  of  the  cor<l,  whicli  prolmhiy  aocoiints 
for  (he  peripheral  or  .mniilar  tlegeneration  present  in  some  cases  The 
bl.x..lvessels  are  sliKJitiy  thickened,  but  the  vascular  phenomena  are  not 
ol.irusive  Dana  has  recently  observed  a  peculiar  porosis  of  the  cord 
both  of  the  white  and  gray  substance,  which  is  due  to  dilatation  of  the 
perivascular  spaces. 

.Many  different  opinions  have  been  expressed  as  to  the  nature  of  the 
(hscaso.  1  he  fact  that  the  affection  is  most  fre«|uently  met  with  in 
chiMh<KKl  and  IS,  moreover,  apt  to  run  in  families,  suggests  that  some 
anomaly  of  development  is  at  fault.  Some  have  held  that  this  consists 
in  hypoplasia  of  the  third  primary  vesicle  and  neural  canal,  when-bv 
the  cerebellum  medulla,  and  cord  lag  In-hind  in  their  development. 
Dejcnne  and  U-tulle  have  suggested  as  the  cause  a  primary  gliosis  of 
..vclopinental  nature  in  the  posterior  columns.  Others  consider  the 
.l<'jr<n.ration  of  the  ner%e  elements  to  be  primary  and  the  sclerosis  sec- 
ondarv.  Senator's  idea  that  the  essential  lesion  is  atrophv  or  hvpoDlasia 
(if  tlic  (•«Tel)elluin  has  not  lieen  widely  accepte<l.  ' 

Fio.  164 


Fri.dr.i.li'»  ataxia.     Lumbar  cord.     (From  the  collection  of  Dr.  Colin  K.  Ru,»cl.) 

Hereditary  CerebeUar  Ataxia.-Somewhat  similar  to  the  l.ercditarv  a  taxia 
0  spmal  origin,  ji^t  .lescrilKHj,  is  what  is  known  as  hereditarv  cerelH^llar 
ataxia  (cerebellar  heredo-ataxia  of  Marie). 

In  this  affection,  ^v-hich  comes  on  somewhat  later  in  life,  flic  ataxia 

IS  kvs  marked,  and  there  is  no  scoliosis  or  cluWoot.     Atroniiv  of  the 

opt,,  nrnes  is  frequent  and  the  knee-jerks  ar^  incrca.sed.    Spasm  of 

h.'  n„i..|es  comes  on  quite  late.    The  most  striking  lesion  found  is 

yFH|I.!..s.a  of  the  cerebellum.      The  posterior  and  lateral  tract."  ai^e 

n  V  r  r  -ri'  '"'^•'  '.*'*''*  :'  f'^'P^'y  °^  "»'  ""t*'""^  '^"d  posterior 
nor m^  "  T  v  VT^  '"°^'  ^''^^'■^''  '^'  somewhat  smaller  than 
hm  ,rv  ""'1  T  f"""\'^''«-7n  hemlitary  -creWlar  ataxia  and 
timMiian  spinal  ataxia  have  been  descrilx-d. 

h,.  nilluence  of  toxic  substances  in  bringing  about  degeneration  is 
«ell   Illustrated    by  the  spinal    lesions  which   wcasionally  accompany 


il 


;    • 


U 


ill 

i 

J 


t  ■. 


m  ■< 


5% 


TiiK  SPINAL  conn 


sikIi  <lis<>uses  as  iMTiiicioiis  uiieniia,  tiiljcrcMilos.'.s,  (liulH-tcs,  and  (nivi- 
noiiia.  Thf  first-nain* d  cuiulitioii  may  he  Uikvn  us  the  fyjH',  the  oili,^ 
liciiij;  siinilnr  save  (lint  thev  an-  not  so  oxtmiie. 

Pernicious  Anerjia.— The   lesions  in  pcrnieions  anemia  arc  most 
commonly  found  in  the  posterior  am'  lateral  columns  of  the  cord,  less 
fre<|uently  in  the  anterior.     The  posterior  columns  are  more  extcnsivcjv 
and  uniformly  affwted  than  are  the  other?.     In  the  early  sta^'cs,  tlic  (],'.. 
generation  is  systemic,  hut  a.s  the  disease  progresses  the  lesions  l)(roiiic 
more   irregular  and  extensive.     Annular  sc-lerosis  may  he  found,  or 
multi|)le    scattered    fwi    not    unlike    those   in   disseminated    sclerosis. 
The  lesions  in  the  posterior  columns  are  tho.se  of  a.scending  dencncmiion 
in  the  cervical  and  upper  dorsal  regions.    The  postero-internal  (ohimns 
arc  much  more  markedly  involved  than  are  tin-  postcro-extcrnai.    The 
ventral  portion  of  the  postero-extcrnal  columns,  the  Lissaucr's  rnii  ts, 
and  the  posterior  nerve-roots  escape,  constituting  a  marked  ditlVniKT 
lictwcen  this  form  of  degeneration  and  tabes  dorsalis.     In  the  di.scmi. 
Mated  form,  the  lesions  differ  from  those  of  di.s.seminated  .sclerosis  in  tliat 
in  the  latter  c»>rtaiii  ncrve-filwrs  within  the  sclerotic  areas  art   id  xunc 
xtcnt  at  least  preserved. 
In  the  cirly  stages  the  medullary  sheaths  an-  swollen  and  stiiiii  liaillv, 
hut  the    ixi.s-cylinders  may  be  fairly  well  preserved.     Later,  the  jixis- 
cylii  .  ,s  are  degenerated  or  have  entirely  di.sappean-d,  Icavin;;  small 
cavities  in  the  myelin  .sheath.s  in  which  they  formerly  lay.     TIhmcsmIs 
an-  usuallv  not  nuich  alten-d.    In  the  most  advanced  cases  the  fonmnivf 
tissue  i^     onsiderably  incrcase<l,  the  walls  of  the  smaller  v<sm  Is  aiv 
thickened,  and  there  is  proliferation  of  the  cells  of  the  advcntitia. 

The  exact  pathogenesis  of  the  degeneration  is  imknown.  It  mav 
lie  that  the  important  element  is  tlic  lack  of  nutrition  due  to  iUr  di  ^inu'- 
tion  t)f  the  bloo<l  corpuscles.  Most  observers  .seem  to  think  iliai  this 
is  not  the  ease,  but  that  the  degeneration  of  the  nerve  filK-rs  and  of  ilic 
l)l<M)d  cells  is  referable  to  the  same  primary  cause. 

Amyotrophic  Lateral  Sclerosis.— The"  last,  and  one  of  ii„  most 
inil»)rtant,  .system  diseases  with  which  we  shall  deal  is  aiiivnin.pjiic 
lateral  sclerosis  (Charcot).  This  disease  is  one  of  the  ciiiirv  iii;!,pr 
system,  and,  anatomically,  presents  the  combined  lesions  .  '  lateral 
sclerosis  and  progressive  spinal  muscular  atroi)hy.  The  patlmld^'jcal 
changes  are  found  espwially  in  the  cord  and  Dcriplieral  imXi'  nnvcs 
but  extend  frequently  to  the  medulla,  and  in  sonic  instances  to  ili.  unial 
(•ap)sule  and  motor  cortex  of  the  brain. 

Clinically,  the  di.sea.se  is  characterizwl  by  muscidar  wasting, 
amount  of  spasm,  increased  knw-jerks,  with,  in  .some  cascv 
of  involvement  of  the  "lotor  nuclei  of  the  methdla  (glo-ssolalii. 
paralysis),  and  (K'casionally  tremors. 

The  cord  is  firm  and  .somewhat  wasted  hxiking,  parlic  iil 
cervical  region.     On  section,  the  lateral  pyramidal  tracts  arc  ^ 
tiie  rest  of  the  white  substance,  and  the  gray  matter  is  somcwl. 
and  reddened.     Analogous  changes,  though  less  extensive,  iin 
to  be  observed  in  the  medulla.     The  anterior  nerve-roct 


ii'ialilc 
Jrnces 
vnL'eal 


111  the 
r  than 
'lencil 
'  linic< 
iifleii 


AMYOTKOPHW  LATERAL  SCLKnoS/S 


597 


(Ik-  hy,K,Klo,s.sal  and  Kl(,.s.sophary,.geal  nerves,  are  atroph.V.1     The  cor 

Flo.  ISA 


A]iiviirrc.|iUic  lateral  «lerii«i».     ( 


Wvi,.al  c-.„l.     ,Kr„„,  ,he  collee, of  l.r.  c„|i„  k.  KuH.sel.) 

Kii;.  160 


Aiiiv 


lerior  column.,     (^r„m  the  tollevlion  of  Dr.  tolia  K.  Hu«e|.) 


""•■•.  nr    i  m.r     7      ''  '^'l""'^'' '""'  "•  *''^'  '"teral  tracts.     the«^^  is 
less  marked  degeneration  of  the  dinvt  and  cro«s«l  pyramid 


i 


>p 


I '  M 


t\ 


::t 


I 


598 


THE  SPINAL  CORD 


tracts.  In  some  instHnces,  the  anterolateral  column,  the  lateral  limiilnp 
layer,  and  those  tracts  extending  from  the  gray  matter  of  the  ventral 
horns  to  the  surface  of  the  con!  are  involved.  Degeneration  in  the 
posterior  columns,  es|)eciully  the  columns  of  (loll,  has  lK>en  nottd  liy 
Ilcktoen,  Marie,  and  others.  It  must  be  remurki>d  that,  while  tin 
degeneration  of  the  lateral  columns  is  very  striking,  when  pri'scnt.  it 
is  the  most  inconstant  of  the  lesions.  On  the  other  hand,  wastitig  ol'  the 
motor  ganglia  of  the  ventral  horns,  or  of  their  homologues,  is  invarialdy 
found.  The  substance  of  the  ventral  horns  does  not  present  iniicii 
shrinkage,  but  the  ganglia  arc  greatly  affected.  They  are  not  only 
diminished  in  number,  but  those  that  remain  are  wasted,  stain  irrci;- 
ularly  or  more  diffusely  than  normal,  iind  the  nuclei  may  liave 
disapjieared.     The  protoplasmic  processes  are  atrophied  or  absent.    In 

Fio.  167 


Amyotrophic  lateral  Hcleroais.     Lumbar  cord.     All  parts  are  degcnerate-1  ti>  Huiir  extent 
except  the  posterior  columns.     (From  the  collection  of  Dr.  Colin  K.  Itu.^Ml ) 


l'!l   :ifl. 


some  preparations  the  ganglia  may  have  tlropjH'd  out,  givini,'  li 
a  somewhat  porous  appearance.  The  blo<Klve.s.sel.s  arc  intni 
thickened,  the  perivascular  lymphatics  are  dilated,  and  tluro 
minute  hemorriiages  1:  're  and  there.  The  changes  in  tlie  fil)ii' 
pyramidal  tracts  are  tHose  that  have  so  often  been  dcscriliid 
The  glia  is  but  slightly  increased. 

The  involvement  of  the  medulla  i.s  not  .so  extreme  as  that  cf  il 
The  nucleus  of  the  hypoglo.ssal  nerve  and  the  nucleus  of  lln 
degenerated,  somewhat  rarely  the  motor  nucleus  of  the  fifth  im 
the  posterior  nucleus  of  the  vagus.  The  pymmidal  tracts  in  i!ii 
are  only  slightly  involved. 

The  degeneration  of  the  pyramiilal  tracts  hits  been  in  soim  r: 
lowetl  into  the  brain.  The  large  pyramidal  cells  of  the  inoloi  <  •  i 
the  tangential  fibers  have  been  found  to  be  degenerated.     >"    ' 


If  horns 

or  lf<> 

may  Ix' 

>  of  till' 

1  ii'i'orc. 

It'  coni. 
lltT  arc 
rve  ami 
<  region 

ises  fdl- 
lex  and 
•  of  the 


TUMORS 


599 


..  lis  Lave  disupneurejl.    I„  ,he  ck.e,HT  layew  .,f  the  t-ortex  the  cells  mav 
1h.  ,,  r..phied,  while  the  tangential  HIkts  are  unaffected  ^ 

I  he  degenenition  of  the  in-ripheral  motor  WIhts  is  slight,  not  nearly  so 
iiiiirked  as  that  of  the  anterior  roots.  ^ 

Tlu;  muscles  corre.s,K>„ding  to  the  affected  ganglia  are  atrophied  while 
ihtrc  IS  an  interstitial  lipomatosis.  """pnieu,  wniie 

T« .,  main  thcH.ries  have  been  advanced  to  explain  the  proc-ess  The 
..r.,u.al  view  o  Charcot,  in  which  he  has  been  followed  by  E^'is  thai 
.my..tr„ph.c  lateral  sclerosis  is  a  .-  'em  disease,  the  main^Sn  b^  n^ 
suua  ,.,1  in  the  pyramJal  tracts,  the  changes  in  the  gray  su  Stance  and 
peripheral  nerves  being  secondary.     Gowers    v    I^vden    n.?n  i 

;..l...rs  n-gard  the  disease  as  a  fo/m  of  p^g;sIive'1itda^T^;h;' 
llH.  affection  of  the  peripher  I  motor  nninme  is  primarv  "haVZli; 
jrn.ral  motor  neun.ne  is  secondary  or  associated.     The  questimicamiol 
..■  .•..nsulercd  as  .settle.!.     There  is.  however,  reason  to'.rpZe  Z™ 
.I..'  .Inmal  ..oui^e  of  some  cases  and  the  stu.iv  of  the  cord'h  Jert™  n 
-..np  ..us  forms,  that   the  .legenerati.m  of  tlu-  pvramidat  acts  mav 
ii>.-.ln.e  the  changes  „,  ,he  g„„gli„„  ..^lls  of  th^  ventral  horns  3 
I-   ...r.,,heral  motor  neurones.     Possibly,  amyotn.phic  laTemHdeii 
^     K-  ..f  the  .hseases  to  which  Edinger's  ••exhauiion"  .Zryl^Z 


PE0ORM8IVI  METAMORPHOSES. 


I)  111  (lie  neiKhlK.rhood  of  the  **nfr„1  .0....1    ..,.:..    ....  ^«f"«™*- 


Rbromaa   aarconuw,  and  »ngiog»rcoinM  are  rare     Afultinir  ^r"""'"'- 
S'c.,„l,„v  i,„„„„  „„  mdnom.^  .momM,  and  mydom... 


• 


m 


n 


n 


CHAPTER    XXVIII. 

THE  PEKIPHERAL  NEIIVES 

The  peripheral  iierve-niechanisin  consists  of  tiiree  purts,  the  pi?ij;li:i, 
the  nerve  trunks,  and  the  end  plates.  The  nerve  trunks,  whiili  will 
concern  us  most,  are  composed  of  medullate<l  fiU-rs,  continuous  with 
the  central  nervous  system,  and  of  non-medullate<l  fil)ers,  derived  from 
the  sympathetic  ganglia. 

OntOULATORT  DISTUBBAWOU. 

Anemia. — Anemia  can  lie  recognized  with  difficulty,  hut  rimy 
he  sui>|)ose<l  tc)  lie  present  in  cases  of  general  systemic  anemia,  iirid. 
IcK-ally,  in  obstruction  of  the  nutrient  vessels,  and  from  the  prt-xsure  of 
tumors  or  dislocated  Ikhics. 

Hyperemia. — Hyperemia  is  met  with  in  cases  of  inflammation. 

(Edema. — Qiklema  is  rare.  It  may  .sometimes  l)e  oh.servcil  wliert' 
nerves  puss  thn)Ugh  inflammatory  fo<'i. 

Hemorrhages.— Hemorrhages,  usually  petechial  in  character,  are 
found  in  iiiHummation  and  tniumati.sm. 


nrrLAMMATIONS. 

Neuritis. — Inflammation  of  the  peripheral  nerves,  or  neuritis,  is 
due  to  circulating  toxins  or  bacteria,  "o  trauma,  or  to  the  cMcnsioii 
of  inflammation  fmm  adjacent  parts.  It  has  l>een  custoiiiarv  wiili 
some  writers  to  distinguish  a  puenchynutouB  neuritis,  in  wIik  li  the 
primary  lesion  is  degeneration  of  the  nerve-filn-rs,  an.l  an  interstiti«l 
neuritis,  in  which  the  changes  l)egin  in  the  connective-tissue  ]>(iiii(in<)f 
the  nerve  trunk.  It  may  l>e  again  remarked  here  that  deui m  nitimi 
and  true  inflammation  of  the  nerve  sulwtance  cannot  always  l>t  iliffcr- 
entiated.  I'or,  atrophy  and  degenerative  changes  in  the  m  iM-filKrs 
may  l)e  followed  by  reactive  inflammation  in  the  interstitial  iili<laii(f 
of  a  .secondiiry  nature,  while  primary  interstitial  inflummalii'i  iiiicklv 
leads  to  .sec-ondary  wa.sting  of  the  s{)ecific  nerve-elements,  [n  nlialcvcr 
way  the  condition  nuiy  l»e  initiated,  degeneration  of  the  mi 
leads  to  well-defined  results,  and  all  such  conditifms  an-  ■rrcu 
criminately  by  the  clinicians  under  the  term  neuritis.  Prim  i 
chyniatous  neuritis  is  practically  the  .same  thing  as  atro|)liy  (i 
fibers,  and  is  dealt  with  more  precisely  under  the  "Degenera:; 


iriiiiks 
I  iiidis- 
|iar<'n- 
■  ii(T\e 
"  later 


INTERSTITIAL  NEURITIS  ^qj 

(,..  (KW).     In  its  cuusution  uI«,hol.  lead.  «rs..„i,..  and  the  toxins  of  iH 
vano.,s  infective  diseases  play  a  leading  part.     The  disease  Sm.c  h 

■i-rUurcattrv    *■"'  '""^"  ^'  ''""■'''"  "'  "^'"''•'^'"  P-'-»''y  -- 

Acnte  fat.nUti.1  H.nritli.-A<uU.  interstitial  neuritis,  or  neuritl.  in 

...  restmtet   sense.  IS  hematoKenie  or  lymphoKe.nV  in  oridn   aTd  niaj 

Ik- pnxliHvd  l»y  various  infettive agents  K'".  tt"u  may 

rir  toxins.     The  affeeted  ner\e.tnink  is 

svyoiien.  cedematoas.    and   hypereinic, 

witli,  sometimes,  minute  hemorrha>,'es 

into  the   sulxstanee.     Mitrosfopicallv, 

we  find  in  the  enc'ine.irii.m  and  epi- 

iicnrium    all    ths    ordinary  sijfiis    of 

infiiinimation.     The    vessels   are   i-on- 

>r<'s(ed,  the  interstitial  substance  is  in- 
filtrated with  serum  and  inflammalorv 

hiikmytes.     If  the  process  have  gone 

I'll  for  some  time,  it  is  common  to  find 

llif  onlinaiy  degenerative   manifesfa- 

lioiis  in  the  axis-<-y|inders  and  mvelin 

slifiiths.     In   suppurative   cases  small 
aliscfsses  may  l)e  found  here  and  there 

ill  llu'  interstitial  suKstance.  Neuritis 
limy  also  arise  by  direct  involvuneiit 
or  lyiii|)hogenous  extension,  as  in  tiiose 
cases  \vher<>  an  abscess  or  infective 
jrraniiloina  has  formed  in  the  neighlKir- 
lioixl  of  a  nerve-trunk,  or  where  men- 
iiiKiti'^  involves  secondarily  the  cranial 
iitrvcs  or  the  nxits  of  the  spinal 
nerves. 

'IVaiiinatic  neuritis  arises  from  sec- 
tiniiof  a  nerve  by  acciil.iit  or  design, 
i's|Mrially  where  the  w<.iii;.i  has  l)e- 
loMie  infected,  or  from  contusions  or 
lacerations. 

^^li^'lit  grades  of  neuritis  heal  with- 
out causing  any  permanent  damage. 
More  severe  forms  may  lead  to  degen- 
craiKKi  of  the  nerve  elements,  with 
'•"I'-cc.ifive  atrophy  jf  the  as.sociated 
iiiMscies.  or  to  ar'ual  necrosis  or  gan- 
grene of  the  nerve  trunk 

Chronic    lnfr.titi.1    Ka«riti..-rhn,nic  interstitial  neuritis  arises  bv 

'  ..  ...-,'en,r  or   iyn.phogen.c   ,nfe<-tion   or   intoxication,   and    bv   the 

McMsion  o    chronic  inflammation  fn,m   neighlK,ring  parts      It  „    v 

I-  '«-„r  withont  obvious  cause.     Micn,scopi„.llv,  the'cCVtive^  !  'e 

"11^  l'--ve  markedly  proliferated,  aiul  the  s/roina"  may  show  vol^ 


Multiple  periiiherni  nruriliK  (wrist  and 
f™)t-<ir.M>)  in  chrouic  lea.l  iM.i.-»,„i„g 
(••".m  the  Medical  Clinic  of  the  .Mont- 
real (Jeneral  Hospital.) 


Ml 


tm 


THE  PERIPHERAL  NERVES 


of  .smull  ruund  cells  (neuritin  prolifera).  Thin  overjjmwth  •)f  the  iiil«  t- 
stitial  8uli.staiic-e  inuy  Ih*  mi  f(reut  thut  the  nerve  trunk  is  eunsidenililv 
enlurp^l.  Scxiner  or  later,  the  nerve-fil)ers  utniphy  anil  (li.su[>|N-iir. 
Ddjerine  hits  drawn  special  attention  to  this  fonn  under  the  nniiic 
chronic  huMrtrophic  iieuritiit 

Neuritis,  especially  tiMxse  varieties  due  to  henuiti^enic  infection  ii'id 
intoxications,  is  apt  to  be  symmetrical.  It  affects  a  numl)er  of  ncrvi- 
trunks  {multiple  peripheral  iieuridn  or  poljfneuritin),  and,  nion'ovrr, 
the  toxins  are  liable  U>  sin^^le  out  jiarticular  ref^ions.  Where  exti'ii>i\f 
defeneration  has  taken  place  we  may,  in  some  cas(*s,  fintl  an  luscendin^' 
ile^neration  involving  tne  posterior  nerve  roots,  the  posterior  ctiluinns 
of  the  cord,  or  even  the  nutrient  centres.  The  condition  leads  to 
|>aralysis  and  wasting  of  the  muscles  inner\'ated. 

TttbarcolosiB. — ^This  is  probably  always  sec<mdary,  and  is  foutui  most 
commonly  in  the  roots  of  the  cranial  or  spinal  nerves,  aa  a  result  of  llii' 
extension  of  a  tuberculous  meningitis.  ( )cciusionally,  nerve-filnTs  iirc 
iniplict-'ed  in  ca.ses  of  "cold"  aliscess,  tulierculous  periostitis,  and  Iciio- 
synovitis.  The  process  is  an  interstitial  one,  in  which,  in  the  jHTinciiriuiii 
and  epineurium,  there  forms  the  characteristic  granulation  tissue,  which 
eventually  underg»»es  ca.seation.  The  inKltration  may  extend  ii>  ihc 
eridoneurium  and  the  filnrs  undergo  secondary-  degenenitinii.  In 
other  cases  there  form  areas  of  connective-tissue  induration. 

Sjrphilis.— Like  tuln'rcuiosis,  sypiiilis  generally  attai-ks  tiic  riKits 
of  the  <  ••■•lial  and  spinal  ner\'es,  inasnuich  as  the  prix-ess  coiiiiiKinly 
origimitt-  ■  .  syphilitic  meningitis.  The  interstitial  substance  is  iiilil- 
tiatiii  wi.,1  granulation  tissue*,  which  gradually  is  converted  into  ih  iisc, 
fibrous  material.  The  nutrient  vessels  oft»'n  show  endarteritic  cliiiii^it's, 
when'by  the  circulation  is  interferetl  with.  This,  together  witii  the  |prt  ss- 
ure  of  the  newly-formed  fibrous  tissue,  leads  tt)  marked  degcncraiinn  of 
the  fibers  ami  serious  interference  with  function,  such  as  pjiniivsjs. 
(iinnma  of  the  ner\es  seems  to  be  rare. 

Leprosy. — Leprosy  of  the  nerves  coastitutes  one  of  the  well-known 
clinical  types  of  this  disease.  The  disease  appears  to  pick  out  more 
especially  the  cutaneous  branches.  Microscopically,  we  find  d  Ihilur 
infiltration  of  the  interstitial  substance,  with  a  marked  tendcncv  lo  pro- 
liferation, so  that  scattered  spindle-shaiH-d  nodes  are  formed  on  the 
trunks.  In  the  areas  of  granulation  we  find  large,  epithelioiil  leljs, 
often  vacuolated,  in  which  the  lepra  bacilli  may  l)e  readily  dete(  inl,  or 
the  organisms  may  lie  free.  The  process  leads  to  degtMieration  of  ilie 
nerve-filKTs  and  thus  produces  the  peculiar  anesthetic  and  ir(i[.liic 
changi's  in  the  skin  characteristii-  of  this  form  of  leprosv.  \\\n\i-  the 
ganglia  are  involved,  the  specific  bacilli  can  Ite  found  aiso  wiililii  the 
ganglia. 

With  regard  to  the  ganglia  of  the  sympathetic  nervous  syst«io  ''<  may 
l»e  noted  th.at  they  .ire  apt  to  lie  involved  in  tulierculoiis  i.r...isscs. 
Thus,  the  solar  plexus  and  semilunar  ganglia  may  be  involved  ii  tiilier- 
cuUwis  of  the  suprarenals,  kidney,  or  vertebra;. 


TL1U0R8 


mi 


UTROOKIBSin  MITAMOKPBOfH. 


Atrophy.- Atrophy  of  rwrves  is  of  rather  comm<.n  (Krurrenco  It 
...ay  1k^  due  to  any  h-sion  which  cuts  off  the  ..erve-filH-rs  fn.m  iheir 
m.tnent  centres.  Ihus,  destruct  i  of  the  Kanglion  cells,  either  in  the 
.ram  or  in  the  cord,  may  h-ad  to  atrophy  of  the  fibers  proc-ecdinc  from 
h..,n  Pressure  also  exertel  upon  the  nerve  from  any  caus...  if  cm- 
t....«-<l.  ^•ill  produce  degeneration  and  atrophy.  Severance  of  a  n.Tve 
lr....k  and  mflammation  are  frwpient  causes.  Atrophy  is  also  met  with 
in  (lid  age.  '^  '' 

Atrophy  and  degt-neration  of  nerv-.-filH-rs  usually  begins  at  a  p«nnt 
. h.>  inos  n.mote  from  the  nutritive  cei.tr,.  and  progresses  centriix-Elllv. 
As  the  tyjH;  of  degeneration  may  be  taken  tfiat  form  whi.h  n-  ,s 
fro,,,  he  .severance  of  a  nerve-trunk  by  tra-na  ( Wallerian  degenenu. ,.,.). 
or  f..||.,w.s  continued  pressure  u|K,n  the  tr..  k,  as.  for  instance,  from  a 
....nor,  enlarged  lympi.-glamls,  or  c^onstricting  bands.     (See  Intro<l,Ktion, 

|{e.sides  the  degeneration  caused  by  solution  of  continuity,  just  refern-d 
to.  waiting  of  a  s.m.W  kind  may  ».e  brought  alx^ut  bv  the  action  of 
.■.r.ula..nK  |oxins  and  Ucterm.  by  certain  ci^nlatorv  .li;turban..vs,  and 
In  .n.poverislu.    mitntioii.     Endurteritis  ami  other-obstructive  legions 
o  H,.  ve.s.sels  a„.l  hemorrhages  play  a  part  he«..  largely  bv  cutting  off  the 
nu.ntio,..  as  do  also  sy.stemic  anemias  and  n,aru.smas.     Degeneration 
..ff..n.jg  one    r  more  nerve  trunks,  occurs  .sometimes  in  such  con.litions 
..^  .l.|.hthena.   influenza,    typhoid,    typhus,   variola,   tuberculosis,    the 
-..■.•|.cn..m.  and  intoxications  with  mineral  substances,  such  as  lead 
17  r*"  .  V  '  P'^^^^'y'"}  ^'P^  ^"isi-s  at  least,  a  combination  of  i,,,: 
Hrfn.  ..utrition  and  the  deleterious  action  of  the  poison.     Occasionall v 
mn,  ..o,ne  unknown  infec-tion  or  intoxication,  the  ganglion  cells  of  the 
.  .nor  horns  are  destroy.H.  followed  by  secondary  deg^nemtive  chanp  s 
in  tliL-  hbers  connected  with  them.  ^ 


PROOKBSSIVE  UITAMORPHOSES. 

R.p-neration  of  the  nerve^len.ents  after  injury  is  possible   under 

cortau,  conditions.     Provided  that  the  nen-eK.ent4  or  gangl  a  Tm- 

po...i...g  to  the  destroyed  fibers  are  intact,  restoration  of  Stiiilnd 

^™;;n:;:M;'^    ForafundiscussionoftHissabjecttheJ.:; 

Tumor8.-A    tumor    ■!    ived    from    the  proliferaion  of  the  nerve 

'  r l!!  ?T  *™»k  «'«"'d  be  .ulied  a  neiom..    Such  ar«  distincTl)- 

mr.       1  he  vast  majority  of  tumors  of  the  peripheral  nerves  are  derived 

fi"".  ii.e  interstitial  connective  tissue.  areuernea 

h^ATi7T^^  commonest  grow.n  is  the  fibroma  in  its  various  forms. 

"  ariMs  in  the  endoneurium,  as  a  rule,  and  mav  e.vtend  externallv 

bu.  s„„„,i.ues  internally  into  the  perineurium  and  cpineurium.  sepamSg 


M- 


mi 


Tllh:  PKHIPUKHM.  SERVES 


Km    ll» 


V  •   ,  :;; ~-iiS*   ^     *•  ' 

<VI|h  fri.m  11  iK-nimi  an.!  ii  iiiiilictiiinl  onulionriirniua  in  irui-  in-iin.miii  ri>H(„.. mih  ;  iliv 
("riiHT  (r.iiii  Ihr  narral  irxi.Mi.  (lie  lullrr  fnini  llie  rrtrii|if  ril.iiiTOl  rf«i..ii  ai  thi'  Iim  I  .1  il,.. 
|>iiirmi>      (11.  IWtu'kr  > 

Fki.  170 


Multiple  ebronutoid  overgruwtha  along  the  eourw  of  the  cutaoaotu  nerve',    (i.     --i) 


ilif  iliffcrcnt    liuiultct   utu<   from    tin- 
"iliiT.    The  n«T\'e-filHTs  in  thu  way 
iH'itHiii-  »iirroiiiMl«l  umi  ••oiiipn's-M-*! 
Ii.v  ili(>  |m»lif«TtttinK  'ksiu.  uml  evt-rit- 
iiiill.v    iitrophy.       It    is    Ixlifviti    bv 
M.iiic  (Imt  the  iHTve-filK-rs  in-v  pnj- 
lilVralf  hikI  Rrow  into  the  tuni<,     thus 
foriiniiK  what  niijfht  Iw  rnllwl  ti      vi- 
riimii  or.  nion-  (iirn-i'tly,  a  urunijihromn,    I 
liiK  this  is  (Kinhiriil.     True  iM-ur«>niHs    ' 
arc  .siMtiuliy   npt   to   Ik;    fomii-d    in 
<i.iin<stion  with  the  sympathetic  svs- 
rnn  iinii  ffunjtiiu.    FibVoinas  are  ({I'-n- 
irally  multiple,  aiMJ  ootasionnlly  may 
Ih>  foiuMJ  in  jfreat  numbers  on  most  of 
llif    iMTipliera!    iM-nes.      Mon-  foni- 
iMoiily,    tliey  an-  r<>striei  >d  to  partic- 
ular mm'  trunk-  ..y  are  fouml 
<•"   til.,    main    fi     .,        ut  exhibit    a 
|.r.f.r.-ntv   for   t'       ...laller  branches, 
fN(i(riiil|y  (he  minute    ner\-es  of   the 
^Ivin.     Thus,  there  may  Ik?  found  a 
niiiltitiKJe  of  small,  soft  tmnors  in  the 
^kiii.    varying'     consiMerably    in    size 
iMiiilti|)l.  tibromasof  the.skin;  fihroni'i 
iwillii.irHm).        In     other    eases,     tlii' 
nm.-trunks   pn-sent    a    diffuse    an. I 
«i.l..|)rea(l  <-nhirjrenient  of  (heir con 
lie*  in. -tissue  elements  as  well.   Micro- 
«..|.i<;il|y,  the  fibromas  are  conifKised 
"f  r.lliilar  c.)nnective-ti.ssii<     but   oc- 
•  asioiialiy  dense  ur  hard  fibromas  ar.' 
"lit  with. 

<».(;,si.)nally,  also,   a    hijrhlv    con- 
v..liit,.,|,  tendril-like  ^'rowth    deveIo|)s 
over  a  M>niewhat  ex(end«l  area.     The 
'i»rv,.  ininks  are  .liffusely  thickened 
'|iii  ^Mi.|,|,.,|  with    nmlules  and  spin- 
.ll.-lik.-  .iilarjrements  {plerlform  n,„- 
riiiii'i:    Hniiknineurom).       '"rhev     are 
f<''"Ml  particularly  in  the  distribution 
'>'  '  "   -|>nial  nenes  and  those  «.f  the 
''"••"I    ni.l  develop    by   preference  in 
_'l»'   -iMM    and    subcutaneous   tissues. 
I  .»■;.  -  .tiu'iimcs  form  lai^e,  projectini;, 
"l..'l:..-.l  or  folded   growths,  ov  mav 
'•1<     I"  u    diffuse,    rather   indefinite 
liKk,  ,„„;;  of  the  skin,  which  resem- 
i>le.s  ,|,,^,.|y   elephantiasis  or   pachy- 
Ueniiii,    elephantiaais  neuromatosa).' 


fiOA 


Fio.  171 


Tumor. of  -< iatie  nenes  aod  their  bmnche. 
At  o,  large  tumor  connected  with  small  in- 
e»rmu»cular  nerve.     (Preble  and  Hektoen  ) 


: 


4 


V 

i| 

:# 


fl06 


THE  PERIPHERAL  NERVES 


All  forms  of  mliltiple  fibromas  of  the  peripheral  nerves  are  prol)al)I_y 
to  be  referred  to  errors  of  development,  as  they  are  commonly  found  in 
children,  and  there  may  also  be  a  family  predisposition.  In  rare  cum  s, 
fibromas  have  been  known  to  undergo  sarcomatous  transformation  und 
produce  metastases  (Westphalen,'  Recklinghausen,  Larkin'). 


Fio.  172 


^^ 


Multiple  fibroma  of  the  periphenl  ner\'eff.     Keichert  obj.  No.  7,  without  <«'ul:ir. 
(J.  Alex.  Hutchini*on*H  case.) 

Fia.  173 


Serf  ion  thioUKh  u  fibnimatoid  cutanetius  nodule  nliowinic  the  nervp-Hlire»  in.  /■' 
by  fibroid  overgrowth.     (After  Itibbert.) 

Myxomas,  lipomu,  and  Mreomu  nre  descril>ed.  They  arc  im 
than  the  fibromas,  and  form  isolated,  nodular,  or  spindle-.sli^r 
ftrowths. 

Striated  tnu.scle  cells  have  been  found  in  the  interior  of  nin' 
they  have  l)een  attributed  to  misplaced  embryonal  cells,  !"•' 
known  aliout  them. 


■  1  Idled 

:  'i  rarer 
.1(1  out- 

-iriinks. 
!i!fle  is 


'  Virch.  Archiv,  110:1887:29;  ibid.,  114:1888:29. 
>  Jour.  Med.  liesearch,  (N.  S.)  4: 1903:  217. 


CHAPTER    XXIX. 

THE  SPECIAL  SENSES. 

THE  ETE. 

AN0H1LIE8    or    D2VEL0PMXNT. 

Dkfkcts  ami  irregularities  in  development  of  the  visual  apparatus 
may  mvolve  the  eyelids,  the  globe  of  the  e,e.  or  any  of  its  com^^en; 

(  oniplete  absence  of  the  bulb  («nophtl«lini»)  is  rare.    As  a  rule,  mien>- 
.sf.......  exammation  w.Il  reveal  traces  of  its  substance.    Anophthalmia 

IS  ....rnmonly  bilateral,  and  frequently  associated  with  other  anomahVs 

of  .l.vebpmentcoloboma  harelip,  cleft  palate,  and  imperft^t  closure  of 
u- .  ardiac  septum.  C)rdmarily,  while  the  bulb  Ls  extremely  defective 
...  ,.yel..ls.  conjunctival  .sac,  m,«cles,  and  nerves  are  present,  suggesting 
that  a  some  pt.r,«l  the  growth  of  the  bulb  had  been  an^sted.  Ser  a? 
a  nsult  of  a  defect  m  development  or  of  intra-uferine  disease.  A  les.ser 
>rn..l<;  of  the  affection  is  microphthtlmi.,  in  which  the  globe  of  the  eve 

mi  ."Lr?*^""*  t  "•'  '""''•    ^"  '^^^^'  ^'^•*^'"  anophthalmia  ami 
niiciophthalmia  exist. 

A .urious  and  rare  anomaly  is  cyclopia  or  synophthalmia,  in  which  the 
entm-  visual  apparatus  is  more  or  less  perfectly  fused  into  a  single  organ 

I  Ins  .s  one  manifestation  of  the  condition  known    as   cvdeiuephalv' 
«lur,.  the  normal  division  of  the  prosencephalon  fails  to  <K-cur  ami  the 

t  1 N,  ntncle.  In  such  a  case  not  only  are  the  optic  vesicles  invol^  kI. 
p  t  I  wh  S7  ^""r*  "';  ^"^«'.'he  skull  and  fac^e.  and  the  sof 
p.  ts     In  the  milder  gra<  es  of  the  affection,  two  eyes  mav  Ik-  formed, 

II  7     -V  f"*'^  "'■'"*:  '"■  '*'*  P"''«">'  ^"«^-     In  the  more  marke< 
r    ,l,ore  is  but  one  eye,  situate<l  in  a  single  orbit,  occupying  the  c-entTe 

of  lu.  forehead,  and  provided  with  but  one  optic  nerve.^   I,,  complete 
ul..,..a  the  nose  IS  often  rudimentary  or  absent,  the  bones  of  the  face 
an  ,|,.f,.,tive.  and  the  ears  are  anomalouslv  situated 

Hydropthth*Iinu..-Hydrophthalmus    is  'a    condition    of   early   life 

Tl      1  I      Y.l       ♦".»'«";•«"«  "purring  during  intra-uterine  existence 

i  „K   ,h  '•       '  ''^V  ''"'«'F*''.and  more  or  less  fixetl.    The  cornea  is 

tl"  d.  ptii  of  the  anterior  chamlH-r  is  increased 

A'Hong  partial  defects  shouhl  l)e  mentioned  eonguiital  ptosis  of  the 

rill!',,  'j'ih"*""*^!!!'  '^  •:""'^iH"."  '■"  ^■'•'^'''  ♦"g^*''"  ^•'■♦h  flatness  of  the 
•'"'Ip  ,.f  ,he  nose,  there  is  a  fokl  of  skin  passing  across  the  inner  canthus 


eo8 


THE  EYE 


fn>tn  the  upper  to  the  lower  lid  (a  moderate  f^de  of  this  is  nomuil 
in  the  Chinese  raee);  lack  of  the  iris  (irideremia) ;  periiitaBt  pnpilluy 
membnne;  periiiUnt  hjiloid  uteiy. 

Among  the  more  striking  anomalies  is  eoloboma.  This  is  a  lack  of 
substance,  more  or  less  complete,  in  one  or  more  of  the  primary  nicm- 
hranes  of  the  eye,  due  to  the  failure  of  the  primitive  fetal  cleft  to  ciosi'. 
The  retina  and  the  pigment  epithelium  are  derivetl  from  the  secondary 
optic  vesicle,  about  which  are  formetl  the  choroid  and  scleral  nii-iii- 
branes.  The  primitive  cleft  in  the  secomiary  optic  vesicle  extcmls 
backward  inferiorly  into  the  optic  stalk.  Should  it  fail  to  close  at  its 
p<xsterior  part,  cololnima  of  the  optic  nerve  sheath  results.  If  the 
middle  portion  does  not  close,  the  ordinary  coIolMima  of  the  choroid 
results.  Failure  to  close  anteriorly  results  in  defective  formation  of  the 
lower  part  of  the  iris.  According  to  this,  .several  different  forms  aiid 
grades  may  be  recognize<l.  In  complete  failure  to  elo.se,  the  choroid 
and  .sclera  will  l)e  imperfectly  formed,  while  the  retina  and  pigiiiciit 
epithelium  will  l)e  lacking.  Should,  however,  the  closure  lie  merely 
delayed,  Iwth  retina  and  pigment  epithelium  may  he  completed,  but  the 
choroid  will  l)e  defective  and  the  superimposed  pigment  epithelium  will 
not  l)ecome  pigmenttnl.  In  cololmma  «)f  the  choroid,  owing  to  thiiiiies.s 
of  the  .sclera,  ecta.sia  of  this  membrane  is  a  not  uncommon  result.  This 
wtasia,  or  staphyloma,  of  the  .sclera  may  be  very  marked,  especially  in 
cases  of  microphthalmus,  and  may  indeed  form  a  cyst  as  large  as  tlie 
eyeball  it.self. 

In  cololwma  of  tht  ^  lioroid,  one  finds,  microscopically,  in  place  of  the 
pn)i)er  retina  am)  ''lion>i<l,  a  thin  connective-ti.ssue  membrane,  in  which 
are  a  few  ve.s.sels  and  u  .sc.mty  de{K>sit  of  pigment.  In  other  ca.ses  there 
mav  be  pre.sent  more  or  less  perfect  retinal  elements. 

('ok>lM>ma,  when  affecting  the  lower  part  of  the  vertical  meridian  of  tlie 
eye  is  a  purely  developmental  error.  (\)lolK)ma  in  other  directions,  and 
the  .so-calk-il  (-ololKJUia  of  the  macula,  are  «lue  to  inflammation  (Hciirrin); 
during  intra-uterine  life,  the  defect  in  formation  In'ing  due  to  the  nic<  liaii- 
ical  etfeit  of  atlhesions.  ( 'ongenitally  defective  eyes  are  liable  to  other 
diseas«>s,  such  as  choroiditis  and  cataract. 


The  Oonjunctivs. 

The  upper  and  lower  eyt-lids  are  covered  externally  with  skin,  similar 
to  that  of  the  fon-head  and  cheeks,  but  somewhat  thinner  and  lnostT. 
Beneath  this  is  a  layer  of  I(k>s<>,  areolar  tissue;  next,  the  striated  lilii  is  (if 
the  orbicularis  pal|M>brarum ;  then,  the  soK-alled  tarsal  cartilage,  coniiinseii 
of  dense,  white  connwtive  tissue  rnd  containing  the  MeilMiniian  iihmiis, 
practically  identical  in  structure  with  the  .sebaceous  glands;  a  -nlxon- 
junctival  layer,  containing  more  or  less  diffu.se  adenoid  ti.ssue;  aih!  liually 
the  conjiMictiva  ils«'lf,  conipxsiMl  of  stratifie<i  epithelium.  On  th'  inner 
surface  of  the  lids  the  epithelium  is  of  the  squamous  variety  ami  nitlier 
thin,  but  toward  the  fornix  the  mend>rane  is  lotKser,  more  vasciil  i.  ami 
thn)wn  into  folds,  while  the  epidieliuni  is  columnar.     \Mien  lin   con- 


CONJUNCTIVITIS  ggg 

junttiva  reaches  the  bulb,  the  superficial  cells  tend  airain  to  become 
flattened,  and  the  membrane  assumes  more  the  appearand  of  that  cover- 
ing the  corn«i  The  vascularity  of  the  subconjulictival  tissues  and  the 
loosener  of  the.r  texture  ren.lers  the  membrane,  and,  indeed,  the  lid 
as  a  whole,  particularly  s,«ceptible  to  circulatory  and  infla^matoS 
disturbances,  while  the  results  of  these  conditions  are  usually  striking 

OntOULATORT  OI8TTJBBAN0I8. 

(Edeina.-ffidema  of  the  lids  and  conjunctiva  is  a  condition  of 
cinical  .mportance,  as  ,t  «  frequently  an  indication  of  serious  diseas^ 
It  IS  found  for  instance,  in  chronic  renal  and  cardiac  affections,  andin 
anemia  In  such  cases  the  conjunctiva  is  swollen,  and  has  a  riassy  or 
watery  look  (c  W,«)  (Edema  of  the  lids  is.  also,  a  common  accom- 
paniment of  inflammation,  not  only  of  the  eye  itself,  but  of  its  associated 
structures      Thus   it  is  met  with  in  such 'conditions  as  conwTivlS^ 

o^hTSlTl^ulr^*^^"'''^'  '^'"''""^'  ^'-'-'  -«^  «-W-tion 
Acute  Hypereini».-Simple  acute  hyperemia  of  the  conjunctiva  is 
a  common  symptom  of  irritation.  A  foreign  Inxly  in  the  t  .ijunctival 
sac.  em™  crying,  the  exposure  of  the  eyes  to  the  wind  or  sun.  "ey^ 
strain,  irritant  gases,  and  the  use  of  certain  drugs,  such  as  arsenic  and 
po^.s.,.ra  iod.de  may  all  cause  it.  It  is  an  early  feature  of  many  in- 
flammations o  the  eyes,  and  is  met  with  in  acute  rhinitis  and  fLi^l 
neuralKia.  Chronic  congestion  is  mast  frequently  due  to  errorrS 
^fmction  and  dLsorders  of  the  ocular  rau.sclejl,»t  may  also  be  anTudic^! 
tion  of  alcoholism,  gout,  nasal  catarrh,  and  inflammation  of  thelacryi^l 

Hemorrhage.-Hemorrhage  into  the  loose  tissue  beneath  the  con- 
junc  ival  membrane  may  be  the  result  of  injury  to  the  eye  fracture  of 
.he  skull,  or  may  come  on  without  any  particular  cause.    wScE  o 
snee^u.«.  coughing,  or  vomiting  have  been  known  to  cause  it     PoiSly 
Th  comlirn        ''^«^"*-'^'^"^«  ^^-g^«  •"  '^^  vessel  walls  predisposes  to 


INFLAMMATIONS. 

.iri""""^**"-"-^"^""""**'""  ^f  *»»«  conjunctiva-conjnnctivitl.  or 
^^thalnu. -may  affect  the  membrane  as  a  whole,  or  anyTrtrf  k 

ma  result  from  exposure  to  wind  and  weather,  heat,  irritating  gases 
SSn,\  r  ^  TT  °'  '"'^"'^'•K-"!^™^-  Secondary  aaUeJoS^: 
Sr  ';  V  n  '°  '^'  '"'T'""  ""^  "'fl«n"nation  fr^m  neighbiring 
mmni'         ^^Vcl'ds,   nose,  or  lacry.nai  ducts,  or  may  accompany  or 

Acuu.  .  ..njunctivitis  may  sometimes  also  be  produced  by  the  action 


610 


THE  CONJUSCTIVA 


B  5    i\ 


of  certain  drugs.  Simple  catarrhal  inflammation  is  a  not  infrequent 
occurrence  in  persons  who  are  taking  potassium  iodide  or  arsenic.  The 
external  application  of  chrysophanic  acid  in  psoriasis  has  been  known 
to  cause  it.  The  local  use  of  atropine,  eserine,  and  hyoscyamine  may 
also,  if  long  continued,  or  in  susceptible  people,  on  occasion  produce  it. 

A  considerable  number  of  microorganisms  are  now  known  to  ^ive 
rise  to  conjunctivitis.  Chief  among  these  are  the  Morax-Axenfeld 
Diplobacillus,  the  Koch-Weeks  bacillus,  the  pyogenic  cocci,  the  Gono- 
coccus,  and  the  Pneumococcus.  Exceptionally,  Friedlander's  bacillus, 
the  Diphtheria  bacillus,  the  Bacillus  of  Pfeiifer,  and  the  B.  coji  have 
been  found.  McKee,'  in  a  study  of  500  cases,  gives  the  following 
proportions: 

Morax-Axenfeld  Diplobacillus  in  200;  Staphylococcus,  50;  Strepto- 
coccus, 24;  Pneumococcus,  13;  Micrococcus catarrhalis,  12;  (JontKcxiiis, 
10;  McKee  bacillus,  9;  Koch-Weeks  organism,?;  B.  coli,  5;  influenza 
bacillus,  3;  Meningococcus,  1 ;  Bacillus  xerosis,  B.  Hoffmann;  and  sapro- 
phytes, 102;  negative  results  in  64.  Certain  of  these,  the  KcK-h-Weeks 
bacillus  and  the  Pneumococcus,  are  not  infrequently  to  be  found  (in  the 
normal  conjunctiva,  and  are  usually  innocuous.  On  occasions,  ow  inp  to 
some  increase  of  virulence  or  some  injury  to  the  membrane,  they  may 
assume  pathogenic  properties. 

In  all  forms  of  conjunctivitis  the  process  is  essentially  the  same, 
though  the  intensity  may  vary.  The  conjunctival  vessels  are  conpsted, 
the  subconjunctival  tissues  are  (edematous  and  infiltrated,  the  Ivmph- 
adenoid  follicles  are  enlarged,  and  the  superficial  epithelium  is  sodden, 
swollen,  desquamating,  or  eroded.  It  is  usual  to  classify  the  clinical 
varieties  acconling  to  the  character  of  the  exudate,  which  may  Ix'  scrons 
or  seromucoid,  seropurulent,  purulent,  or  membranous. 

Acute  OaUirhal  Conjunctivitis. — In  the  milder  grades  of  acute  ciitarrhal 
conjunctivitis,  the  inflammation  may  l)e  confined  to  the  piil|)el)ral 
conjunctiva,  which  is  swollen,  rcddenwl,  and  succulent.  There  is  a 
slight  mucoid  discharge  which  tends  to  glue  the  eyelids  togellier  and 
accumulates  about  the  inner  canthus  and  the  retrotarsal  fold.  In  the 
more  severe  forms  the  bulbar  conjunctiva  is  involved  as  well,  and.  owing 
to  the  congestion,  assumes  a  re<ldish  color.  The  conjuncli\!t  is  '■on- 
sidcrably  thickened,  particularly  at  the  retrotarsal  fold,  wliere  it  may 
show  papillary  excrescences  'Ihe  discharge  is  more  abunchmt  and  is 
seropurulent  or  mucopurulent  in  character. 

Acute  Pnmlent  Oonjunetivitif. — Acute  purulent  conjuneti\iii^  is  a 
severe  affection  of  the  conjunctiva,  due  in  the  vast  majority  of  im^cs  to 
the  Gonococcus  of  Nei.s.ser.  The  disease  is  most  commonly  nu  i  wilh  in 
newl)orn  infants  who  have  been  inoculated  from  the  maternal  I'issages 
during  birth  (ophthalmia  neonatorum),  and  next  in  adults  the  -iihjeets 
of  gonorrhoea  of  the  urethra,  vulva,  or  vagina.  Occasionally,  ii  i-  found 
in  young,  debilitated  girls,  who  are  suffering  from  non-specili:  ;  'irulent 


'  A  Clinical  Study  of  Five  Hundred  Cases  of  Conjunctivitis,  .Anier    i  ^ 
Sci.,  134:1907:716. 


Med. 


PLATE  VI 


FIG.  1 


Kuch-Weeks   Bacillus.    (Weeks.) 


FIG.  2 


Morax-Axenfeld    DiplobaciUus.     .Weeks. 


fARINAVD'S  CONJUSCTIVtTIS 

tense,  swollen,  and  reddpnoH     <J™„ii  i,  l  ^^"J""''"va,  tne  lids  are 

conjunctiva,  which  bSlukeS^^^^  T"  '"^^^''^ 

«r.,us.  soon  becomes  cn-amv  and  rhn„,LT  a-  ^^^''^'  «'  Ant 
yellowish-green  color.  Tn  chiWm,  a^a  rl^  »k"  °'  *  ^""?'^"''  °' 
as  would  be  expected.     In  adS  on.  Z   '  ^     ^^^  •"*  '"^^'^^^J- 

RreatdangertosStin  JnorrS'onhrh?"-^^^^^  ^"^r*"  '^'*>«'*  « 
b  apt  to  te  involved  "n^XtS  ophthalmm.  inasmuch  as  the  cornea 

A  diffuse  opacity  my  sp^^^'over'  fh.      '  "'  '™P'?P«'-"y  '-^ted  cases. 

uicers  n^ay&^eaiyirrt'o^-rri'ti:-  ".Vhan  tr^or" 

Mo.  .  .ess  permanent  thickening  of  ?Se  c^njun^dva'C^sihth 

c.o!;;:^ris:ha^Sdtt:i^*^7''T^''^"""^  -  --po- 

for  .  of  a  pateh;ri1„^;;  ^^^^^^^^^^^^ 

("  the  conjunctival  tissues.    Occasionallv    rm^n^/  ^  attached 

irm>  diphtheria  nf  the    ■  liunctiva  i?  mm      i»  ^      • 
extension  from  the  nasal  n«  Ji^f     .      i^       •  ^'  """a^'onally  arises  by 

material.  Ua^  v  it  m^vKlrv  ^^U^'  '"T'"*'""  ^''^  '"f«-»ive 
ojxn,tive  prmX.s  BotrSl  '  '"^\«'f> .b«-n  known  to  follow 
imohW.  'l^e  hi  a«-  S^  irsK"*'  "".'^  ''"'•«''  conjunctiva  are 
tease  and  b^wn/f^m  i.E  ion  7w''  * '?k'^^''*''; ^'"^  "'^.^  ^« 
n«ulatio„  there  is  S^vrcWr  t^l  ti!  '^  '"  he  interference  with  the 
•ivitis.  The  membm™\  S  fir.n  T"'I1. '"  "^'^  '"™  "^  ^«"i»nc- 
•ival  tissues  arc  ais^  co  LKi.U  Tn  "?*'  ?'"""?"*•    '^^''*'  -"•>^-on  "nc- 

this  lea.ls  to  the  formation  of  i«rr;  •  )  *""  '"''''"''^' '«''''''  P'«ce, 
"f  tl-  h-.l.s.  TheXhZe  iH  fi  7  ""'  '"f'r^l»^"'>.v  to  incurvation 
punilent.  •I'^'harge  is  at  first  scanty,  thin,  and  ichorous,  later 

S'ai.lnl,.„m  may  thusSt  IthJ  1v°'  "'^•**'^^>°'«  «f  the  cornea. 
^hor..i,li,i,s  and  JanophSmit"        '°"'''''°"  '""^  ^  '^"  *«  «»PP"™"ve 

in£:l^r,t!ll?r''-"'™V«..  'h-Kh  rare,  form  of  acute 
i'  P-.  u;iar  Tn  d,at  i  7,  J  '  «'nj"ict;v'tis  (lymphoma  conjunctivae).  R 
tioiis.,r,W.;"ion  ««'"'"P''«'««  ^v  local  and  sy.stemic  luaniLta- 

'"at:'t;!ri!s:  :'•?  "'s^^.^p*"'"''  °f -"junctivitis.  wwch. 

■fciit  ptosis,  with  lacrymation  and  photophobia.     The  con- 


( 


612 


THE  CONJUNCTIVA 


i&k 


junctiva  of  the  Ikl  is  much  swollen  iiiul  mldcnnl.  iiml  •  sttMldt-*!  with 
numerous  papillary  uranulatioiis.  which  arc  espccialiv  i  i  evidence  in  tlic 
retrotarsal  foKls.  The  conjunctiva  Inilbi  is  not  involved,  save  that  it  is 
somewhat  inj»'<letl.  Soon  the  jTranulations  enlarge,  forming  reiati\(lv 
enonnous.  papillary,  and  coek's-comlHlike  masses.  The  pre-auriinlur. 
inframaxillarv,  an<i  cervical  glands  sw»ner  or  lat«'r  In-come  enlarmKl, 
and  there  is'  a  sligut  evening  rise  of  tein|)oratiire.  The  secretion  is 
scanty  ami  mucopurulent  in  character.  Ulceration  does  not  take  place, 
nor  is  a  membrane  producwl.  The  enlarged  glands  may  suppurat.-  or 
mav  resolve.  Stirling  and  McCrae,'  in  a  case  met  with  in  Montrtal, 
found  a  bacillus  intermediate  in  pn)j»crties  In'twecn  the  Bacillus  .lipli- 
theriw  and  the  Bacillus  xerosis,  which  they  reganleil  as  prolwbly  spn  iHr. 
TrMhonu  or  Orannlar  0onjnnctiTltl8.-  The  most  important  of  the  chronic 
inflammations  of  the  conjunctiva  is  the  so-i  ailed  trachoma  or  granular 
conjunctivitis  This  affection  is  essentially  chronic  in  its  course,  but  nwiiii- 
fests  occasional  acute  exacerbations.  Anatonjic-ally.  it  is  characterized 
in  the  main  by  overgrowth  of  tissue,  which  in  time,  when  absorption  lias 
taken  place,  is  foUowwl  by  cicatricial  contraction.  Although  the  ilistase 
is  a  common  one  in  certain  countries,  and  has  l»een  known  for  a  loiij; 
time,  its  etiology  Is  still  obscure.  The  disease  b  undoubte<lly  coiitajiioiis, 
b«-ing  transmittetl  from  jH-rson  to  person  by  the  secretion,  usually  hy 
meaas  of  towels.  Sattler  has  descril)ed  a  coccus  which  he  n'^'anKHi 
as  the  specific  cause  of  the  disease,  but  the  evidence  is  as  yet  far  from 
convincing.  Some  hold  that  the  disease  is  the  chronic  form  of  acute 
epidemic  conjunctivitis,  which  is  usually  due  to  the  GomK-cxcus  or  the 
K(K-1»-Wecks  bacillus.  ... 

The  process  l)egins  and  is  always  most  marketl  in  the  conjunctiva  of 
the  lids  and  retrotarsal  fohls,  but  '  •■  v  eventually  extend  to  the  tarsus  and 
conjunctiva  bulbi.  At  the  onsci  .;..  during  the  acute  relapses,  the 
lids  are  considerablv  swollen,  the  conjunctiva  is  nuich  injecttnl,  aii.l  tiiere 
is  a  moderate  amount  of  mucoid  or  mucopurulent  .secn>ti(>n.  I'liolo- 
phol)ia  and  blepharospasm  may  Iw  marked.  Later,  the  (•oiijiiiictiva 
is  congested  and  consideraldy  tliickeniHl,  In-ing  studdc<l  with  i-apdiiiry 
outgrowths  (p»piU»ry  conjunctivitis)  antl  "granulations"  (loUicular  con- 
junctivitis). The  trachoma  botlies  or  follicles  are  most  numerous  in  the 
retrotarsal  folds,  and  on  eversion  of  the  lids  can  be  seen  small,  ^'ravish. 
translucent  nodules,  resembling  grains  of  lM)ilcd  sago  or  frog's  ^pawn. 

Histologicallv,  tin-re  is  found  a  diffuse  infiltration  of  the  (•oiijuiKtiva 

of    the    li<ls   with    Ivmphoid  cells.     The  papillie  are  much  .  nlar).'c.l. 

The  trachoma  iKnlii-s  are  not  typical  graiudation  tissue,  but  .liic  to  a 

local  hviH'ri)lasia  of  the  Ivmphoid  ami  connective-tissue  cU'iiirii-.  stir- 
• '_    '  .      '      -    .  /.i  ..I       rill I. — . 


Miii-tival 


roun.led  bv  a  more  f)r  less  jn-rfi-ct  fibrous  capsule.  The  sul mm .1 1 j 
tissue  is  also  hv|H-rplastic.  In  long-standing  cases  cicatricial  <  on.iadion 
of  the  conmWiv  tissue  takes  place,  with  atrophy  of  the  conjunctiva, 
so  that  the  retrotarsiil  folds  are  gradually  oblileialed,  the  in()>(:n-ms*>f 
the  eveball  interfcnHl  with,  and  a  coiulition  of  xerophthslmia  1^  .  Mhiced. 


'  A  Case  of  riirinaud's  Coiijunrtiviti-s,  Montreal  Med.  Jour.,  33:  ll'o 


ECZEMA  OF  THE  CONJUNCTIVA  513 

Tl..-  eyelids  are  often  cune<l  inward  (ntoopian)  «,  that  the  lashes  are 
.l.r.-<te<l  EKairtst  the  ronjinKt.va  (WcUmI.;  dyrtriehiMli).  From  the 
n..nf,.n«l  result.,  «f  fnct.o,,  «n,l  inflammation,  the  cornea  .sometimes 
lHr.,.m-s  clou.Jy.  the  .s„,H.rfinul  epithelium  .somewhat  rouKhen«l.  and 
siuw-sh  uk-ers  may  lKH-..me  mar.ife.st.  The  cornea!  tissue  mav also ^jften 
an.  I.„l«e  ou  war.  .  No,  ,„frec,uently.  the  inflammatory  proI.e.s.s  .sn„.„d., 
..Hhr  he  sulK-pithehul  layer  towar'  the  c-entre  of  the  c-oinea,  the  newly 
foriiMMl  ti.s.sue gradually  Ux.iming  vaseularim]  (puaui) 

follicutar  Oonjuactiyitl..-S<.me  authorities,  notably  Saemi.seh,  de.st-ribe 
a  follH  ular  conjunH.v.t.s,  wh.eh  In-ars  a  strong  r^vsemhlanee  to  traehoma. 
at  Nus  m  Its  ,ary  .stage..  The  disease  afftxts  the  conjunctiva  of  The 
uls  only  and  leads  to  the  fonnation  of  node.s  of  hyix-rtrophitnl  lymphoid 
rsMu..  Lore  are,  however,  no  hy,H.rtmphi«l  papill/  The^eZn^ 
in  hy  far  the  majority  of  ca.ses  art-  quite  superfitiil  and  never  lead  to 
ru_«tn,-m  contraction,  ulcerat|on.  or  pannus.  The  condition  may  heal 
«.tlmut  leuvuiK  „„y  trace.  The  .lisc-ase  is  «ud  to  be  feeblv,  if  at  all 
!">,.  «,.ou.s  It  nmst  Ik.  said,  however,  that  it  is  l,v  no  meias  p«,ved 
.  a  .Ins  ahcrtion  .l.ffers  essentially  from  trichoma, 'either  etiologicall^ 
on  other  partHulars.  In  fact,  transitional  forms  are  by  no  meaA^ 
unknown.    Some  of  the  ea.sc-s  are  attributable  to  atropine  irritation 

Vem.1  OonjnacUviU.  (Spring  Cttrrh;  OeUtinon.  InfltotiSn  of  th« 
Lmbu.;  Phlyct«»  P.lli<U).-Vernal  conjunctivitLs  is  an  apparend^ 
spcrifu  and  extrc-mdy  obstinate  affction  of  the  conjunctiva  The 
diM  .s..  „ff„.ts  lK.th  eyes  and  is  most  c-ommon  in  chil.lren  As  its  name 
mplus.  ,t  ,.s  most  troublesome  with  the  onset  of  warm  weather,  tendinj^o 
-Jsapjuar  dunnK  the  winter.  It  may  last  for  years,  and  is  WievK 
many  ,0  l,e  fcrbly  contagious.  Both  the .xular and  palpebral  con  Sv« 
;',,;"■  •"™  '"•  ^'''  ^""J^n^'iva  of  the  upper  lid  which  Ls\he  one 
.M  IK  nn-olve,!.  presents  a  ,muli«r  bluish-white,  milky  appearai^ce 
ha  a.  ...nstic  of  the  disease,  and  is  covered  with  flat,  rounded  elev^S 
h  nu.st  cart.„g.nous  hardnes.s,  giving  it  a  cnriou.;  te..selS«T ap^Tr! 

n  ;  f  ,'  '  -f '  •'  f'"'}'^-  ""*•  ^^"'^  «'*«^"«1'  ♦■'•^vated,  gelatimn  s 
n.a>M  s  „f  a  browni.sh-p.nk  color,  close  to  the  limbus  of  the  cornea  So 
Knnv.l,  „.ay  spread  laterally,  or  occasionally  mav  encircleX  eon^f 
«hu  1,  .nay  also  Ik?  more  or  less  encroache.1  upon.  ' 

•Ml. n,s,;„p,cally,  the  patches  are  composcnl  of  c-onnc-ctive  tissue  and 
2'  v  ,l...kenecl  epithelium,  which  tends  to  .send  prolongltio,  .^1  tEe 
u        M„g  structure..    Accorcling  to  Fuchs.  the  patches  are  comi  of 
areola,  ,„n„e«.t,ve  t..s.sue.  which  has  undergone  hvaline  detreneraHon 
-.r...   uuh  tlnckend  epithelium.     There  is  but  little  LSnl^S 

K  n  o  p.  nnu..   {)<.ea.sional ly,  the  fH-ripheral  zone  of  the  cornea  undergoes 
^><j.  .l.K.-..erat.on,  producing  an  appc-aranc^-  similar  to  that  in  S 

// 'rT?,  ?!  ^^  Oonimctiva.-EcEema  of  the  conjunctiva  (conjnnc- 
0,  '  '•'f"'"^"*--;  co»Ju»ctivith  lymphatica  sive  sJo/ulo.a)  s  usia  ly 
^MNoung  children,  especially  tho.se  who  are  wiakly  or  of^he 
«Kallc,J    scrofulous"  temperament.   Unlike  most  other  forms  of  conjunc! 


A I 


614 


THE  COSJUNCTIVA 


i  i' 


W-n 


f 

i 

't 
*  ■ 

:  i 

1. 

1 

ll 

li 

tivitM,  it  M  invarittbly  a-iMx-iatinl  with  some  roastitutional  (listuiliiiiKf, 
furred  ton)(ue,  \o!»  uf  appetite,  cmastipation.  It  a  not  infretiiiciiily 
seen  in  comhinution  with  ecxema  of  the  face,  nose,  ears,  ami  .muds. 
Onlinarily,  one  eye  onl>  is  aff    tetl. 

The  disease  is  eharacteriz«>d  by  the  formation  of  one  or  more  pupiilc^ 
or  pustules,  varying  in  size  from  that  of  a  mustanl  see<l  to,  in  rare  ciis^s, 
that  of  a  split  pia  These  are,  hLHtolo);ically.  c-omptxsed  of  a{q;n>pi lions 
of  inflammatory  leulcwytes,  coven-*!  at  first  with  the  epithelial  iiivir. 
Eventually,  this  may  give  way,  so  that  an  ojien  ulcer  is  the  result.  'I'lic 
papules,  pustules,  or  ulcers  ure  delimit«-d  liy  a  zone  of  catarrhal  iiitlaiii- 
mation,  or  the  bulliar  conjun<-tiva  as  a  whole  may  \w  diffusely  nNlritnt'il 
and  swollen.  There  is  a  uiucopundent  exudation.  Not  infn-<|Ut'iillv, 
the  cornea  is  involved  in  a  similar  manner.  The  conjunctiva  of  (he 
lids  almost  always  escapes.  The  affix-tion  may  run  an  acute  cour'H-,  l>iit 
often  is  chronic  with  occasional  acute  exjicerlwtions. 

Xerosis. — Xerosis  of  the  conjunctiva  (prmphigiu  of  ihr  iinijiinctira) 
is  a  curious  and  somewhat  rare  disease,  the  e.xact  nature  of  which  is  not 
entirely  un<!erstood.  It  occurs  under  the  guise  of  a  chronic  inflmnma- 
tion,  in  which  the  conjunctiva,  chiefly  that  of  the  bulbus,  slowly  iitroiiliits 
and  contracts,  owing  to  the  formation  in  it  of  cicatricial  tissue.  'Hh- 
membrane  it.self  is  dry  and  lustreless,  and  is  covere<l  with  fine,  wliilish, 
fatty  scales.  The  pnx-ess  may  resolve,  but  not  infre(|uently  pr<>;;r(s<c.s 
until  the  free  edges  of  the  lids  an>  lM>und  down  to  the  glol)e  and  iKfoint- 
continuous  with  the  cornea,  thus  limiting  greatly,  if  not  entirely,  the  move- 
ments of  the  eyelwll.  The  cornea,  in  turn,  may  IxH-ome  invtih^-d.  The 
scales  consist  of  stratifietl,  keratinize*!,  epithelial  cells,  often  futtily 
<legenerate<!,  together  with  fn-e  fat-<lr«)plets.  The  des(|uamating  niiilerial 
also  contains  a  small  bacillus,  the  so-called  Bacillus  xerosis,  wliicli  !h;i^ 
.some  resemblance  to  the  Bacillus  of  diphtheria.  Its  specificity  is.  liow- 
ever,  by  no  meaas  lieyond  question. 

Tuberculosis. — Tulx'nnl(».sis  is  quite  rare.  '  (  far  as  is  known  at 
present,  it  Is  always  secomlary  t*>  lupus  of  the  *.-.■  > .  In  the  (oniurtive 
tissue  of  the  lids  an*l  bulb  are  forme*!  more  or  Ic  .rcinnscrilHsl.  IliiittiKsl 
outgrowths,  rcc-alling  the  fung*)i<l  masses  sc«'ii  ii  tuberculous  s\Movitis. 
These  are  re<!dish,  warty,  an*l  l)car  a  close  n-semblance  to  grainiliitioTis. 
In  time  they  bn-ak  down,  giving  rise  to  larger  or  smaller,  imjjular 
ulcers,  in  the  floor  of  which  grayish  or  yi'llowish,  casi-ous  tulxrdi  s  inay 
.sometimes  Ik?  .seen.  From  the  confluence  of  the  tul)ercl«'s,  lar<;(r  niHluies 
may  Ik-  forme*!.  Tlie  irritation  *>f  the  tulHTcuknis  princss  ofii  n,  aki, 
leails  to  enlargement  *)f  the  follicles  in  the  retrotarsal  folds  i  nllicitlar 
conjunctlpttis). 

Syphilis.  ~ Primary    and    secon*!ary    lesions    may  «Kciir,   mil   also 
gm     itts.    The  conilition  is  very  uncommon. 
Lbprosy. — I^eprasy  is  also  rare. 


PTERYGIUM 


(iir) 


PMOUMIVI  MnAMOBrHOIII. 

PinjflMCIlU.— PinRuwiila.  culltMl  so  fnmi  fhe  Iwitin  "niiiLMiis  "  fat 
..wmjt  »«>  an  orninw.iw  nojion  h.s  to  its  .stnutim-.  in  a  v.-llowish  ,.|e- 
viit.-<l  m«.s.s  sitiinl*-.!  in  tlio  tonjuiHtiva  l>iill.i  uim|  the  snUonjunrtivul 
(iss.li.,  iwua  ly  t.)  the  nu.s.,1  si.!.-,  I>ut  ocmsicnallv,  thou»{h  mrrlv.  t..  the 
«.in|H.ral  .s„U-.  It  is  fouiul  in  ini<l<lli-aKr.!  iH^opk-.  Its  iK«ition  .,n  the 
must  .-xp.^st.d  iH.rt.on  of  the  conjuiMtivH  .suRKi-sts  that  the  (M>ncliti..n  nmy 
Ik-  the  ««.iilt  of  irrittttuin,  such  as  ex|)«wun.  t..  win.1  an-l  rain.  Mwro. 
s.o,,H„||y,  then,  w  jlown-Krowth  of  the  epithelium  in  pja.rs.  wiih  the 
formation  of  ghiiMl-iike  pnxe.s.st..s  and  ev,.n  « ysts.  The  c-onn«tive  ti.s.sue 
Ls  .iurt.a.sed  and  there  is  a  ,narke.|  <levelopn.ent  of  new  elusti.-  HlH.rs. 
B()th  hl.rons  ami  elastic  tissue  pre.s«.nt  hvaline  «lep.m.ration 

Pterygium  (.Tri/-r>c.  «  win^^.-I'teryKium  is  an  overKrcwth  of  the 
conjunetiva  aiul  sulK-onjunctival  tissues,  iisimHv  (Krurrinir  on  the  nasal 
a.s|H.,  t  of  the  eyeball.  It  takes  the  fonn  of  a  triangular  elevation, 
mor.-  or  less  va.s<.Hlar,  the  apex  U-ing  toward  the  centre  and  the  base 
towar.1  the  |K.riplu.rv  of  the  eye.  The  ^n.wth  te.uls  to  encroach  uiK.n  the 
T'r":«  \'"";»P*''-''t'al  .-pitheliuni  is  thrown  into  folds,  and  is  comiMmHi 
of  stratified  trils,  the  dwper  of  whi.li  an-  culmidal,  while  the  others  are 
more  cylindrical  or  pointt.<l. 

The  overgrowth  of  epithelium  in  places  leads  to  the  formation  of  dand- 
hk.-  str..ctur,..s  and  ev.-n  cysts.  Numerous  Kohlet-cells  are  to  be  found 
in  the  sha  lower  .lepressions.  .„cHth  the  epithelium  then,  is  an  ..  -e- 
pition  of  lymphoid  cells  with  ..  .nerous  small  vesst'ls.  The  Bowiiiairs 
•"'•inl-rane  is  substitute.!  by  a  Hbrillar  layer  of  ,onn«tive  tissue,  con- 
tiiiimij;  large  bkxxl-  and  lymph-vessels. 

Thr  cause  or  cau.ses  ar^  not  altogether  .lear.  Most  authorities  attril>. 
iKf  the  tissut-overgrowth  to  irritation  or  hvperemia.  Crises  often  follow 
exposure  to  heat,  dust,  or  noxious  va,K,rs,  and,  also  occasionally,  trau- 
nialism.  tyestrain.  by  pro.lucing  eong,stion  of  the  vessels,  may  ^ssibly 
IH- a  cause.     I'lngutMula  not  infrtHjuentlv  precedes  pterygium 

Cy8tS.--(>tsare  due  to  .lilatation  of  the  lyiiiphatics'or  to  obstruction 

of  tl„.  glands    with  retcnti..u  of  the  s,rretion.     In  lymphangi..ctasis, 

nal,  ro„nd„l  vesicles   hlU.    with  .•k-ur  fluid,  are  forfnetl  on  the  con^ 

u.ui.va  of  the  bulb,  where  they  are  arranged  in  little  cluster,  or  after 

the  fashion  of  a  string  of  In-ads. 

IliMoIogieally.  these-  formations  coasLst  of  a  miml)er  of  intercom- 
niinn,anng  cavities,  cfjiitaining  a  few  lymphatic-  cells,  and  bou.uk-d  by 
mr,„.vtive  tissue  on  which  may  sometimes  U-  m-ognize.l  the  MaiitV 
rcniainsofancndothcliaMining.  "t-i.ii.iy 

Srrnnscyst,  may  result  from  a  lymphangitH.t.a.sis  in  whi.h  the  separat- 
ni:  |.a,„(,ons  l»etween  the  spa«.s  have  given  way,  thus  pnKlucing  a 
■    .^'■  '  av  ify.     1  hey  ;.rc,  however.  iK-casionally  found  at  birth,  or  result 

Sa  l,',l?r'7'.°r'  "^''"".'  T'  ••^  •''"'  '"  '■-^■''*'^"  <H'f«HTation  of  small, 
Riilar  lobules  in  the  fornix.  They  form  roun.l.  oval,  or  oblong 
^«(lln,-  in  the  c'.Hjunctiva,  of  a  somewhat  yellowish  color.     Micr(> 


<s, 


It 


616 


THE  COSJ(  VCTIVA 


scopiroll.v,  they  havr  a  w«'ll-<lpfiiM><l  wall  of  connwtive  lUsiie,  usiiullv 
lirwHl  wuli  •'miotlH'liu!  (fll.s.  Trlfanijirrtn*!*  of  the  ttinial  ami  biiUxir 
M»Hiun(  I  .  is  (Mva.Hionally  im-  with,  uhiuIIv  iH>artlK' lachrymal  famrH'Ic. 
TniDors.     Fibroaaa.     Kibroiiius  .ipriiiK  from  the  pal|Ml»ra!  roiijutu^ 


tiva  or  TuHi  'le  ciilHlivsac,  ami  are  fn-jjm'nlly  pe«lk-le<i.  'V\w\  mnv 
he  flattcm-il  ti  tn  pn-HKurt'  or  may  even  atHiime  a  eiip  »\\u]h:  Slii  ni- 
sc'Opieiillv  ,  an-  ('oiii|N>se«i  of  dcase,  filmni.i  tissue  with  iilrtintiv 
few  vf  V  Is,  uli'i  'UkIi  tlif  siiinller  ones  may  lie  more  cellular. 

Pilrfll'.Ti'^.-    1  ipillonm   of   thr   eonjinictiva   is  extn-mely   rare,  nixl 
iiflual)\   ^,      ijrs     (Mil  the  .sflenworneal  junction.     Tlie  »unir»r  pox^NMs 
a  p»'!i  1.      ,hI   I    coniiMxsiii  of  a  richly-hram-hinf;  coii    of  eoiineclivc 
T'l   \  'til  a  tliiek,  stratifi«><l   investmei  f   of  epitlwILtl  (clls, 
vlii    ii  al,  or  .s|nmlle-.sha[N-<).     Towanl  ihe  p«"ripher     of  iIr> 
ill.  .•■  ,,  is  in<    • '   "  liir  unii  infiltrated  with  leulcocytes. 
-I-ij<«!ir         ,i   i:  i.icr  rare  tumor  of  the  conjunctiva.     Ii  is 
ami 
.uai 


tissue  I  (>\ 
culK>iiij«', ' 
proe<  ■  M  ^  I 
Liuu  ut 
eonj:  i.i'iil 
loliulntcl. 


i,  ji    •  I  in  the  form  of  an  elevated,  wwto'-shafH'd  iii!i>s, 
f         ilowish  color,  situated  usually  In-twix-n  the  e\-(riial 


and  ini  f-ior  riftiis.  Microscopicnily,  it  is  coinpose<l  of  fatty  amj 
fil>r()us  ! issue,  lov.rid  villi  thickeiuHi  conjunctiva.  It  is  supp(is<(|  to 
orifjinarr-  in  a  liemii  of  'he  orUital  fat. 

Darmoid. — Aiiofher  ronjrenital  tumor.  (M-casionally  met  with,  is  ihc 
dermoid.  As  its  name  implies,  it  is  com|M>.sed  of  the  elenu-nts  of  the 
skin.  It  is  usually  of  small  size,  of  a  siiHK)th,  sl.iny  ap|)earaii(f.  tiiul 
is  situated  at  the  ioriieos<lerHl  junction,  partly  on  the  sclera  and  jwirtiy 
on  the  '.•ornea.  The  <'oriical  swtor  is  commonly  lH)Uii(h-<l  hy  an  (i|)iiijuc 
line  similar  in  apiH-uraiiee  to  an  areiis  senilis.  'I'lic  sufM'rficiid  epiilielinni 
is  somewhat  similar  to  that  of  the  skin,  .save  that  it  does  n(»t  Uidtnc 
keraliniztsl,  hut,  f)n  the  contrary,  is  soft  and  s«\'ollen,  nppareiitjv  t'n)iii 
maceration.  I'ndcrncath  there  is  a  di  use  coiiiHHtive-tissue  iiieniliriiiif, 
containinj;  clastic  filK-rs,  hhMMlvessels,  jjlands,  and  fat.  I'rojectiii;:  tiuni 
the  surface  are  more  or  less  numerous  hairs.  Alt'  has  <K'S<rilKMl  «  IkiI  lie 
calls  a  chondro-a^bnoma,  a  conjjenital  tumor,  composcnl  of  j{land-iii!iiil(s 
sugfiestinj;  those  of  the  lachrymal  ulai"!,  to>;ether  with  a  mass  of  enilin  (Uiic 
cartilage.  The  two  elements  were  s«'piirated  one  frfjm  the  other  li>  iml 
enclos«'d  in,  coimwtive  tissue.  The  growth  was  the  si/e  of  a  s|>li;  .n-a, 
situated  on  the  hiilhar  conjunctiva.  It  was  sessile,  snuM.tli,  anii  .i!  a 
whitish  color.     Prohahly  this  should  In-  classtHl  as  a  tantonaa. 

Osteoma.— Osteoma  has  Ik-ch  met  with  in  a  few  instances  If  i  ihiuhI 
on  the  outer  asp«(t  of  the  vyv,  usually  iH'twwn  the  points  of  in  •  nun 
of  the  sujU'rior  and  external  rectus.     It  apfx'ars  not  to  U-  cungciiii;!!, 

The  malignant  tumors  of  the  conjimctiva  nrc  the  epitfii'liuiii:i  niu!  (he 
sarcoma.  'I'hey  may  U-  j)rimary,  hut  arc  most  frt-quenliy  se<-,.i'.(,irv  to 
growths  of  the  eyelids  or  orbit. 

Epithelioma.—  Kpithelioina  is  the  comiiioiMst  tumor  of  tlie  coniiiii^  liva. 
It  l>egii)s,  ti-aially,  tu-nr  tlie  cornco-:  leral  juiK  tiosi,  with  t' -  f.v  :=!t<«j 


'  Refcrvncc  llumlhook  of  tlip  Mcdioal  i^ciences,  Xpw  York,  Win.  \S . 
4:  1902:  IIKI. 


\.  t. 


TRAVMA 


617 


oj  «  8in.ll  nodule  covemi  witli  .lwtrtKl«l  bl.KMJveweU.     The  growth 

>I™pK.ally.  th..  t»n.«r  <«a,i.,l,  o/  «  thickened  epithelium,  which 
nutiires      Ihc  h.rny  Uwr  w  «ft,.n  .-..nsi-lerably  thickened.    Alnnit 

lien's  tz;:r ''-  ^"-^"^ «-  ""^  -^ '-  •-- 

r;fT'"-7?r*"""V""'  'iw'i'H'ly  ran.,  and  are  iMually  pi«mented 
or.  ran-ly    in  the  fur,..x.    'I'hev  form  rou«le.l.  sometii... .  Iobulate.1 

an.   I  kmJ  readily.     Ihey  do  not  t.ii.l  to  uUvratc.  ami  apiK^r  smooth 
an.  sl,...y.  ow.„«  ro  the  fu,  t  that  they  are  cover..!  by  epithelm 

\luroH,op,eall>-^  the  >«r..«„H.  ««•  of  the  smMfrolui^elM  variety 
mor,.  rart-ly  .p,nMe^elM      The  ve..cU  are  „u„,er„u,s    u„d  ,\n"ll^ 
eudiiicH  of  both  old  and  recent  *H-Hiorrhagcs. 


TBAUMATIBH. 

Tl...  .-..n  unctivtt  ma.v  \>e  cut  or  torn,  and  .such  accidents  nsuallv  dve 
nv   o  .....siderable  hcn.orrha^n-  int.,  (he  hnxse  .suU-<,niuM<.tival  t, -sue 

J.m-.    In    „r.-.Kn  IkxI.cs  p,„„„^,  «  i„,lp.,„cnt  on  it;  or  bv  ihc  action  of 

'"I  ...  the  nor,,  .seven-  n,j„r,cs.  inHaminati..n.     (i-casio,,,,!       wher^ 

-om..s,v,„d.n.  portions  of  ,hc  .K-ular  and  p„lp..bral  .«nju i.a  a^ 

, -l^-'l.  «...l  there  .s  loss  of  th.  epithelium.  „    ion  of  -he  c^^,,.,  «?t^ 
tlie  ev,.  may  take  place  (symblepramn).  'e  ,  w,.i  «,th 

The  Cornea. 

The  cornea  of  the  eye  i     .  stratifi..,!  membrane,  an.l  is  p.    u.ar  in  u.  u 
u<  I'-  onhnary  c.rcums.a uces,   „  .s  ,,<.rfecfl     transp,  ..  h     Vyt 

r  ;i;;;r  t  ^  ^'"^?-.p'-"^j  •"  t^e  Lme  o,  ,h.  a  .  u  i  z^ 

nd        «        r"  "^^;"^'."'«  »'"   "-^  «^    -hi-l'  are  somewhat 
.ind  .rrangetl  practRally  at  right  a-.glc  .<  (,  other.     Be- 


Sattc 


'II' 


1 


;i 


'  if 


618 


THE  CORNEA 


tween  the  bundles  are  numerous  lymph-spaces  or  lacunse,  conamunicnting 
with  each  other  by  means  of  delicate  canaliculi,  and  continuous  with 
similar  spaces  in  the  sclera.  In  f'le  lacunie  are  to  be  found  the  so-ciilled 
"corneal  corpuscles,"  fixed  cells  which  send  delicate  processes  into  the 
canaliculi,  recalling  in  appearance  the  asteoblasts  of  bone.  Iksides 
these,  wandering  cells  may  be  seen.  Next  comes  the  posterior  limiting, 
or  Dcsceniet's,  membrane,  a  clear,  structureless  sheet.  At  the  edfjo  of 
the  cornea  it  is  thicker,  forming  a  ring-like  zone  (the  annular  liganuiit), 
and  may  lie  traced  as  far  as  the  insertion  of  the  iris  as  separate  l)iiii(iles 
of  fibers  (the  pectinate  ligament),  Injunded  by  minute  clefts  (the  spaces  of 
Fontana).  The  posterior  component  of  the  cornea  Is  a  single  layer  of 
flattened,  endothelial  cells,  similar  to  thase  lining  serous  cavities,  and 
continuous  with  those  covering  the  anterior  aspect  of  the  iris. 

The  normal  cornea  is  avascular,  being  nourished  by  the  lymph  system 
above  referred  to.  Bloodvessels  in  the  conjunctiva  and  sulK-oiijunctivai 
tissues  and  in  the  sclera  send  out  fine  branches  which  pass  in  radially 
in  the  direction  of  the  cornea.  These  branch  dichotomously,  ami  form 
an  elalwrate  series  of  anastomosing  loops  in  the  limbus  conjuiutivae, 
but  do  not  encroach  upon  the  cornea.  The  structure  is  so  coastitiiteil  as 
to  be  perfi-ctly  transparent,  all  its  components  possessing  the  same 
refractive  index. 

From  its  exposctl  position  the  cornea  is  particularly  liable  to  injury 
ami  irritation,  and,  being  avascular,  is  apt  to  suffer  in  all  conditioris 
of  lowered  vitality  of  the  system.  Under  ordinary  circumstances  it  is 
able  to  deal  with  motlerate  injuries  and  grades  of  inflammation  without 
suffering  much  in  the  process,  hut  all  severe  processes  of  this  kind  lead 
to  extensive  and  permanent  changes,  often  producing  marked  int.'r- 
ference  with  the  function  of  vision.  Thus,  opacity  in  the  pujjillarv  area 
interposes  a  physical  impediment  in  the  visual  axis,  and  cicatrices  of 
the  cornea  result  in  alterations  in  the  angle  of  refraction. 


'3 


i'H  1 


OONaSNITAL  ANOMALISS. 

Congenital  abnormalities  of  the  cornea  are  often  asswiatcil  witli  other 
defects  of  the  eye.  The  cornea  may  be  smaller  than  nornial,  as  in 
microphthalmas.  In  this  case  it  may  also  Ir;  somewhat  flattened,  or  its 
curvature  may  l>c  the  same  as  that  of  the  sclera,  and  its  outline  may 
depart  more  or  less  widely  from  the  normal.  The  cornea  is  larj,!  r  than 
normal  in  mAgalophthalmus,  and.  moreover,  may  l)c  thinner  tlum  usual. 
The  anterior  portion  of  the  sclerotic  is  also  thinner  than  iiorniiii,  ^'ivmg 
it  a  bluish  appearance.  In  such  cases  the  anterior  chamlM-r  i^  ii-nally 
increasetl  .ii  depth  (hydrophthalmuB  anterior).  Partial  <)r  <  miplete 
opacity  of  the  cornea  is  also  st)metimes  observed,  and  is  a  tre(iuent 
accompaniment  of  microphtl.uhnus,  megalophthalmus,  ami  liMJroph- 
thalmus.  A  condition  resembling  the  arcus  senilis  is  tx-casioniliy  met 
with  at  birth— embryotoxon. 

Congenital  abnormalities  in  the  cunuturc  of  the  cornea  are  th;- 
cause  of  many  cases  of  astigmatism. 


KERATITIS 


619 


IHTLAMBIATIORS. 

Keratiti«.-The  various  forms  of  inflammation  of  the  cornea,  known 
as  keratitLs,  are  of  gn-at  practical  importance,  and,  owing  to  the  anatom- 
i.al  peculiariti^  of  the  part,  pn-sent  certain  features  which  differ  from 
tliose  fouiKi  m  mflammations  occurring  in  other  parts  of  the  body 

Heing  an  avascular  structure,  the  cornea  is  at  some  distance  from  its 
base  of  supplies  and  is,  then>fore.  comparatively  poorly  nourished. 
It  IS,  consec,uently,  hut  imperfectly  able  to  resist  acute  <lisease,  and  is 
particularly  liable  to  suffer  from  the  deleterious  influence  of  impoverished 
blood  or  circulating  t..xins.  Ulceration  of  the  cornea  may  dways  be 
taken  as  an  evidence  of  ,leficient  vitality  of  the  general  system.  Acute 
infwtious  keratitis  therefore,  if  not  checke.1  by  treatincnt,  is  apt  to 
proceed  apace  and  bring  aliout  serious  damage  to  the  cornea,  while 
the  more  chronic  affections  are  liable  to  l»e  sluggish. 

Again,  owing  to  its  exposed  position,  the  cornea  is  particulariy  ex- 
p<«ed  to  traumatism  and  irritation  of  various  kinds,  and  especially  to 
infection.  "^         ■' 

Finally,  any  condition  which  interfer&s  with  the  transparency  of  the 
structure,  or  its  normal  curvature,  will  seriously  impair  its  function 
as  a  refractive  medium. 

Keratitis  may  .  -  .lesc-ribed  as  partial  or  cirnumcrihed,  generalized 
or  nijfuse.  As  a  rule,  the  corneal  sulxstance  proper  is  affectcnl,  but  the 
epithelium  on  the  outer  and  in  ..r  asjiects  may  alone  be  involved 
Keratitis,  moreover,  may  be  primary  or  secoiidury  to  disease  ..f  the  con- 
junctiva or  other  parts  of  the  eye.  as.  for  instance,  the  ms-iridokeraVHs 
oTSikm-scl^okerahti.',,  or,  again,  may  l)e  an  expression  of  some  con- 
stitutional dehciency  or  taint,  suc-h  as  syphilis. 

The  changes  in  the  cornea  pnKJuced  by  inflammation  differ  somewhat 
acrording  to  the  nature,  the  localization,  and  the  intensity  of  the  process 
nin-e  mam  types  are  usually  descrilied.  infiltration,  ahsce-ts,  and  w/cera- 

Inflammation  of  the  cornea  (keratitis)  always  results  in  diminution  or 
loss  of  Its  transparency,  the  degree  depending  on  the  extent  and  the 
sever,  y  of  the  condition.  Slioul.l  the  anterior  layer  of  epithelium  be  in- 
^('lv..,i,  the  cornea  has  a  steamy,  pitted  appearance,  .somewhat  resembling 
a  .mrror  that  has  im-n  breathi-d  upon.  Thickening  of  the  epithelium, 
an;,  to  a  greater  degnx-.  infiltration,  causes  the  cornea  to  assume  a 
nnlky  someu-hat  c)palesceiit  ap|M-arance.  pas.siiig  on  into  a  whitish 
»fn..v.sh,  or  yellowish  opacity.  This  loss  of  transparencv  is  due  to  an 
»^r.ss,vi.  ac-cumulation  of  leukcK-ytes  within  the  lacuiue  'and  canaliculi. 
til.  rvsu  t  of  chemotaxis.     The  infiltration  inav  be  sinierficial  or  deeply 

oon'  1^7  "*  "•■  *'f  "•'^-  ^^'*>^^^  K™''*'''  •"«>•  ••«'««'^«''  '«iving  The 
c  rn.  M  little  or  none  the  worse,  but  it  i.s  by  no  moans  uncommon  to 
hn.l  v,iiie  degree  of  opacity  persisting.  The  condition  may,  however.  l,e 
y,  as  to  give  rise  to  ulceration  or  abscess  with  distinct  lass  of 

siii^lancr,  which,  on  healing,  results  in  the  formation  of  a  fibrous  scar. 


I 


I?      i 

i  1 


620 


THE  CORNEA 


Prolonged  keratitis  of  moderate  severity  frequently  results  in  opacity, 
more  or  less  fibrosis,  and  vascularization  of  the  cornea. 

An  abscess  is  a  circumscribed  infiltration  in  which  the  nutrition  of 
the  part  has  been  so  interfere<l  with  that  local  death  has  resulted.  It 
may  extend  to  the  surface  of  the  cornea  and  discharge  externally, 
forming  an  ulcer;  more  rarely,  it  may  evacuate  itself  into  the  anterior 
chamber. 

Ulcers  may  be  the  result  of  infiltration  or  abscess,  or  maj  exist  as 
such  from  the  first.  Perforation  of  the  cornea  may  occur  or  the  ctructure 
may  he  almost  vholly  destroyed.  Adhesion  and  prolapse  of  the  iris  are 
not  uncommon  results.     In  not  a  few  instances,  the  inflammation  jouls 

Via.  174 


Milil  itrmle  of  influnmntion  of  tlie  cornes  in  inai;  (kpratilis  e  lagnphthalmo).  rhamrH'ri/ii|  l)y 
enlarKrmpnt  and  direct  division  of  the  nuclei  of  tlie  romenl  cor]>u(*cle9  c,  wiili  hut  sliKht  iri\:»-ion 
of  polynuclear  leukocytes  p,  and  lyniphorylea  /.     (Tuoke.) 


f       I 

!  1 


to  the  deposition  of  pus  in  the  ante  ior  chamlx'r  (hypopyon).  Should 
the  process  heal,  the  loss  of  tissue  k  ..iude  goo«l  by  the  prtKcss  i<(  i  ita- 
trizrtion.  Milder  gra<les  are  followed  by  slight  opacity  (nebula i.  mure 
severe  forms  by  the  formation  of  a  dense,  fibn)us,  pearly  star  (leukoma). 
The  reparative  material  lieing  softer  than  the  normal  corneal  sui)  iniice 
frequently  gives  way  under  the  intra(K>ular  pressure  ami  U>vv.<^  nil 
anterior  protrusion  (corneal  itaphylonu).  Sometimes,  again,  ili-  Ikss 
of  sukstanc-e  is  not  entirely  repain-d  and  the  surface  of  the  lieali  i  ilicr 
does  not  quite  reach  the  general  level  of  the  cornea,  while  the  n  t;:  I  irity 
of  the  curve  is  disturlied  (eometl  Ikeet). 

Diffuse  Keratitis. — Diffuse  (interstitial  or  parenchymatous!  !   iititis 
is  characterized  by  a  more  or  less  uniform  inflammatory  infiltr:  '  ii  of 


KERATITIS  BULLOSA  ggl 

the  cornea  throughout  its  whole  thickness,  which  exhibits  no  tendency 
towajd  ulcerafon  or  a^«<^s.,-formation.  The  epithelium  pSt"  a 
shppled  appearance  and  the  underlying  cornea  b  opaque/s^ewha" 
r,-serabhng  ground  glass.  The  process  generally  Wgha  Zh7omt 
ai.a.7  congestion  followed  by  th^e  formadonTne&  ^ies^n 
the  cornea  which  gradually  extend  until  the  whole  structure  S^mes 
.nyolved.  Delicate.  ch>sely-set  vessels,  derived,  from  branXsTThe 
chary  vessels   gradually  make  their  way  from  the  periphery  into  the 

^ivMcutor  kerahtu)  These  newly.forme<l  vessels  are  in  the  substance 
o  the  cornea  and,  consequently,  present  a  dull,  reddish-pink  S 
(salmon  pa  ches"  of  Hutchinson).    Salmon  patches,  when^small   are 

a  "tor^n^oTh^r  '^"^^  ''"'  "^^^M^'  '-^  to  as.sume  the  foVS 
a  sector.    In  other  cases  a  narrow  fringe  of  vessels  Ls  formed,  continuous 

kerultu,.  Mwed  forms  are.  however,  not  infrequent.  As  a  rule  the 
conchtion  js  bdateral.  but  days  or  wt^ks  may  elapse  before  thcTnvolv^ 
me„t  of  the  second  eye.  The  aff.Ktion  is  a  coastitutional  one  a„T 
as  a  rule,  due  to  syphUis  It  is  said  to  be  met  with  also  in  strumous 
and  gouty  md.v-,duak  The  disease  runs  a  chronic  course  and  reWs 
are  common.    Complete  restoration  of  the  transparency  of  the  cJ?n^ 

SrriH.s^ig?''""^'^  -^•-  ^-  --"^  «^o  -"pS 

.n^Uous  eonjunct.v.t..s  or  repeated  attacks  of  phlyctenular  kemtkir 

I-  superficial  epitheuun  iK.,m,es  irregular  frem  erosion  and  hvper- 

fn.,    .   overgrowth,  wh.le  new  vessels  are  fonmnl  more  or  less  Zfn- 

dauiy  between  the  ep.thelal  layerand  the  Bown.an's membrane  andTn 

h..  .orneal  .sul,stance  .fself  ,p«nu.).     When  the  newly  formal  Uo^. 

.■».ls  are  few  and  scattertnl.  the  condition  Ls  spoken  of  ^  paTus 

kJ.^rT'^,''  Keratiti..-NVnroparalytic  keratitis  is  a  form  of  diffuse 

i/l'^ir  ^'"««'«'\^''r"'7'  ^"""^  "'  "-^^  -'•-'^  "'«  faction 

0  tlu  hfth  ne^^e  ,s  .mpaire,!  or  .lestroyed.    Symptoms  are  lan«.|y  in 

a  H  a„,;,.  owing  to  the  insensibility  of  the  cornea.    There  may  k^ere  J 

.     rajjon  of  the  tissue,  but  the  pnK.e.s.s  is  very  apt  to  ^on To  s„ZS 

K.r..V  "  rr"""^"'  "'"*-"'^"«'»  i«  eompamtivelv  slight.  ^^ 

Kemuu  BnUo«.-  Keratitis  bullosa  is  a  rar.  disease,  characterized 

s  rf   ;.,;Tr'     ""  ■"  "^^P"'   ''"y"'''''''  °^   transparent  resides TS 

...  of  ,|„.  ...riH-tt.  accompani«l  by  market!  parexysms  of  pain.    1  he 

e^i.l..  ar,-  comparatively  large,  sii^le  „r  multiple.     They  may  reach 

"::  'ixt:rt  -^i  "■■""^"''  "•*•  "-'-'^'-'^-"^^  E!l 

the,.,         =  I  •       T^  "^  Parend.yiimlo.vs  keratitis.    As  a  rule 

i  I K    .i;    r^r.'"  """T.;^">-^=  '«■•  r^«""'.  from  glaucoma  or  dd 

of...  I^SSani^E^f  firnl''-'-''--  '"^  "^  ^^^^  ^'^'-'-- 


t 

I 

i 


'J 


••J, 


822 


THE  CORNEA 


Not  unlike  this  affwtion  in  some  particulars  is  herpas  of  the  coriicu. 
Here,  one  or  mori'  small  vesicles,  containing  clear  transparent  fluid,  form 
on  the  surface  of  the  cornea.  When  rnpturetl  an  excoriated  surface  is 
left.  Severt'  neuraljjic  paitLs  accompany  the  eruption  of  the  hlLsttTs. 
There  is  often  marked  pericorneal  injwtion.  HerjH-s  of  the  coriua 
may  come  on  without  obvious  cause,  or  may  Ik-  asstx-iateti  with  catarrh 
of  the  respiratory  passaj?es.  In  herprx  zimter  ophthnlmicut,  which  is 
prolmbly  due  to  some  inflammatory  disorder  of  the  fifth  nerve,  ulceration 
and  infiltration  of  the  cornea  are  quite  marke«l  and  the  condition  is 
slow  in  healing.  The  eruption  of  vesicles  ixt-urs  in  the  district  supplied 
by  the  fifth  nerve  and  is  accompanied  by  much  pain  and  local  anestlnsia. 
The  cornea  is  apt  to  be  involve«l  only  in  those  cases  in  which  the  nasal 
bram-h  of  the  first  division  of  the  fifth  is  affected.  (Complication  with 
iritis  and  hypopyon  is  not  uncommon  in  this  form  of  herpes. 

Ulcerative  KeratitiB. — Several  varieties  of  corneal  ulceration  are 
recognize<l.  The  simplest  form  is  the  snuJl  central  nlear,  met  with  in 
young  badly-nourishe<l  children.  It  Ix-gins  as  a  small,  grayisli-wliitc 
elevation  at  or  near  the  centre  of  the  cornea.  S(X)ner  or  later  this 
bn-aks  down  in  the  centre,  forming  a  minute  excavation.  The  jjhm tss 
apj)ears  to  he  somewhat  siuggisli,  as  the  cong«'stion  is  slight  ami  tlio 
symptoms  usually  imobtrusive.  The  ulcer  is  mast  often  single,  but  i>  a|it 
to  recur,  or  the  other  eye  may  l)ecome  involvwl.  Ocrasionally,  we  Hnd, 
in  anemic  or  strumous  patients,  somewhat  similar  ulcers,  but  even  more 
sluggish,  which  run  a  clironic  course  with  frc(juent  relapses.  Tin  re  is 
little  or  no  infiltration  and  the  loss  of  substant-e  Is  only  iinjH'rfcctly  made 
g(HHl,  .so  that  a  shallow  depression  or  a  flat  facet  is  apt  to  be  left,  Imt 
without  nnich  damage  to  the  transparency  of  the  cortiea. 

Oaturhal  ulcers  are  not  infre<]uently  met  with  as  a  result  of  caturrhal 
conjunctivitis  in  elderly  jxt)ple.  The  ulci-r  usually  forms  at  or  near  ilie 
margin  of  the  cornea  as  a  shallow  sulcus  or  there  may  Ik-  several  niiiiiite 
delicate  abrasions  of  the  surface.  There  is  a  mcKlerate  amotnit  of  |Mri- 
corneal  congestion.  The  nicer  usually  heals  readily,  unless  it  Ihkoiiu' 
inf«'te<l,  when  .serious  suppurative  inflammation  may  sujhtvciu. 

FUycteimlar  ulceration  is  closely  relat«'<l  to  phlyctenular  conjiiiM  livitis 
(q.  V.)  and  is  often  iLs.s(xia ted  with  diffu.se  conjunctivitis.  It  U^''"'' 
with  one  or  mon>  superficial  infiltrations  al)out  the  size  of  a  inilli  i  >«ii, 
cither  on  the  white  of  the  eye  near  the  cornea,  or  just  within  the  i  onieai 
margin,  c»r  upon  some  other  part  of  the  cornea.  The  papule  is  i  irdilar. 
surroundetl  i)y  a  zone  of  congestion  and  opacity,  and  may  as^iiMn-  the 
appearance  of  an  acne  pustule.  The  epithelium  is  ■^ixm  destro..  1  ami 
a  .small  abrasion  or  aphthous-l(M>king  ulcer  is  the  result.  I'm 
congestion  is  always  present  and  may  Ik-  marked.  Phlycteiiiil  > 
tend  to  advance  in  an  almost  radial  dinrtion  towanl  the  ceiiin 
cornea,  carrying  with  them  a  leash  of  ves.sels  lying  upon  the  • 
opacity  left  by  the  ulcer  (pblyctenutar  pannus).  When  the  pn*. , 
the  ve.s-sels  gradually  disap[)ear  but  more  or  less  opacity  remain- 
he  present  at  or  near  the  ceiitn-  of  the  cornea,  considerable  ili- 
of  vision  will  result.     ()cca.sionally,  the  condition  develops  iiii" 


■  rncal 
1  leers 
..f  tht 
L  k  of 
.  la'^'i 
If  this 
iiatice 
ippu- 


ABSCESSES 


623 


rative  keratitis  and  may  perforate.  In  extreme  cases,  the  inflammation 
sprciKls  to  the  vitreoas  and  may  destroy  the  eye 

1'l.lyetenular  ulcers  are  met'with  usually  in  children,  sometimes  in 
apparently  goo<l  health  otherwise,  but,  as  a  rule,  the  subjects  ar*  strumous 
or  suffer  from  grave  errors  .,,  nutrition.  Not  infrec/uently,  there  is  a 
history  of  measles  or  some  other  infectious  disease 

(  nscentic  ulcers,  close  to,  or  actuallv  upon,  an  areas  senilis  are  some- 
t.„us  met  w,th  m  elderly  debilitate,!  .ubjects.  They  m^y  formXp 
pnH,ves  around  the  cornm,  which,  if  it  be  cut  off  from  its  nutritio™.  S 
tht'rtMipon  exfoliate.  ■"■"■i,  luny 

Stippurative  Keratitis. -The-e  are  certain  forms  of  suppurative 
k,n.m,s  which  should  Ik.  referred  to.  Absces.s  or  infective  ulcerrmay 
onjimate  spontaneously  or  may  result  from  some  trifling  injury  l2 
ably  the  condition  arises  from  the  infec-tion  of  the  cornea  rendered 
p.Ks,l,le  by  the  preexisting  in  ury,  and  as.sisted  bv  debility  and  malnT 
.nno,.  of  the  p^ient.  Such  a  condition  tends  to  Spread  intone  diSm 
«1„ ..  lu-a  ing  .„  another,  is  unattendcnl  by  the  formation  of  new  Z^k 
Zi^:^''  "'  ''"""^'  '"«»«>-''-«.  and  is  frecjuently  compiS 

The  Acute  Serpiginoue  Ulcer.-Saemisch  has  de.scril,ed  what  he  calls 
.I..'  nn„.,erp,;,,n„u.  ucer,  a  form  which  t.-nds  to  penetmte  deeply  and 
ext,..ul  UKlely.  csfH^Mally  in  one  direction.  It  Ik^HiW  as  a  gmS'sZ 
pr....nnng  slight  ulc-eration  and  having  a  sharpUut  borde^C  S 
of  Mull  IS  more  opacpie  than  the  rest.  The  p^cess  is  ant  to  ..v/.u.H 
rap..ll,,  and  may  lead  to  perforation  of  the  cornc^Wtis^n^  h:ii,p^^^^ 

Kenitom.l«i..--The  soK-alled  keratomalacia.  met  with   in   infants 
S?'  t'",^'^T""  '''«'".■•'«»--.  -  «  "^'vere  fonn  of  s tppurSe 

x.K  N  .uireuv  Ihe  affcvtion  l>egins  apparently  from  the  inft-ction 
of-,„..  small  fissure  or  abrasion  of  the  cornea,  which  rapi.lly  devdops 
"n.;","  "Th[-T"""*''  laterally  Hn.l  dc.ply  into  the  substance  of X 
M-.;...  the  c-otl'"^  ""  «"'-"^^'  '^"^'  ^"•'  •-"--'•  ^^^^  «nd  tends  to 

„         n    ."'7'  ""•     ^  ''ey  may  oc-cur  as  a  primary  infec-tion.  or  may 
'?'  "  :7PV'f'"'"»'r'"-^'  "'«"™»"'".  f"'m  traumatism.  c3   u  c^ra- 

r    I    I  •  ''*'f|^'^'  '-""Kested  area.     The  s,wts  enlarge  ranidiv 

r^ r  T'lvi;:""'  "^""  '^'  '"-^''--K'nK  forward,  thus  pro,lucin'g  a7ulc  ^ 
Z  ^^  "'.•''•^^^"'•"'"'t  exudation.  When  perforation  of  the  cornea 
occurs  posteriorly,  hypopyon  results 

In  s,„no  C8.se.s  of  iritis  the  lower  part  of  the  cornea  lje«,mes  secondarily 

m    K,,i    „p,H.„nng  somc-what  h,-.zy.     Not  infrc.,uentlv.  a  numln-r  of 

S      .,:  ;;,:';E!'  f -■P'.v.dcfined.  and  of  a  wllitish  o'r  gra.Wsi:;,!;' 

u-^'"   I.Mnma.     Ihese  dots  are  arrangcnl  in  the  form  of  a  seJtor  with 


624 


THE  CORNEA 


the  apex  tpward  the  centre  of  the  cornea,  the  smallest  dots  bein>;  mar 
the  centre  (kerntitis  pundatti).  Keratitis  punctata  is  nearly  alwavs  tin- 
result  of  some  affection  t)f  the  cornea,  iris,  choroid,  or  vitreous. 

The  RMOlti  of  8"pptir»tiTe  Keratitii.— UKhts  of  the  cornea,  when  they 
heal,  not  uncommonly  leave  iH-iuiid  them  traces  in  the  form  of  pennmuiit 
opacities  of  the  tissue  or  even  xcars.  These,  if  situated  over  the  pupil 
of  the  eye,  may  seriously  interfere  with  vision,  not  only  by  introdiuiii); 
an  opaque  substance  in  the  visual  axis,  but  by  altering  the  cunatun-  of 
the  refracting  medium.  In  severe  «-ases  of  ulceration,  the  whole  or  the 
greater  part  of  the  cornea  may  Ik-  destroyed,  and  the  inflammation  may 
spread  to  the  iris,  choroid,  and  the  humors,  leading  to  total  destrm  tion 

of  the  eye. 

Smaller  ulcers  may  perforate  and  lead  to  the  escape  of  the  aqueous 
humor  through  the  'opening.  Occasionally  a  permanent  fistuln  may 
result.  This,  according  to  De  Wecker,  is  due  to  the  eversion  of  Dtstt- 
met's  membrane,  which  forms  a  lining  to  the  fistulous  track.  ( kcasion- 
ally,  where  perforation  is  not  quite  complete,  Descemet's  raembraiu-  may 
prolapse  and  present  as  a  small,  clear  vesicle,  resembling  a  glass  Uad, 
m  the  base  of  the  ulcer. 

Prolapse  of  the  iris  and  adhesion,  of  the  iris  to  the  region  of  tlic  ulcer 

may  occur. 

Hypopyon.— Hypopyon,  or  pus  in  the  anterior  chamber,  may  occur 
with  anv  ulcer,  whether  it  has  perforated  or  not,  and  with  any  suppnnilive 
condition  of  the  cornea.  The  pus  may  l)e  derived  from  an  abscess  or 
ulcer  which  has  cnKltHl  tiirough  to  the  posterior  surface  of  the  < ornca, 
or,  oc-casionaily,  may  Ix'  due  to  the  extension  of  inflammation  from  the 
iris.  In  some' severe  cases  of  suppurative  keratitis  the  pus  .sinks  down 
between  the  lamellae  of  the  cornea  (onyx).  Onyx  and  hypopyon  may 
co-exist. 

Spedflc  Keratitis.  TnborculoslB,  Byphili*,  and  leproiy  only  rarely  (.'ivo 
rise  to  circumscrilKHl  lesions  in  the  cornea. 

Kentomycosis  aspergiUina  has  been  de.scril)e<l,  but  is  very  rare' 


RETROORESSIVE  METAMORPHOSES. 

▲rCTU  SeniliB.— Arcus  senilis  (gemntoxon)  is  a  degenerativ.' 
in  the  cornea,  found  in  eiilerly  people.     The  condition  Inui 
the  formation  of  a  light  gray  arc  at  the  periphery  of  the  (oii 
liegins  lioth  alwve  and  Ih'Iow,  the  two  arcs  gradually  extcii<iiiiu 
complete  cinle  b  prcKluced.    The  ring  is  sharply  definetl  from 
bus  and  is  separated  from  it  by  a  narrow  transparent  baml. 
gradually  loses  itself  on  the  concave  side  in  the  clear  cornea.     1 
is  at  first  silvery  gray  in  appearance,  but  later  becomes  denser  ai; ! 
Both  eves  art-  iisuaJly  affettcd.  although  the  condition  may  !h'  ■ 
According  to  Fuchsj  the  condition  is  not,  as  has  usually  b»t '. 


clianjif 
I-  with 
,a.  It 
until  a 

ihi-  lilD- 

wliilc  it 
n-  arcus 
( n-amy. 
i!:!!eral. 
taught, 


»  Leber,  V.  firaefe's  Arch.,  25:  Die  Entstcliung  der  Entzundung,  U-\y 


!s91. 


TRAUMATIC  DISTURBANCES  (J25 

?i  '?!fri^"^"'*iTu°'"  •"«'♦"'!'«"  Of  the  cornea,  but  a  hyrdine  deRenera- 

he  deposit  of  hme  salte  in  mjnute  particles  in  the  superficial  layers  of 
lu.  cornea  near  the  i.mbu.,.    The  c..n.iition  is  to  l«  attributed,  no Sb" 

to  the  .mpensh«   nutrition  of  the  cornea  due  to  senile  cha^  in  the 

vascular  loops  encircling  the  cornea 

i.lil'^ir'  ^•f^^r**?""-  f'alcareous  degeneration  of  the  cornea 
IS  met  with  occasionally  in  the  form  of  a  transverse  l«nd  of  opacity 
rormsponding  with  the  palnebral  fi.s.su«..  This  is  of  a  grayish  or  Sli 
ish  color  2  to  3  mm.  UnJi  and  is  found  in  elderly  or^matui-ly  S 
pcple.  It  IS  also  met  w  th  in  eyes  affected  with  deeply-.seated  I'Ze. 
an.)  Ill  those  with  ^  tendency  to  glaucoma  u'"«»se, 

Pi«in«lt»tion.-U«l  MJa.  not  infmjuently  oc-cur  after  the  applica- 
I  he  stains  are  dense,  white,  opacju...  and  sharply  defined. 

PKOOBUSIVI  MKTAM0KPB08E8. 

Tuinor8.--Primary  tumors  of  the  cornea  apfK-ar  to  In.  unknown 
1  mors  of  the  conjunc-tiva.  es,HHi«lly  thase  which  spring  fmmTe 
«^l|T,x.ornca   junction,  such  as  the  papiUoa..  the  d«Joid,  the  epith^ 
liom»,  and  the  ureonu,  may  invade  the  cornea. 

TRAUMATIC  DUTUKBANOES. 

Tl...  cornea  In-ing  firm  and  rc-sistant,  and  supportc-d  bv  an  ekstic 

t r'tc-lHir'""  iT'''""    '  •■  "  '''T '"  '••^-  ""•^'  '""'•'-  increase- of  iS- 
MU    TZr,   ■    ""!>■•  .'"'r'^'*''-'  »•«■  '"J'T"!  I.y  the  impac.t  of  foreign 

Hl-nvs  ufK,,,  the  cornc-a  from  small  IkkHc-s  may  msult  in  l.xs.s  of  the 
MJ.rh,..al  epithelium,  bruising.  ..r  even  nec-rosis^.f  tie  p"rt  In  the 
U..  ..vent,  from  the  consecutive  inflammation  and  inf Jtio  wh  ch  i^ 
so  l,al,l..  o  octur,  a  corneal  aksc-ess  often  results.  The  various  intel' 
t  rs  Miul  lyrnph-spa«..s  iKKxmie  infiltrated  with  .serum  and  pus  cell 
Ihe  .oMjnnctiv^  «  reddend,  and  there  is  ciliarv  c«nS"n  n  a 
f  «  .l.y>  he  injured  part  becomes  opaque  and  of  a'gravish  col."  The 
L    ;;•     r  ■".f^''!  •'"P-^*-!"'  'ayers  ;.r  mav  extcml  inon.  .tplv      ' 

nm     .  I  ,0  Ss    M  -"^     'T  •    '"I'**'""  ('•yJ^Py"")'  a™'  the  condition 
2>  I.  ,,.1  to  iritis  and  iridocyclitis.     If  the  abscess  disc-harge  cxtcrnallv 

Ls  ;;::':;'" ':s.'"  '"'^  'Tr^  ''^''''^'""  «"^'  i"flammation,*'p;x;^ 

sul    ;„..!?        -     "  panophthalmitis  and  phthisis  bulbi.     Anterior 
X      ';  «/  ""'  "'"o"""""  result.     Should  the  abscess  heal 

»Hi,,,,„.  more  or  less  interference  with  vision.  .F««"n, 


^  i 


626 


THE  SCLERA 


SliRht  wounds,  where  there  is  merely  loss  of  the  sujK'rficial  epithe  iiiin 
or  of  a  trifliii}?  p<jrtion  of  the  deejier  corneul  sulwtamv,  heal  up  without 
much  trouble  and  without  any  serious  after-conse<|ueiK-es,  exc-ept,  |m.s- 
siblv,  in  the  ease  of  weaklv  or  dehilitatjnl  jH-rsoits  and  from  lack  of  sur>;i.  hI 
clea'nliness.  Unless  the  injury  exteiul  to  Dest-emet's  membrane  no  h(  ar- 
rine  will  result,  but  mit  infrtHjuently  the  curvature  of  the  cornea  is  ah.r.-d 
and  the  refracting  p«iwer  c)f  the  structure  correspondiiiRly  interfere<l  w  itli, 
a  iioint  of  great  practical  iinportanc-c  when  the  injury  is  at  or  near  the 

visual  centre.  i    ■     •  • 

In  the  case  of  larger  wounds,  the  vitreous  may  escajie  and  the  iris 
and  lens  iH-coine  attached  to  or  incareerate«l  in  the  wound,  or  may  cviii 
l)e  prolapseil  through  it.  There  is  asuallv  considerable  loss  of  tissue, 
with  the  formation  of  a  large  cicatrix,  to  which  the  iris  and  lens  may  Ik- 
permanently  attacheil.  .  •     i     • 

Burns  scalds,  or  caustic  erosions  are  more  serious  than  similar  in- 
juries to 'the  conjunctiva,  inasmuch  as  they  lead  to  considerable  rem  tioii- 
ary  inflammation,  with  ojmity  or  scarring  of  the  cornea,  uiul  .veii 
symblephuron. 

The  Sclera. 

Sderitis.— The  disorders  of  the  sclerotic  meinl)rane  are  coinpara- 
tivelv  few.  The  most  important  is  in'.lammation— icleritli  (epucleritii). 
This  is  much  rarer  than  keratitis  and  usually  involves  the  anterior  half 
of  the  membrane.  It  mav  exist  alone  or  in  association  with  inHam- 
mation  of  the  cornea  (kentosctoritls),  iris,  or  choroid  (uveoictontisi. 
\,  Simple  KcleritiK  occurs  usually  on  the  exposed  portions  of  th.-  (iliarv 
region,  generally  to  the  outer  side,  hut  it  may  Ik-  found  at  aiiv  part  o 
the  cirele.  and  mav.  exceptionally,  extend  wiilely  and  far  back  out  of 
sight.  The  affecti.m  is  subacute  in  character  and  relapses  art-  the 
rule.  The  disease  is  generally  met  with  in  adults,  espcially  in  those 
exposed  to  cold,  or  who  have  a  gouty  or  rheumatic  tendency. 

The  pn>cess  In-gins  with  one  or  more  patches  of  congestion  in  the 
ciliary  region,  accompanied  by  swelling,  and  lea.ling  to  eievaiion  o. 
the  «)miinctiva.  The  atTecti^l  area  ap|K-ars  reddish  and  rusty,  liie 
coniiinctiva  overlying  the  part  is  swollen,  aMiematous,  and  conpM.'.l. 

Microscopically,  one  finds  infiltration  of  the  tissue  with  Icnko.vt.s, 
estx'ciallv  in  the  lieighlH.rh.xxl  of  the  vessels,  with  some  dilatation  of  the 
lymphatics.  The  inflammation  may  subside  after  a  longer  or  shorter 
,Wri.Hl.  resolving  entirely  or  Waving  a  gmyish  <li.scoh.ration  of  tlu'  Miern. 
Occiusionallv.  the  inflammatory  infiltration  extends  more  or  lcs>  wi^td; 
into  the  cornea.  .Stleritis  may  also  set  up  .liffuse,  interstitial  k.ratit.-s 
or  chronic  iritis.  ..r.  again,  chon.iditis.  .Sclenx)  rrjiditis  I.  ..is  to 
thinning  of  the  tunics  of  the  eyeball,  with  ectasia  ilatat. 

anterior  part  (.«/a;>/(i//(wia  .ir/rrff). 

•ji'uberculosiB.— Tiiliereulosis  of  the  sclera  has  «>nly  rareh 

served. 

Syphilis.— S>i)hilis,  esjH-cially  the  gumma,  is  somewhat  mor. 


[I  of  the 
..»  ah- 
'  iinmon. 


PERSISTENT  PUPILLARY  MEMBRANE 


627 


polv  ledral  cells,  Imv.nK  a  .spherical  or  sliffhtly  oval  nudeus(2\TAK    . 

>.||.a,  (5)  the  posterior  layer  of  epithelium,  composed  of  JSvhS 

The  sulwtantia  propria  contains  in  addition  both  circular  rsohincter^ 
bundle,  of   unstrjped   muscle.  «n.l    radiating  fibe«  SSor  duSS 

OOROUriTAL  AHOBCALm. 

'kin-  ,„,.hnL£S     T  '  ''""'">''""«  /«  ^^e  pigmented  moles  of  the 
.u-,r- ,' v,l "  ^  '"^  '"'*>■  P™^"'*" "  «♦«••»'■•«  point  'or  malignant 

''^^f^l^Sn^^^T^'-^'r  "'  ^— t  anomali. 
leas  i,   -urmmded    .V    a^v^     r    """»'™"*'-     J>"ring  fcetal  life,  the 

anterior  ,.«,,    Tthe  rU  !    f       '^  °    ""^  'T  ""''  """^tomose  on  its 
nlosa.    Ihe  portion  of  the  tunica  occupying  what  is  event! 


628 


THE  IRIS 


vMy  to  be  tho  pupil  is  called  the  pupilUry  membrane.  As  a  nil.-  «t 
birth,  the  membrane  an.1  iU  vesseU  have  l«en  al»«.rl)ed.  but  «-t-asi..nallv 
portwns  of  them  perswt  as  stramls  of  tissue,  often  hmh|y  iMRineni.-. , 
which  arise  fn»n  tlie  anterior  surface  of  the  iris  ami  project  int..  the  impil. 
Oorectori*.— The  pupillary  openinR  Is  situate<l  rairmal  y  a  httl.-  t.. 
the  nasal  side  of  the  central  p.>int.  In  coreetopia  the  pupil  is  .lispla..,-.! 
outward  and  upwanl.  and  is  small  awl  im-Kular  in  outline  as  well.  I  lie 
iris  mav  lie  otherwise  mirmal  ami  react  |)erfe<-tly  t«.  light,  and  iii  ^ii.  1. 
cases  the  i-ondition  is  usually  unilateral.  Often,  however,  there  an-  ..tl.,.r 
congenital  .lefects  in  the  eye.  such  as  buphthalmos,  micniphtl.alm.H. 
coloboma  of  the  lid  or  iris,  or  albinism.    Not  infrequently,  th.r.-  is 

ectopia  of  the  lens. 

l^iCOrta.— Dyscoria,  or  irregularity  of  the  pupil,  is  a  very  .ynirnon 
coiwlition.  It  is  due  either  to  |K>sterior  synwhia  from  fwtal  intis.  ..r  t.. 
a  proliferation  of  the  pignientetl  epithelium  fonning  the  poster«.r  (■..vmiiR 

of  the  iris.  ,  ,  ...  . 

Polycori*.— Polyuria,  or  multiplicity  of  the  pupil,  d(x>s  not  .Mciirtn 
the  sease  of  a  numln-r  of  pupils. each  surrouiMle«l  by  a  sphincter  in.wl,.. 
The  term  is  eommonlv  employed,  however,  to  designate  the  .oiMh;!..!. 
in  which  an  iris  contaii'is  a  number  of  openings  in  addition  to  tlu  i...nnul 
pupil.  These  openings  usually  appear  as  radial  clefts,  but  in.iv  .Krur 
at  the  peripherj-  of  the  iris.  The  app«-Hrancc  of  polycona  may  als<.  l>e 
pnxliiced  by  a  bridge-<-oloboina  of  the  iris,  or  a  persistent  pupillarv 

membrane.  ,  ,. 

Aniridia  or  Iridiremia.-  Aniridia  <.r  iridm<mia  may.  so  far  as  (lin- 
ical  examinarion  g.K-s.  In.  total  or  partial.     In  complete  ";'"•'<•"'  '"" 
eyes  are  involv«l.  as  a  rule.     Ihe  incomplete  fonn  is  often  .l.rt«i. t 
to  distinguish   from  eololwma.     Other  congenital   jieeuliamus.  si.<h 
as  microphthalmas,  ptosis,  persistent  hyaloi.l  artery,  may  Ik-  |.i^'s.i.t. 
The  most  frequent  i<miplication  is  eataraet,  but  <-orneal  and  v.tn-...is 
opacities,  choroidal  atrophy,  an.l  detachment  of  the  retuia  mav  U-  md 
with.    Luxation  of  the  lens  may  oe»ur.    (ilaucoma  is  anotlur  m..i  un- 
common complication.  .  ,  x  i  .-..i-.,^ 
Ooloboina.-CololH)ma  of  the  iris  is  one  of  the  most  common  .I.m lop- 
mental  defcK-ts  of  the  eye.    The  cai«e  has  already  !•«■"';"";;»";; 
(see  p.  COS).     In  this  condition  there  is  a  cleft  of  the  ins  wliu li  .xUnds 
into  the  pupil,  forming  with  it  a  pear-shaped  owning.     Hh  "rnm. 
may  be  complete,  the  defect  exten.ling  to  the  chary  Iwrder.  ..r  ..com- 
plefe,  a  bri.lge  of  iris  remaining  at  the  apex  of  the  gap.     1  he  oi«  ■  * 
situated  downwanl.  or  downward  and  inwanl.     'Ihe  pupil  i~  -iM«all} 
also  displaced  downward,  less  often  upwanl. 

OntOULATOBT  DUTUKBANOBS. 

Anemia.  Anemia  of  the  iris  occurs  in  all  general  ..ystcini.  ...tniition' 
associated  with  anemia  or  loss  of  blood.  , 

Hyperemia.— Hyjjeremia  is  met  with  in  the  early  stages  ,  '  intisana 
associated  with  tumors  of  the  irb. 


IHITIS 


629 


\M\ 


DrPLAmUTIOMI. 

e}.'.     1  he  rausfs  are  local  or  coa'Jtitutional.  ponions  of  the 

AraonK  the  l«.al  eau^.s  ,uay  be  .wntionwl.  perforadnK  wou.hJ,  of  thi. 
rplwll,  esp«iall^  ,f  lac-erated  and  i-omplicale«l  wit™ iZrvTn  /L  I 
injury  to  the  lens,  without  wouihJ  of  the  iris  a  S  Ji  h  nnU  .7  u      *  '*"' 

1  ho  chief  coastuutioiial  taiw«-s  arp  svohilii   <».■.«    =„  i    u 
Inas  ...av  also  eon,plio.te  the  acu.^hf^&.f    XMi:?^^ 
hav.-  ^'.nerahze.!  spteinic  inanifestatio.u..     Gonorrhu-anr  tU^^! I 
to  K..n,.rrha.al  arthrit«.  is  ocr.isio.mlly  .m-t  wTth  ^'  '"^'"«°'" 

al.lv  iM.,.rfm,|  with    ar!T.m  W   ?     •  «  '  ''"'"',"'  "''""'f""'.  consider- 

of  'l'<   pupil,  turbSi"v  if  S  v^l  ^ «l>""'''">t.  g'vinK  ri.se  to  occlusion 
«>rm.:..    TI^S^  f„ll^';'','^"''  •""*.  ''^•^"  ''"Kht  opacity  of  the 

'he  P''|il  a^Z  SmT mS     S-  '"  '"^•'f'"^  'J'^"  •^«'^"'  -  that 


630 


Tllf:  IMS 


\ 

'S 

t 

J 

1 

'^^^^H 

^^^^^^^^^H 

1 

II 

8 

jTs 

III 


fe  ij 


i'.  -a 


oiuitly  inet  witli  wliii  h  nre 

I!      thi'  .serous  foniis.    Tims, 

the  pla.Mtif  Vf«riitv,  inav 

of  the  iris  ami  the  f.»ri'mtion 

k'ail  to  (lt>po8its  of  lynipli  uii 


toou  Wtii.— Serous  iritw  is  a  nof  um-ommon  affection,  the  pBtho).'<ny 
of  whieh  is  by  im>  means  «h>»r.  Souh"  i-hsis  ap|H>ar  to  lie  dejH>n«leiu  on 
a  rlieumati«-  disposition,  while  odiers  u  n-Hex.  In  this  form  tluro  it 
a  sp«tial  tendeiKV  for  the  whole  uveal  t  w  to  \w  involved.  iTic  dis. iw 
ueiierally  ruiw a  suUcute  mirs*'  ami  Is  im.  dways  very  amenable  to  tr.ut. 
ment.  Peri<H rneal  iiijwtion  nmy  lie  trifling  and  tlie  iris  is  mA  j^nutly 
alterwl  in  color.  The  teiMk-ncy  to  th«-  fonmtion  of  synechiw  is  not  ^, 
pwit  as  ill  the  plastic  form,  llie  exuiltile  is  of  a  j(ravis»i  or  gruvish- 
brown  color  ami  Ls  found  in  the  ft>nn  of  line  points  on  the  lowei  Imlf  of 
I)«-;«-eniet'8  membrane.  The  vitreous  may  kwine  .somewhat  <  l(>u.l) 
and  contain  floatiiiK o|»a<itie.s.  Siit  infrc*  -"nth  the  ciliary  l»o«ly  uixl  the 
choroid  are  slij?htly  inflame<l  (cy'«/»«;  Khcroldith).  It  .shoul.l  !» 
noted,  however,  that  cases  of  iritis  are 
intermediate  in  type  between  the  pla- 
iritis,  which  to  jjross  app«'aramt'  i. 
be  assiciateil  with  considerable  infilt: 
of  adhesions,  while  the  plastic  tj-pe 
l)e.sceinet's  incinbrane.  i       i     • 

InpimntiT*  IritU.  Suppurative  iritis  Is  less  common  than  the  jilastic 
variety.  It  mav  .superxene  upon  plastic  iritis,  but  is  usiwlly  .In.-  to 
trauma,  operations  opening  up  the  glolx-  of  the  eye.  and  to  ui( ■nitivr 
keratitis.  , 

'Hie  inflammation  is  more  inteasc,  the  congestion  is  gn-uter,  tli.  ,mi- 
date  mon-  abumlant.    The  pas  may  c-ollect  in  the  anterior  .  l.ainUr 

(hypopffon).  .    ,  ,  ,     . 

SypWlii.-  This  resembles  closely  in  anatomical  featun-s  plii^iK  "r 
serous  iritis,  but  mixetl  forms  also  occur  here.  S)metimes  miimtc 
gumma.s,  frt)m  2  to  f.  mm.  in  diameter,  are  to  lie  obscmsl  ii|"«ii  ilie 
iris,  and  by  [nicn)s<-opic  examination  even  those  forms  whi*  li  »\,\«-ut  io 
res«^mble  simple  inflammation  «an  l)e  seen  to  l)e  of  gniiiuloiniito.i-.  tpx- 
(iiimmas  of  the  iri.s  do  not  differ  appreciably  from  tliosi>  ,•  N.  wlun, 
and  are  made  up  of  young,  prolifcniting  connective-tis.suc  (ril-,  luwh 
forme<l  and  congt-stcd  ve.s.seLs,  and  the  ordinary  va.sciilar  changes  <  liarac- 

teristic  of  syphilis. 

Tuberculosis.— TuIktcuIous  iritis  is  rare,  ami,  unlike  syjihiliN  ion. » 
to  affwt  only  one  eye.  It  mav  U-gin  in  the  form  of  .serous  iritis  l.m  Miiall 
grayish  notlules  can  usuallv  l)e  .seen  on  the  iris  near  the  cilmrv  imxtss 
aiui  in  Fontana's  spac-e.  These  luxliiles  gradually  eiilarg.-  a.»l  ,ui.i  ly 
coalesc-e,  so  that  we  get  a  warty,  grayish-nil  mass  containing  tmr  mss«I>, 
which  encroaches  mo«>  or  less  iijwn  the  anterior  chainUT.  '1  li.  ".riitii 
usually  shows  .some  foggincss  and  vascularization.  The  pr<Kr»  .ii  timf^ 
may  n-trogr»>ss  and  Anally  come  to  an  en.l,  but  very  coinnu.nl  ilio  ii>- 
filtration  extends  to  the  ciliary  process  and  the  ailjacent  schra.  r.-ulting 
in  1-j.siation  ami  total  dcstriK-tion  of  the  eye. 


CYCUTia 


fi31 


UTxoeuunn  mrAMoa  qpai. 

Atrophy.  A.r..phy  of  tlu-  \m,  cl.,.ra,teriz«l  bv  thiniiiiu;  of  iti  sub- 
siaiiop.  lc«.s  ..^  ,,vu,rnt.  urul  fihn>as  ti  ..wfomwti;,,,.  .M.urn  ««  «  ,«,ult 

Klauc.m«.     ih..  l.l«.Hlve.HH..|s  ..„.  fhaen«i  ami  hvalim..  ..  that  th"? 
Iiiinina  are  often  »l.liicim«|.  '  "miiinir 

Figlll«m.,'wi.  TIm-  appli.afi..n  of  „i„rtt..  »f  silver  ami  protnrRol 
n.  f»e  r»n,u,„.t.va  has  resufre.)  in  ,mt.„«,..„,  staining  iarg„ria\o,.},^c. 
tn;t>  i-he  meml.r  „.,•  lH-.on., s  of  ,„  „live  or  ,|«iv  no|„r.  A  similar 
result  has  iH^i-n  r,.,H.rt<.i  in  the  ,as<.  „f  „.ptai„  pers^.w.  who.  from  the 
na  im-  of  their  .K.vu,mti..r,,  Imv.-  ?»,.„  ,..,^,se.l  to  M,,.  actio,,  of  silver  dast 

In  ,ases  of  ,r^,r,«*.  « 'u-th.-r  ..  .|„.  oKstruetiv.  ,r  toxic  f„riiw  the 
n..jju,..hvH  IS  .nvanai.lv  i,nolv,..i.     !„  fa.f    ..  eari    »n.l  .so.hara.  teristic 

.s  tl...  MamiOK  that  h^  always  I.K.k  ar  ,lu ju,K-tiv.,-  for  the  Hrst  evidence 

..r  jaumlHr.      I  he  "wh.,,-'  ol  ,|..  ew-  i„  sueh  ea«.  ,.,vs.T,ts  «  more  Z 
1.-VS  u.,.....s<.  sluM le  of  ye  !..«.     A  .h.i!,  a.r.hy.  or  su,  .-..roKl  .-olonLn 
..  also  ,„et   with  „.  o^,ruH,v,.  canliae  dts^-ase,   ,,.  ,ni<i„u.,  anemia 
tox.ii.ius,  and  -n  the  each,  a  in  ,f  <.|„  ,„„.  „,,.;„„  ,,j^.;.„. 


i 


PE0OUS8IVE  METAMORPHOSES. 

.  *!« WO**-  Sar.on«i.  iisimlly  pi^.u-nLsl.  is  ,l„.  onlv  ttin.or  oriifiimtin.- 
in  thr  ins  and  is  the  rar...st  f..r.n  of  in.ra-Kular  sttr.-.Hna.  Much  more 
often  NHrtoma  oriKitmte.s  in  the  <  lioroid. 

The  Ciliary  Body. 

CycUti8.-InflHnunation  of  the  .iliary  (k.Iv -<.v,litis--s  .ommonlv 
•K.-  m...    with  .nHanunation  of  ,he  iris  ..r  c-hor;.id.     The  prcxess  is 
eM.le„,.n    l,y  shjiht  ,lo..din^.  of  ,i,e  aqueoas  humor  and  the  anterior 
,j.m„„  of  the  vtreous.     With  this  there  is  a  deposition  of  exuda",  ^^n 
I .  l...,te.  tor  surf«,.e  of  the  eornea,  w.th  slight  exu.latio,,  into  the  pupillary 
ana       1  he  whole  ,H.stenor  as,H-<t  of  ,he  iris  Im. otnes  adherent  to  the 
.-IM,.  of  ,l,e  lens  with  ntni.-tion  of  th-  ciliary  (n.rtion  of  the  iri.,  so 
a      he  anterior  chan,l,erlK^^„.es  enlarKe.|.     The  exudation   wl.ieh 
ll.vt,  lH.tu.rn  the  .r.s  a.ul  the  lens  and  iHtween  the  pc-ripherv  of  the 
•"".  flu-  «•.  lary  p.-oc-t>s.s  jrra.lually  utulerKm-s  orp.ni.!atio„  a,;,|  |e,,.|, 
''}    '    <ontr«et.u„  to  disl.Kation  of  the  iris  backward.     Similarly    the 
.  vu,  .,,.,n  K.fore  and  In-hind  the  leas,  as  it  is  transform^  into  conLtive 
-    .  .ads  to  tHMtion  u,H,n  the  ciliary  IkkIv  „way  from  the  sc-lera  and 
•■  tl'.  ..  «*t,o„  of  the  axis  of  the  bulb.    The  invoKement  of  tj...  vit^t,™ 
.  -  u  constant  accompaniment  of  rv.iui..  with  the  .lei.  sit  in  it  <,f 
--  '  ar  and  hbrtnous  ex.ulation.  r.  the     une  ,vay  n-sults  in  ....nplete 
^P  '  'ion  „f  the  n.Hna  with  catiinntons  tnmsfonnafion  of  the  lens 
^^"'  >y  alls  may  Ucome  suppurative  an-"  lead  to  the  pr«Rluction  of 


683 


THE  CHOROID 


hypopyon,  or  even  involvement  of  the  whole  uveal  tract  (jpanophthnU 
mitU).  Fibrinous  cyclitis,  inasmuch  as  it  is  not  so  severe  an  affection, 
leads  gradually  to  phthiiU  bulbi,  with  more  or  less  diminution  of  the 
intra-ocular  tension.  .  •       ■  •    i 

Apart  from  inflammations  which  spread  from  the  ins  or  choma,  the 
chief  causes  of  cyclitis  are  injuries,  especially  such  as  are  due  to  wounds 
or  foreign  bodies.  Occasionally,  wounds  of  the  sclera  near  the  i.wrnin 
of  the  cornea,  when  cicatrizing,  cause  tension  upon  the  iris  and  ciliary 
body,  and  eventually  inflammation. 

One  of  the  most  important  consequences  of  cyclitis  and  iridoc-y<Hli.s, 
especially  when  the  result  of  penetrating  wounds  of  the  tunics  of  the  <ye, 
as,  for  instance,  stabs,  incisions,  or  of  rupture,  ulcers,  or  foreign  iMxlits, 
is  the  so-called  sympathetic  ophthalmitis,  which  affects  the  uninjured  v\\. 
Svmpathetic  ophthalmitis  usually  sets  in  from  six  to  twelve  web 
after  the  primary  injury  to  the  fellow  eye.  It  rarely  otrure  before  tliree 
weeks  after  the  iijury,  and  exceptionally  its  appearance  is  delaytHJ  for 
many  years,  ".he  p'rocess  tends  to  relapse,  and  may  continue  willi 
alternate  exacerbations  and  ameliorations  for  months  or  even  a  yoar 
or  two.  Anatomically  speaking,  the  affection  takes  the  form  of  a 
plastic  iridocyclitis  or"  iri<liKhoroiditis  with  exudation  leading  to  total 
posterior  synechia.  1  n  the  early  stages  there  is  apt  to  be  a  dottwl  il(|>osit 
on  the  posterior  surface  of  the  cornea,  clouding  of  the  vitreous,  and  often 
neuroretinitis.  The  vessels  |X'rforating  the  sclera  near  the  ciliary  ny^mx 
are  congested.  The  intra-ocular  tension  is  often  increased.  Tiie  niililest 
cases  do  not  go  farther  than  a  chronic  serous  iritis,  with  keratitis  pun(  tata 
and  disease  of  the  vitreous,  usually  also  with  neurort-tinitis.  In  more 
severe  cases  the  eye  remains  glaucomatous,  with  total  posterior  synithia, 
corneal  opacity,  and  a  varying  amount  of  ciliary  staphyloma.  In  the 
worst  cases  the  eye  finally  shrinks. 

The  Choroid. 


i»  :ii 


CONOEHITAL  ANOMALIES. 

Coloboma.— ("ololKiina  affwting  the  lower  part  of  the  clioioid  may 
exist  alone  or  in  asscK-iation  with  cololKima  of  the  iris.  CXra>ionally 
the  cololwma  is  liniitetl  to  a  small  ami  around  the  nerve,  or  ii  may  >« 
si'parate  from  it  (s-t-  p.  COM).  Albinism  has  also  already  l)i<  n  suffi- 
ciently dealt  with. 


OIROULATOBT  DUTURBAMOES. 

Hyperemia.— HyjH'remia  of  the  choroid  is  not  infre(|\ieiit.  It  otfiirs 
in  cases  of  systemic  passive  congestion,  congestion  of  the  head  ii-  If,  aiid 
in  early  inHaintnatioii  of  the  choroid,  retina,  or  associattil  parts. 

Anemia. — Aiwmia  is  met  with  in  general  anemia,  if  severe. 


CHOROIDITIS 

H«monrh«gM.— Hemorrhages  into  the  choroid  in  the  form  of  multiple 
minute  extravasatioas  are  otrasionally  met  with.  They  oftea  lead  to 
atrophy  and  pigmentation  of  the  membrane.  The  cause  is  obscure. 
Larger  hemorrhages  may  be  due  to  traumatism,  smaller  ones  to  disease 
of  the  vessels. 


nmAlOfATIOHS. 

Choroiditis.— The  term  choroiditis  is  often  used  in  a  loose  way 
to  include  not  only  the  frankly  inflammatory  affections,  but  also  some 
forms  of  atrophy  which  are  by  no  means  cic  ,ely,  if  it  all,  related  to  inflam- 
mation. We  shall,  however,  in  the  course  of  the  following  remarks, 
emplc)y  it  in  the  strict  sense,  namely,  to  designate  inflammation  of  the 
choroid. 

Owing  to  the  close  relationship  that  exists  between  the  choroid  and  the 
retina,  disease  of  one  membrane  is  excee<lingl^  apt  to  extend  to  the 
otlicr.  Thas,  changes  in  the  pigment  epithelium  which  forms  part  of 
the  ntina  may  be  due  to  deep-scate<l  retinitis,  or,  again,  to  superficial 
choroiditis.  It  is,  therefore,  not  always  easy  to  determine  in  which  mem- 
brane the  inflammatory  process  has  liegun.  Moreover,  the  retina, 
even  if  not  directly  implicated,  often  shows  secondary  atropnic  changes 
as  a  result  of  choroiditis.  On  the  other  hand,  in  'ases  of  ec  ually  severe 
choroidid  inflammation,  the  retina,  curiously  enough,  may  escape. 

The  (iiiises  of  choroiditis  are  not  very  varied.  Sone  few  cases  are 
considered  to  \te  due  to  some  systemic  dyscrasia,  such  as  gout;  others 
are  due  to  traumatism;  others,  again,  and  bv  far  the  larger  number, 
art"  inanifestatioiis  of  infection,  usually  metastatic  in  type.  In  the  last 
mentioned  class  .syphilis  Is  the  most  important  single  factor.  Choroiditis 
may.  however,  be  also  found  in  other  infections,  such  as  tuberculosis 
rhcninatism,  occasionally  in  typhoid  and  relapsing  fevers,  rarelv,  in' 
le|)r()sy  and  gonorrhoea. 

.\(i«nling  to  the  nature  of  the  exudate  produceO,  we  can  recognize 
piiriilciit  and  .lon-piirulent  forms. 

SuppuraUve  Ohoroiditii.— Suppurative  choroitlitis  is  invariably  due  to 
iiiftr.ion  with  pyogenic  micmorganisms.  This  may  \te  brcjght  about 
by  iMiu'trating  wounds  of  the  eye,  ulceration  of  the  cornea  or  sclera  by 
einlH.hsin,  or  l)y  extension  from  the  meninges.  The  tn)ul>le  In-gins 
aciittU  with  chemasis  of  the  conjunctiva  of  the  bulb,  mo«lerate  ex-idation 
into  lb.  pupillary  area,  and  hypopyon.  The  exudation  into  the  vitreous 
rails,  s  the  apiM>anuice  of  a  ycllowish-gmy  reflex  on  optical  examination 
In  III,  ,  a-se  of  some  of  the  milder  forms  of  infwtion,  such  as  that  ocxiirring 
in  (•■  1,  l.mspinal  meningitis,  the  disease  may  lH>have  much  as  an  ordinary 
p.liiw,  Imt  in  many  instances  the  pr<K-ess  extends  to  the  whole  uveal 
tract,  and  hiiully  results  in  paaophthalmitU. 

In  Ibis  .„,„|i"tion  the  inflammation  is  intense.  The  conjunctiva  and 
ttiecvrli.ls  an-  usually  enormously  swollen,  and  the  loose  tissue  of  the 
orbit  I , , iihltratcd.  so  that  the  e.-.elwll  is  puslunl  for^vard.  The  intraocular 
teiLsioti  uj  usually  much  increased,  leading  to  diminution  in  depth  of 


634 


THt:  CHOROID 


1? 

•IP 

IV- 


the  anterior  chamber,  but  occasionally  it  is  somewhat  diminislied. 
The  cornea  eventually  is  infiitratetl  and  may  even  slough,  allowing'  the 
exudation  to  appear  externally  in  the  form  of  discharge.  After  some 
days  the  severity  of  the  prcK-ess  diminishes,  and  in  thn*  or  four  wtcks 
the  acute  symptoms  come  to  an  end,  with  gradual  shrinkage  of  the  nlol)e 
(phthisis  biJhl). 

Metastatic  choroiditis  is  a  manifestation  of  a  generalized  septicemia. 
The  choroid  of  one  or  lK)th  eyes  may  l)e  involve<l  together  with  other 
parts  of  the  Iwdy,  or  may  be  the  sole  area  of  metastatic  deposit. 
Embolic  or  metastatic  choroiditis  is  due,  of  course,  to  the  di.s.semiiiati(  ;i 
of  pyogenic  organisms  throughout  the  system  and  their  deposit  in  the 
capillaries  of  the  choroidal  membrane.  The  primary  source  of  the 
infection  varies.  It  may  Ik-,  for  example,  an  infected  woinid,  the 
puerperal  uteriLs,  acute  endocarditis,  smallpox,  pneumonia,  or  erj  si|K'liis. 

Seroflbrinoni  Ohoroiditii. — Several  forms  of  non-suppurative  clioroiilitis 
are  descrilieil,  most  of  which  are  somewhat  sluggish  in  their  course. 
One  of  the  roost  important  is  .serofii)rinoas  choroiditis.  This  iitfiHtion 
begins  .somewhat  suddenly  and  runs  its  course  in  from  six  weeks  to  six 
months.  The  choroid  is  injet'te<l  and  slightly  nedematous,  and  tlic  [htI- 
corneal  vessels  are  (x-casicmally  engorge<l.  There  .soon  appears  an 
exudation  of  .serofibrinous  material  into  the  vitreous  humor,  oltsdiriii); 
the  ophthalmo.s«-opic  picture  of  the  fundus,  which  may  event  ually  in- 
volve the  anterior  chamljer  and  the  posterior  surface  of  the  cornea. 
The  condition  may  finally  clear  up  with  little  or  no  impairiiuiit  of 
vision,  but  not  infrequently  the  choroid  shows  small  patches  of  atropliv. 
Adhesion  of  the  iris  to  the  anterior  surface  of  the  len.s-eapsule  inav  (Htur. 

Ohronic  Choroiditis.— Chronic  choroiditis  may  lie  dissemimilid  or 
diffuse. 

Chnrouiitis  disseminiifa  Ix'gins  with  the  formation  of  romided  patches 
of  exudation,  rather  pcwrly  defined  at  the  margins,  in  certain  parts  of 
the  ftmdus,  usually  near  the  periphery.  The  patches  iniiliiplv  in 
numlx'r,  and  some  Of  them  may,  in  time,  coiilesce,  involviiii;  a  hirjic 
part  of  the  surface  of  the  fim<liis.  The  retina  overlying  tlie  -pots  in 
question  is  not  elevated,  i»ut  (Krasionally  apj»ears  to  Ik-  .somewliat  hazy. 
indicating  some  infiltration  of  its  sulxstance  with  iiifianimatory  pKMhicts 
{chorioreiinUis  dl.i.irmiii(if<i).  rsiially  the  cornea  anil  the  liiiiiiors  ate 
unaffected  and  n-inain  clear,  but  <K-<asional\y,  the  condition  ina.v  U 
complicated  with  pan'nchymatous  keratitis,  (iradually  the  c\iiihition 
di.sjipjH'urs,  the  patches  lH'<()nie  piiN-r,  and  at  the  margin-  iMronic 
irregulariy  pigmente<l,  apparently  owing  to  an  iticreasetl  dcin>-ii  of  pifT- 
nietit  at  certain  points.  Spots  of  pigment  may  ofli-n  also  !«■  i.iiMTVcd 
in  the  patthrs  themselves.  Occasionally  pigmentation  d(Ks  noi  iKvur. 
Eventually  the  exudate  disap|H'ars  entirely  or  is  partially  (i-iiiii^^'d. 
while  the  afTe<te«l  areas  go  on  to  complete  atrophy  with  oliliti  i  iiioii  "f 
the  vessels  and  the  formation  of  cicatricial  tissue.  The  atropln.  pat(lie< 
may,  in  time,  incn-ast-  in  size,  even  when  the  inflammatory  pnH  c  npjHars 
to  iiave  come  to  an  end,  owing,  appan-iitly,  to  impairment  of  utriiion. 
The  whole  prix-ess  may  run  its  course  in  a  fev.  months  or  in;'    Ik-  [>r>y- 


CHRONIC  CHOROIDITIS 


635 


longed  for  years.  Relapses  are  not  infrequent.  A  curious  feature, 
(K-casionally  met  with,  is  the  formation  of  plates  of  bone  as  a  result  of 
tlu<  long-standing  irritation. 

Destruction  of  the  choriocapillaris  at  the  points  of  exudation  prob- 
ably always  takes  place.  This,  by  interfering  with  the  blood  supply 
of  the  retina,  leads  to  atrophy  of  that  membrane,  and,  if  extensive,  may, 
ill  turn,  lead  to  partial  atrophy  of  the  optic  nerve.  Degenerative  changes! 
(hie  to  the  lack  of  nutrition,  may  also  take  place  in  the  vitieous  and 
the  lens. 

Fio.  17S 


t..rniati..n  c.f  bone  in  the  rhor<.id,  the  mult  of  chronic  inBiunm«lion.     Zeiss  obj    UD 
without  ocular.     (From  the  collection  oj  the  Hoyal  Victoria  Hospital.) 

ForstiT  lm.s  dc.s<TilHNl,  under  the  term  chimmUtii  ahrolnrh,  an  affec- 
tion, usually  found  in  children,  which  up}H-iir.s  to  Ix-  a  form  of  choroiditis 
ilbsnninata.  Thi.s  Ix'gins  at  or  near  the  jMjstcrior  jwle  of  the  eye  with 
tlic  formation  of  areas  of  pigmentation.  These  gradually  l)ecome 
if:lil«r  in  the  crntre  and  the  pla<|iies  thin,  until  we  get  atrophic  areas 
ImmmiiIimI  by  fairly  deiLsc  rings  of  pigment.  Such  patches  inav  coalesce. 
I  ill  IV  luay  U-  only  two  or  tlirtH-  patches  of  atrophy  and  pigmentation  in 
1 1^  direction,  or  a  largi'  part  of  tlie  fiindiis  of  the' eve  mav  k-  involved. 
llii  iirtH-ess  may  la-gin  ami  remain  more  marked  at  the  periphery  of 
til.-  iMMilus,  or,  again,  may  iiivohe  chieHy  the  j-entral  portion  (choroiditis 
l>ii-ft' ri,)r). 

(Ii'nmlitin  (lifftim  iH'gins  gradually  and  i)rogre.s.scs  in  a  .somewhat 
slu--i.li  way.  It  l)cgiiis  with  the  formation  in  the  choroid  of  large 
plii.i  II  s  of  exudation,  of  a  pale  yellowish-pink  or  orange  color.  These 
art  iM.t  pigmented.  The  overlying  rt-tina  is  .slightly  o-dematous.  The 
Pill.  i".s  coulesi-e,  forming  large,  irregular,  map-like  areas.    The  chorio- 


636 


THE  CHOROID 


capillaris  and  the  pi)^ent  layer  of  the  retina  undergo  atrophy  and 
the  vessek  are  thickened  and  become  obliterated.  The  disk  and  optic 
nerve  may  occasionally  show  some  evidences  of  atrophy.  The  de«'j)cr 
layers  of  the  choroid  jmictically  always  escape. 

Syphilis. — Syphilis  uf  the  choroid  may  take  the  form  of  a  serofibrinous 
choroiditis,  or,  again,  a  diffuse  or  disseminated  choroiditis.  Inasmuch 
as  the  retina  is  almost  always  involved,  it  would  be  more  strictly  corntt 
to  speak  of  these  conditions  as  syphilitic  chorioretinitis.  In  one  form 
of  syphilitic  inflammation  the  vitreous  chiefly  appears  to  be  involved 
and  becomes  cloudy,  especially  in  the  axial  portion.  In  another  variety 
the  chorioretinitb  is  most  marked  in  the  neighborhood  of  the  postcriur 
pole.  Atrophy  and  connective-tissue  formation  are  marked  features  of 
syphilis. 

TnbarculOBis. — ^The  usual  form  of  choroidal  tuberculosis  is  the  miliary 
eruption,  although  massive  tulxrculasis  is  not  unknown. 

Miliary  tul)erculosis  of  the  choroid  is  but  one  manifestation  and  locali- 
zation of  a  general  miliary  infe<'tion.  The  tuliercles,  which  are  similar 
in  all  respects  to  miliary  tubercles  elsewhere,  may  be  few  or  very 
numerous  and  are  situated  under  the  choriocapillaris.  The  retina  is  not 
affected,  save  that  it  may  lie  elevateil  somewhat  where  it  overlies  tiie 
milia.  llie  vitreous  is  also  free.  The  ciliary  body  and  the  iris  are 
but  rarely  attacked  by  tulierculosis.  'l^e  discovery  of  tubercles  in  tiie 
fundus  of  the  eye  by  ophtliulmascopie  examination  Ls  .sometimes  a  valu- 
able aid  to  the  diagnosis  of  .systemic  tuberculosis. 

In  the  massive  form  of  tuberculosis,  the  choroid  is  the  seat  of  larjjer 
nodules  or  tumor-like  mass«'s,  which  caseate  in  the  centn-.  The  priM'i'.ss 
may  lead  to  perforation  of  the  sclera  and  the  extension  of  the  tuberculous 
process  to  structures  outside  the  globe. 


BKTROOBI88IVK  BUTAMORPHOSU. 


I       ! 


m 


Atrophy. — Atrophy  may  he  the  result  of  choroiditis  or  hemorri  laic's 
into  the  membrane,  or,  again,  of  imjHTfwt  blood  supply,  ami  occurs 
in  small,  scattered  areas  or  in  hirger  irregular  patches.  It  is  fviiliiKfd 
by  [Hillor  of  the  affecte<l  part  of  the  choroid,  with  an  increase  in  tlit- 
amount  of  pigment.     Atrophy  also  is  met  with  in  myopia. 

There  is,  also,  an  affection  calle^l  "colloid  diioHe"  of  the  choroid  wliidi 
may  lie  dis<'usse<l  under  this  lica<ling.  Very  snial  no<lules,  at  lii--i  suft, 
later  liecomiiig  luml  like  glass,  arc  fonneil  in  the  thin  lamina  cla^iicii. 
The  exact  natun-  of  these  is  not  fully  known.    They  are  found  in  '  ,i -cs  of 

partial  atrophy  after  choroiditis  and  in  eyes  removal  for  old  influn iiory 

disturbance. 


TBAOMATISM  AHD  ALLIED  OOiroiTXONS. 

DetAChment.  ~1  )eta('linient  of  the  ch(m>i<l  is  rare,  but  nla^ 
witii  as  a  result  of  hemorrhage  or  exudatiuu  of  inflammatory 


met 
lucts 


ANEMIA  OF  THE  RETINA 


637 


Intween  the  choroid  and  sclerotic.  It  mav  also  be  caused  by  a  tumor 
and  may  acxompany  degeneration  of  the  vitreous  humor  in  the  course  of 
irulo-cycl«x'horoiditis. 

Snptnres.— Ruptures  of  the  choroid,  either  single  or  multiple,  are 
occasionally  met  with  as  a  result  of  blows  upon  the  eye.  They  are  accom- 
panied by  more  or  less  hemorrhage  and  eventually  exudation,  which 
may  find  their  way  into  the  retina  and  the  vitreoas.  When  the  extra- 
vasated  materiab  are  absorlied  an  atrophic  patch  is  left.  The  rupture 
may  I*  of  almost  any  shape,  but  is  usually  arranged  with  the  concavity 
toward  the  dtsk. 

Wounds.— Wounds  of  the  choroid  may  l)e  of  all  kinds  and  usually 
involve  other  structures.  If  exudation  take  place  into  the  vitreous, 
fibrous  adhesions  may  Ije  formed,  sometimes  leading  to  detachment  of 
the  retina.    Infected  wounds  may  bring  alx)ut  panophthalmitis. 

The  Eetina. 

The  retina  is  the  highly  .specialized  terminal  of  the  optic  nerve. 
Owing  to  Its  preeminent  importanc-e  in  the  visual  apparatus,  disorders 
which  would  elsewhere  lie  of  no  consequence  are  here  of  the  greatest 
practical  moment.  The  retina  is  rarely  diseased  alone.  Owing  to  its 
dase  proximity  to  the  choroidal  meinl)rane  and  the  nature  of  its  blood 
siij)pl.v.  inflammation  of  the  latter  membrane  and  disorders  of  its  va.scular 
appanitus  are  particularly  liable  to  involve  the  retina  .secondarily. 

.\gain,  retinal  di.sease  is  very  frcfiuently  an  expression  of  some  general 
systemic  condition,  and  may  U-  of  great  .liagnostic  value.  Among  such 
toiKhlions  may  l)e  meiition«l  general  arteriosclerosis,  pernicious  anemia, 
Uiikcmia,  Bnght's  disease.  dial)etcs,  syphilis,  and  septicemia. 

Finally,  disonlers  of  the  optic  ncr\e,  particularly  those  which,  like 
coM>;cstion,  cedema,  or  inflammation,  tend  to  hamper  the  blood  supply  of 
the  part,  often  lead  to  serious  disturbance  of  the  retina. 


CONGENITAL' ANOMALIES. 

llic  retina  may  In;  defective  in  the  condition  known  as  coloboma 

uriiii  (<|.  v.). 


OIRCULATORT  DISTUBBANOES. 


Anemia.- Anemia  of  the  n-tina  is  of  great  practical  importance. 
It  "'•IV  l)e  «!ue  (o  extrinsic  caii.se.s,  such  as  general  svstcinic  anemia  or 
l<-  «{  .lood,  or,  again,  to  some  Uxal  disturlmnce  in  the  vessels,  leading 
"  |i  .l(  h.icnt  supply  of  blcKnl.  General  anemia  must  be  of  high  grade 
'Hi  r'  It  will  pnHluce  noticeable  changi<s  in  the  retina.  The  papilla 
•M;'''.  tile  arteries  are  narrower  than  normal  and  imfx-rfectlv  fillet!, 
«  ii;  iIr.  veins  are  also  somewhat  diminished  in  size,  although  o^-casion- 
alh  p.,  V  may  be  overfilled.  ^ 


638 


THE  RETINA 


iiil 


'.«|| 


8*' 
11 


The  anemia  of  the  retina  resultiiij;  fn»i«  cxteasivc  heraorrhnjji'  may 
lea«I  to  atrophy  and  fatty  lieKenenition  of  the  incinhninr.  UliiHhicss 
may  result  an<l  !«•  jH-nnanent. 

Total  anemia  t)f  tiie  retina  is  chie  to  ohstriiclioti  of  the  eentnii  artirv, 
wliether  l)y  eniUihsm.  thnmilMjsis.  spasm  of  tlie  iniisciilar  <>uat.  htiiior- 
rha)(e  into  the  optic  sheath,  injury  to  the  artery  within  thr  m-rvf,  „r 
pressure  upon  it  by  a  new-j;rowth. 

KmboUun.—  Emlwlism  of  the  e«'ntnil  artery  of  the  retina  is,  acfortiinj; 
to  recent  investijijatioas,  eonsii)eral>ly  more  uneommoii  tlian  has  usimlly 
been  thought.  The  primary  cause  is  to  l>e  l(M)ke<l  for  in  emliK-ardiii^. 
aortic  aneurism,  or  arterios<-lerosis.  The  einlK»his  usually  ohstnicts 
the  whole  vessel  liefore  its  bifurcation,  although  (K'«'asion8ny  ime  of  tlic 
terminal  branches  is  alone  atfe<'te<l.     Instant  l>lin(iiiess  is  the  n'sult. 

On  ophthalmoscopic  examinaticm  a  short  time  after  tlie  tiulK)ilsrii  \\.i< 
ixx'urre<l,  the  n>tinai  arteries  an-  almost  completely  empty,  the  snmll.  r 
branches  Ikmiij;  nearly  invisible,  while  the  lar>;<'r  ones  present  onlv  a 
fine  central  threail  of  blcKnl.  'I'he  v«  ins  of  the  papilla  and  its  iM'ijjhlH.r- 
hood  are  also,  though  to  a  less  extent,  tleficieiit  in  blinxl.  The  i>[iii( 
disk  is  pale,  with  sharp  »Hlges.  In  course  of  time  a  inarke<l  wliiii>li 
turbidity  of  the  retina  iK-comes  manifest,  situattnl  round  alKHii  liic 
optic  ner%e  ami  fovea  centralis.  The  contour  of  the  pa|>illa  is  ilunliy 
obscuretl  and  the  whole  of  the  macular  region  and  its  neighlxirluKHt 
liecomes  cloudy.  In  the  centre  of  this  area  can  Ik*  seen  a  ritldisli  >|hiI 
•orresporaling  with,  though  somewhut  larger  than,  the  c«'ntre  <if  ilif 
ovea.  The  affecte*!  jMirtion  of  the  retina  gradually  underg(K's  airc>|iliy. 
so  that  the  chon)id  .shows  through.  Small  hemorrhages  may  -oinr- 
times  also  Ir'  strn  in  the  neighlwrlKHxl  of  the  papilla.  Finally,  tlie 
cloudiness  di.sjip|H'ars  and  the  ]>apilla  and  the  retina  atrophy  and 
iH-come  functionless. 

Thrombosis.  ThronilM>sis  of  the  arteria  centralis  retime  givi^  ri>c  to 
a  train  of  events  similar  to  those  in  the  case  of  enilK)iisin.  The  ininli- 
tion  is  rare  and  is  probably  in  all  cases  to  be  attributed  to  arterial  iii-(a>»'. 

Spasm.  -Spasm  of  the  retinal  artery  and  its  branches  liii-  Urn 
oKsenitl  in  cases  of  migraine  (Wagemuaiui).  with  the  priHliurini  i.f 
temporary  blindness. 

Hyperemia.-    I lyjH'remia  of  die  retina  may  U-  arterial  or  vciion- 

Artarikl  Hypwemi*.  -  Arterial  or  activt-  hy|H'r»'mia  results  from  inllain- 
mation  of  the  ntina,  eyestrain,  irritation  of  the  eye,  from  keratiti  .  Iriib. 
chorf)iditis,  iuid  is  met  with  in  cases  of  meningitis,  (ir.ives'  di--iM 
neurasthenia.     The  arteries  in  this  condition  are  ovenlistendril. 
ently  lengthciM-d,  atid  varicose. 

Venous  Hyperemia. — N'eiions  hyjHTemia,  or  passive  congesiiim 
to  .some  interference  with  the  n-turn  flow  of  bliKMl  from  tin-  ■ 
a  rule,  the  obstruction  is  referable  to  some  diseas«Hl  condition  of  ■ 
papilla,  such  as  optic  neuritis.     Here,  the  swelling  of  the  di^k 
compression  of  the  central  vein,  and  the  same  thing  may  be  i  • 
by  glawoma  and  by  disea.s*-  pnM'cssi-s  in  the  orltit,  as,  for 
tenonitis  and  orbital   cellulitis.     Occasionally,  meningitis,  in; 


'.  ami 
Pjiar- 

^  (lui- 

jU  to 

liutii 
iii|ilt'. 


~aniai 


iiil 


IIEMORRHAQE 


639 


tumors,  or  tlirombosis  of  the  cavernous  sinus  may  be  the  causative 
factors.  ConRenital  heart  diseaw.  when  associateti  with  general  cyan- 
osis, jire  a.s.sociatc«l  witli  noteworthy  congestion  of  tJie  retina.  Throm- 
Ixisis  of  the  central  vein  is  on.-  of  the  rarest  causes  of  venous  hyperemia. 
It  i>  L'eiierally  due  t(.  angiosilemsis,  but  oc-casionally  has  been  observe*! 
ill  iirliitai  celhiiitis. 

\ nions  livfierenua  is  «lmraeteriM>.l  by  <h*stention  and  tortuosity  of  the 
veins,  ami  the  disks  app«-ar  also  to  In-  hypereniie.  In  niauv  cises  the 
art.ri.s  look  somewhat  attenuate*!.  In  the  severer  forms,  hemorrhages 
into  ilie  fimdus  may  <xrur.  \isi«iii  is  not  usually  entirely  impaired 
and  t.iii|M.rary  improvement  muy  take  place.  UeJapses  are,  however' 
cimiiiioii,  and  the  sight  may  ultimately  Ik-  lost. 

Hemoirhage.  -Uetiiial  liemorrha'^i-s  are  du«-  to  a  great  variety  of 
caus.s.  OiH-  of  the  most  im|>ortant  is  trauma.  Thev  ar«>  often 'also 
nict  «ith  m  certain  constitutional  dis«-ases.  esp,riallv  those  that  damage 
the  integrity  of  the  ves.sel  walls,  and  in  sonic  kxal  affectioas  of  the  eye 
il.s«'lf.  ^ 

\  jM.tciit  factor  is  passive  congestion.  We  then-fore  are  liable  to  get 
rrtitial  hemorrhages  in  cases  of  suff.xation,  thromiM)sis  of  the  central 
win  of  the  retina,  in  pn-ssure  u|)on  the  vein,  such  as  may  Ik-  prtxluced 
l.v  ..ptie  iicimm-tmitis  and  neuritis  or  glaucoma.  Occasionally,  licmor- 
rliairrs  are  found  in  (-mi)olisi.i  of  the  central  arterv  of  the 'retina  or 
infantion. 

\  a^iilar  changes,  sclerosis  or  ciulartcritis.  pr«-<iispo.st-  strongly  to  hemor- 
ria^'e.  and  an-  met  with  in  conditions  such  as  gen.-ral  arterio.s<l,-rosis, 
Unt'lit  s  dis,.tt.s,-.  <lialH-t(-s,  gout,  fx-rnicious  anemia,  leukemia,  scur\v. 
and  in  liver  atft-cfions  a.ss<Hiatt-d  with  jaundice.  Among  other  general 
<auMS  may  lu-  mentioia-d  septicemia,  malaria,  relapsing  fever,  extensive 
Imrii^  of  the  skin,  and  poisoning  witli  phosphorus  and  lead.  Among 
ranr  -aiises  an-  mention«-<l  disonh-rs  of  menstruation  ami  vicarious 
""  M^irualion.  Fatty,  hyaline,  and  amvloid  changes  in  the  vcss.-I  walls 
may  on  (Krasion  lead  to  extravasation  of  bl<K)d. 

a.tinai  lieniorrhagcs  vary  consideraldv  in  number,  size,  sliai)e  and 
(>««iiinn.  r|„.  putelies  an-  pale  n-<l.  dark  n-.X,  or  black,  acconliiig  to 
taiii;. .  and  frc<|ueiitly  assume  a  nidiate  or  "Ham»-shap.>d"  apiH-araiicc 
Ins  i~  owing  to  the  fact  that  the  extravasation  often  takes  place  into 
""■  II.  rvr-fiU-r  layer,  when-  it  follows  the  cours,-  of  the  fiU-rs.  The 
Iwt'.  1  .Fusions  of  bIcHKl  may  fon-e  their  wav  into  the  vitn-oiis,  which 
tli.Ti  h\  f,..,oiiies  opa(|ue,  or  U-twcc-n  the  chon)i<l  and  the  n-tina.  ()( ca- 
M">uill>  llie  bliMKl  colhvts  iK-neath  the  hyaloi.l  membrane  (subhvaloid 
''<'lliiirrii:ii;e). 

ill'  i|.H„|  is  often  absorU-d  nipidly  but  leaves  whitisli  i)at(lies  in 
"«  r-'  M.  whul,  an-  due  to  fatty  dcgc-ncration  an.l  atn.pliv  of  the 
imn.ii.  .,.,  resulting  fnuii  the  interfen-ncc  with  the  nutrition.  '  .\ot  in- 
'rciiiYiii.v,  such  spots  lH-«-oine  pigmented,  usualiv  at  tlu-  p."riplurv,  and 
mav  rl.  r  i„«anl  the  ccntn-.  They  may  oft.-n,  lu.wcv.-r,  <oiitaiii  scatten-d 
""•'I"  'I  pigment.  In  cases  of  liemorrliag*-  into  tin-  vitn-oiis  the  dots 
'"•',^  "     im  attachetl  to  the  n-tina  and  U-com.-  organize,:,  fonning 


i  I 


Pljl' 


'^Ki 


A40 


THE  hetisa 

This  is  lielieved  to  be  the  caaw  of  the  so-called  rrllnlt'u 


cunous  tags 
proliferatu. 

The  dlsturbaiK-es  of  vwion  whirh  result  ilepend,  of  course,  on  tlie 
extent  and  localization  t)f  the  hemorrhages.  Extravasations  ih  the  iiuk  iila 
will  lea<l  to  serioas  interferem-e  with  the  sifjht.  Even  moilerate  ••ffiisions 
of  blood  into  the  vitreous  will  prcMlucc  cloudiness  of  vision.  In  (tllier 
ca-ses  we  may  have  metuinoqjhopsia,  less  often,  photopsia. 

Hemorrhage  into  the  .sheath  of  the  optic  nene  may  caust;  pressure 
upon  the  central  artery  an<l  anemia.  It  has  lieen  known  to  follow 
trauma  to  the  eye  or  hemorrhaRe  at  the  ba.se  of  the  brain,  the  bl«Kxl  in 
the  latter  case  fon-inj?  its  way  alonR  the  sheath  of  the  nerve. 

Aneurism*.— Aneurisms  of  the  n-tinal  arteries  are  very  rare.  They 
are  usually  miliary  in  size  and  multiple,  though  larger  single  ones  may 
(Hcur.     I'raumatic  arteriovenous  aneuri.sm  has  Imh-u  dcsc-rilH-*!. 

Phlebactaiia.'  FhleiHtta.sia  is  a  rare  condition  in  which  flic  retinal 
\eins  pr«'scnt  a  iiiarketUy  U-aded  app»-aran«',  due  to  alternate  coiistric- 
tioiLs  and  dilatations.  It  has  Ixiii  noted  in  connection  with  suppnssetl 
menstruation. 

DfTLABIMATIOllB. 

BetinitiB.  -Under  the  term  retinitis,  which,  strictly  speakinj;,  should 
1m'  emplovetl  to  designate  inflanmiatory  conditions  of  the  retina  only,  are 
usually  cia.sse<l  a  nuniU'r  of  affe<-tions,  chiefly  of  u  <legencrutivc  nature, 
that  are  only  more  or  less  doubtfully  rclatetl  to  inflammation.  Siuii  arc 
certain  forms  of  fatty  «lcgcncration,  atrophy,  H-deina,  hcmorrliap-,  aiiti 
pigmentation. 

Retinitis  may  exist  j)er  ne,  but  Is  usually  dejH'iMlent  on  or  assiKialcil  with 
disease  of  the  neighlioring  structures.  When  due  to  inf»'«tion  it  iimy  lie 
bnxight  alxHit  dinitly  by  trauma,  or  may  Ih-  si-condary  to  soiiir  ilis.a.se 
prcKcss  ill  a  tlistaiit  part.  Aicording  to  the  typ«',  we  can  r.rojrnize 
suppurative  ami  non-.sui)purativc  forms. 

SnpimratiTe  F'tinitU.  Suppurative  retinitis  is,  in  a  larg*-  |iii>|>orti(m 
of  ca.s«-s,  line  to  ,>enetrating  wounds  of  the  bulb,  wlien-by  wpli.  initro- 
organisms  are  imporfwi  into  the  eye.  It  may,  for  example,  follow  an 
operation  for  cataract  extraction.  Metallic  sub.sl;iin«>s,  |)aiiii  iilarlv 
copjMT,  which  have  cntcrt'tl  the  eye  ami  are  disinte>r^lltin^;  tlu  n.  M.ine- 
times  give  ri.s«>  to  a  mild  form  of  sujipirative  iiiHaininatioii.  In  oilier 
cases  the  infwtion  is  meta.static,  the  primary  condition  U-\\\):  I'U.  riHral 
.scptitvinia  or  some  acute  infe<tious  fever.  In  this  variety  li.r  comli- 
tion  is  apt  to  Ik-  a  chorioretinitis.  Where  the  iiiflainmatory  |iii,.  .ss  has 
atTected  nmiiily  the  vitreous  humor,  the  coii<lilioii  may  }.'i\-  rise,  in 
childn-n,  to  the  ap|M'arancc  known  clinically  as  ptradoglioma  In  the 
milder  forms  of  .septic  retinitis,  we  fiiul  in  the  reliim  Ik  iiioirl,  i::<s  and 
white  spots,  not  uidike  thoM-  found  in  albnnniiuri-  nliniii  without 
any  marked  evidences  of  iiiHammation,  and  apparentiv  wtlmut  the 
presence  of  microorganisms,  while  the  severer  tiisi's  go  on  to  >HP|.iirali(m 
and  exudation.  In  the  latter  class  of  cases  staphyhKMH t i  -  -inpt"- 
cocci  may  be  found. 


ALBUMISVRIC  RETINITIS 


Ml 


In  the  earlier  stages  the  retina  appears  to  be  swollen  and  cloudy 
V  .rh  scatferejl  hemorrhages.  Ijiter,  the  vitreous  humor  In^^uies  turbid 
fmrn  exudation  to  such  an  extent  as  to  interfere  with  further  study  of 
tlH'  .ase  by  «>phthalmo««-oni,.  meth»xls.  Micnwcopicaily.  the  retina  ia 
»w..llen  ami  uHleinatous.  th,-  nerv.-fiber  layer  oihI  later  the  ganglionic 
lav.r  are  inhltrate.1  with  leuktxytes.  and  in  the  supporting  stroma  is 
a  granular  and  hbrinoiis  exwJate,  with,  in  sevei*  cases,  hemorrhasic 
exlniva-sations.  In  i-ourse  of  time  the  radial  fil)ers  hypertrophy  and 
ehmgate  in  the  direction  of  the  c.rnea  lltiniately  the  rod,  and  cones 
atn.phv  ami  dmp,H.ur.  The  pr.He.s.s  ends  finally  in  panophthalmitis 
ami  phthisM  bulbi.  ' 

Eatiiiltta  Bimptoi-The  mildest  form  of  non-suppurative  retinitis  is 
that  known  as  retinitis  simplex  (aemua  niiultii,:  wdema  retina)  The 
raiises  are  nc>t  entirely  clear.  Some  ca.ses  are  attributed  to  the  effect  of 
pv.vstn.in  others,  again,  follow  blows  upon  the  eye  (commotio  retina). 
Ihr  condition  Ls  alsi>.s«id  to  be  one  of  the  first  manifestations  (,f  sym- 
patlun.  ophthalmia.  'I'he  retina  is  found  to  U-  c-ongc-stcKl  and  hLy 
apiMirtntly  from  .wiema,  which  mav  Ik-  either  patch v  or  <liffuse  ' 

AlbDiniiiaiie  BttiiUtl..-  Of  much   more  practical   im,K.rtance.   from 
he  standpoint  of  the  diagiuwticiaii.  Ls  albuminuric  retinitis.     In  this 

l!™«-7il'\"""'i'i!"'  T'"'  '"'"■•:  p^p'""  '■'  """""^  '"^'"'^•«' «-  "ell 

(nenrorettoltto).     Ihe  chang..s.  when  well  marked,  are  alincwt  pathog- 
noin.......  of  nephritis,  and  it  n<,t  infriH,ucntly  happens  that,  in  ca.ses 

wher,.  the  general  svmpt.)ni.s  are  .somewhat  in  alH-vance,  the  diagnosis  of 
H'l.t  s  ,|,.sc.a.sc.  LS  hrst  made  by  the  ophthalmologist.  On  examination. 
th.  ..,„,..  disk  IS  fouiHl  to  Ik-  mldened.  .swollen,  and  .somewhat  blurred 
at  tl...  niargin.  while  in  the  m.ighlM.rh.HMl  are  nunuTous  rounded  or 
ra.l.al  v-ilispixsed  streaks  of  hemorrhage,  together  with  larger  or  smaller 
.rnn-'lar.  white  patclu-.s.  whi.h  may  c.Milesce  aiul  form  extensive  area.s 
ar.„n„  the  pup.lja.  1  h,.  re„nal  vcs-sc-ls.  particularly  the  veins,  are  over- 
.lisl.n.!..,!  ami  tortuous.  In  the  region  of  the-  macula  can  often  U-  scvn 
»hit..  stn-aks  arranged  in  rows,  having  a  chanutcristic.  .star-like  form. 
»>.il.  . y.s  are  usually  inv.»lved.  but  one  may  Ih-  more  affcrtcnl  than  the 
Oilier. 

.MiM..s<„pic„||v  we  find  abuiulanf  lymph-con>u.s,l,>s.  esp,viallv  al..i.K 
h<'  v-Y-ls,  with  hbrinous  c-xiulatc  into  the  tissue  .spaces,  togc-th'er  with 
iiMHrplasui  (jf  the  sup|K,rting  stn.ina.  'i'here  is  a  widespread  arteritis 
an,l  ( a|„ll»ntis  resulting  in  thickening  and  sclerosis  of  the  smdler  ve.s.sc.|s 
ilK'  v.Mular  changes,  no  doubt,  ucc-ount  for  the  numerous  small  hemor- 
rH'.'^  . M.t  are  found  in  this  form  of  retinitis.  The  white  patches  above 
rimnl  ,„  ar,.  p„H|i„.,H|  by  dcn.s«.  ac-cuniulations  of  fatfv  granular 
«ll>.  ^«MMh  are  situated  within  and  iK-twcrn  the  granular  lau-rs  „,„1  „f 
n  all,,,  ,„„|  .olloulal  nias.ses  suppo.s,..l  to  Ik-  .lerive.1  from  .legciuratinir 
hl."H|-,  xrri.vasiitions  and  nerv.-.substance.  The  whitish  streaks  in  the 
ni  nln  ivgion  are  due-  to  fatty  d.-gc-neration  of  the  inner  en.Ls  ol  the 
ra  lann.  n,-rve.hlH.n|.  Ihe  optie  papilla  shows  inliltration  with  Ivmph- 
J^K  ■l...„,.ration  of  its  fibers,  and  hv-pertrophy  of  the  inten*titittl  sub- 


ir  I 


I  i' 

ill 


iiii 


ijl 


i    ■ 


(H3 


THh.  RFTISA 


'M 


(f 


In  albuniiimric  retinitis  ilii-  \ntvivT  of  viaion  is  ran-ly  kist  comphtily, 

ami  llils  pwuliaritv  Is  one  of  the  most  important  nK-aiw  of  aistinKiiisliinx 

lH^w«tu  ihw  c-orolition  ami  the  optic-  nrnrilis  n'sulting  from  brain  liirnor 

in  which  the  sinht  Is  always  almost  jiMt.    'llu-  fii<  t  that  the  fovi  a  ..  ii- 

trulls  i.s  rarely  affected  in  albiiminurie  retinitis  aec-ounta  for  the  fact  ilmt 

i-eiitral  vl.si«>n  is  almost  coiistunlly  pn\st'r>'«l.  •     i    •  ■  . 

Uctinal  .hanRes   somewhat   similar  ft.  those  o.    urrinR  in    Hri;;lit's 

cliseas«>  an-  also  met  with  in  lonj;- standing  c-a.ses  of  dialieles.  Itiit  are 

miKli  ran-r.     In  one  forn    <»f  the  tnmble,  multiple  snml!  'i.inorrlia),ts 

are  ti>  In-  s.tn  in  the  n-tiiw  anil  nothinj{  more,  the  hemorrbific  diabatie 

retinltia  of  HirsehlHTjj     'ITils  roinlition  is  prolmbly  not  inflamniuK.ry  in 

its  natnn-.     M«n-  tlianic  teristic  is  cantotl  puneUte  rtUnltU.    Her.-,  ilu- 

retina  presents   numen.u^   Muall.  brijtht,  shininjj  s|M>ts,  ehietly  in  tlie 

neiphiK>rh(Hxl  of  the  optic  -lisk  and  the  manila,  but  not  having  the  sitllatc 

arrangement  of  the  spots  in  ulbuininnric  wtinitis.     With  tlie.s*-  are  to 

\w  strn  multiple  si-altensl  luni(>rrh»n<s.     'i'he  r»-tinal  v.-ssels  s.rni  to  \w 

nonnal  and  ther«<  is  n.)  a-<h  nia  .itlur  of  the  papilla  or  t.f  tlu-  ninm. 

Not  infn-<iuentlv  hemorrliam>  may  take  pla«e  info  the  vitns)Us,  causiii;; 

turbidity  of  that  tne«lium  an«l  <-onsiderabii  impairment  of  vision.   <  iiaiu- 

onia.  Msoialarv  to  the  hemorrhap-,  may  also  (Kriir.     Vision  is  apt  loU- 

ha«l  in  «lialK'ti'c  retinitis,  es|XHially  in  the  central  p)rtion  of  the  ti.i.l 

and  iH-riphenil  vision  may  al.s»)  Ik-  impainsl.  ....        ,    , 

Obronle  DiSnM  Eetlnitii.     A  ihn>nie  diffus*-   n-tinitis   is  <le..  ril»'<l, 

reMiltinn  fn>m  inflammati.>n  of  the  uveal  tract.     It  is  mark.sl  eliietlv  l.y 

cellular  infiltration,  ami,  later,  by  the  fonnalion  of  n.-v  coniai  iiv.  tissm. 

in  the  «lceiK<r  lavers  of  the  membrane.     The  radial  iiU-rs,  lojrelli.  r  with 

the  supiH)rtinn  -stHMim  an<l  the  adventitia  of  the  vesseU.  al^c  ^Imw 

thickeninj;.    The  imreas*-  in  length  nf  the  radial  filn-rs  may  ai.aiii  mkIi 

pnaK.rtions  that  a  laver  <if  n-ti<ulate<l  <onnistive  tissue  is  form. ,1  ii|m>ii 

the  inner  surface  of  the  n-tina.     The  nerve-filH-rs  and  nan^'lia  uh.inai.lv 

atn.phv  and  disapjH-ar.  while  the  nnls  and  con.s  an-  similarly  all.d.il, 

though"  to  a  less  (H'nv.     In  some  few  cas,'s  the  hkIs  and  .•on.-  are  on 

the  contrarv,  liv,,.rtrophie<l.  lK<«niin>;  ln.th  loiter  aiitl  tin.  k.  r  lliaii 

normal.     This  is'  particularly  aj)!  to  U-  the  case  when  deta.  Inn.  i.t  ..f 

the  retina  has  taki'ii  place.  ■        ,   , 

DiMemiMted  aetlnitii.  Somewhat  akin  to  the  last-inciiti.niil  tnrm 
of  n-tinitis  is  «lis.semiiuited  retinitis,  which  is  analop.iis  to  .ii>M  nnn;:!.'.! 
(•horioretinitis,  aliove  descriUsl.  In  many  of  the  cases,  in  fa.  i.  n  is  iK.t 
alwavs  easv  or  even  possible  to  say  whether  the  pnxvss  has  ,.n;;nml..l 
in  the  choniid  and  has  subs<Mpiently  sprea.l  to  the  retina,  or  «li.  iIht  h  Ij 
primarv  in  the  latter  membrane.  Thin  patches  of  exudaii.m  „.,  f..ui..l 
[)etwe.-n  the  choroid  and  the  n-tina.  together  with  cinumscriiM  !  .l.sinH- 

tion  of  the  pijrinent-e|>ilheliuni  an<l  of  the  layer  of  hmIs  aii.l  ' s.    in 

some  parts  the  retiniil  i>iKiiient  tends  t.i  accumulate,  so  tin;  H  "w.^ 
Ik-  rcadilv  rcs<)>;niz«sl  on  ophthalmoscopic  examination.  I  linu  ii.ly  ilif 
comu-ctive  tis,-ii.-  of  the  outer  layers  of  the  r»-tiiia  and  tli.-  loiH.niiif: 
filK-rs  pioliferate  ami  extend  in  (he  dirtstion  of  the  choroid.  I  i  i-  "»■» 
material  can  U-  .seen  moa-  or  less  altered  1".  a^'iH-nts  of  the  nnl-     .4  c.mu's, 


RETISms  PK.'MK.S'TOSA  ^g 

wich  ma*«^  „f  piKmcM,.  ami  |„rK..r  .,r  smHller  Klui«l-Iik..  oxm..v..iH<-s 
.l.r.v«|  fr.«„  the.  larnum  v,.r..u  of  ,1...  ,.|,»r.,i.l.  'IV  «„,nt.ttive..Us.a: 
..rrimnmimul  tho  piKinenlHrioi,  inuv  ..veiUimlly  ...xfe.,.!  to  .he  inmrmost 
h.v.r,s  .,f  Jh,.  ivh.ui  whrr,.  thv  pipiu-nt  is  ..«.„  .„  In-  .l..,K«i.«l  ulontf  .he 
(•(iiirsf  of  Mm-  vi's.s«-h.  '' 

BaUaitii  Pitmiatow.     [„  so,,,,-  msi^Mts  (-(..niwrHhl,.  .„  .he  last-n.en- 
t.o,K..J    onn  IS  th..  .s,M„||«l  r,..i.,i.is  ,,iKn,e„.os4,.  an  «ff«-.io„  i„  which 
p,K„u„.a  ,oi,  IS  «„  early  a.Hl  ,ham<-.eris.i..  fea.tirt-.      I„as,niMh  as  .lie 
mfla„„na...ry  rn«„,festa.,..„s  ar.-  .,f  .he  sliKh...s.  ,le.s,.ri,».i„„,  ami.  in 
f«.t.  ar..  Kenoraily  la.k,.,K.  ..  is  .,„es.io„al.!e  whether  .he  .rnKv-is  is  not 
mor..  pn.|M-rly  ...  U-  ,l«j.s..,|  a,n<.„K  .he  .leKi-.a.ra.io.w  .han  tt.no„K  ,he 
n.tt.„„„a.,.,as       1  he  «ph.h«l,nosc.,pi..  pi,.,„rt.  is  .haraf.eris.ie.     Theiv 
IS  sh^h.  H.roply  of  .he  op.i,.  papilla.  „,  .|„,vv„  hv  its  vellowish-white 
a|.|HMra,Ht.  and  shttq,  .-on.oi.r;  .he  vess4.|s.  |mrti<„l«r!v  .lie  arteries   are 
shrunken   ami  then-  ,s  a  no.al.le  .h-,K.si.  „f  pi^n.e,,.'  i„  «  «„„.  i;,,,.^. 
rn.-.lia(.-  Mw.vn  the  jKw.enor  ,K.le  an.]  .he  e.|ua...r  of  .1,.-  ev,-     The 
pitches  of  pipnent,  which  are  nion-  or  less  n,i,nero„s.  art-  sniall.  irrt-irularlv 
in.l.nte.l    an.l  armn«.-,l  in  JarK,-  |w,rt  alon^  the  eourn-  of  the  ves.sel, 
Uher,.  the  piKnienfation  is  nion-  extn-.ne  the  patches  ,nav  c-cwlesc-e  tu 
for...  lMr>,r.  ch-j-p  l.la.k  clninps.  often  c-ontainin^  ronncleci "s.^.ts  clevoi.l 
of  .olorinK.     HeinorrhaKes  do  not  ,H-c-.,r.  nor  ar,-  the  ,U-«r  s.M.ts  ,^-sulti,iK 
fnm,  in  .l.ration  of  the  rt-tina  or  atrophy  of  the  chon.id  to  U-  seen 

Ihsto  o^neally,  orH-  finds  hyali.H-  thickeninj;  of  .he  ve.s.s,.|s.  with  ohli.er- 
at...r,  ...    Iheir  smalh-r  l.ranch.s.  atrophy  of  .1,,-  pipiu-nt  epi.h.-lium 
W..I.    IH-  new  for,n.Uio„  of  d«.ply-p,>n.e.ited  c-.-lls  in'.he  rc-.il.a.  wl  ere 
h,.y  Us,.,,,.;  IcK-atc-d  ,n  tho  vessel  sheaths.  a„,|  marked  hvu-rtrc^phy  of 
the-  siipiH.rf.njr  stroma  of  the  rvtina.  f  J  "' 

Til,'  .lis,-a.s<-  affects  lM>th  eyc-s.  and  can  U-  ii,l„-rif»-d. 

A,.ion>r  the  nm-r  f,)nns  of  r.-tinitis  niavln-  n,,-,,.!,,,,,,!  retinltii  circinau 

I'l'liiS-Tu!;!;"***  ^■''"^"■"-  ""^*^  '^'^*»  "•'•—  <^^""-"). 

Betiniti.  clrcin*U  is  fo„„.l  „„|v  i„  ,.|,lerly  jK-ople  and  «ffec-ts  one 
or  hntl,  ,.v,..s  ()„  exannna.,..,,.  «  nnn.U-r  of  s„,all.  white  s.M.ts  can  l« 
WM  .rra„ve,l  al,ont  .he  „,ac„la  in  a  „,ore  or  less  .n-rfcK..  c'irele  The 
ma.  u  .  shows  a  grayish  opaci.y.  'I'hc-  whi.c-  s,h,.s  ..,„•  ,|„.,H-r  .han  .he 
Ml...'  v..ss,.|s  and  „,ay  Ik-  slightly  pi^m„-ntc-,l.  There  is  ,lin,i„n,io„ 
H  .Mt.al  y,s,on.  ,ontract,o„  of  tlu-  visnal  Hc-I.l.  and  a  small  central 
'-<ot..,n;..     1„  tins  affcH-tion  one  or  IhXI,  c-ves  ,nav  U-  involv.Hl 

Ret,mt,.  striau  deriv,-s  its  nan,,-  fron,  .1,.-  fa.-t  that  th.-r,-  are  a  n„n,lH.r 

»  ).n.  Y^h  str,|H-s  to  Ik-  .s,vn  ,„  the  retina  in  fn.nt  of  the  pimnc-nt  layer 

■     !.'.„.]  ,h..  vessels.     These  stri,K.s  ,nay  Ik-  thrcv  or  'fcH,r  tinJs^L 

»  I,   ,,.  ,h,.  ye.ns  a„,l  ,nay  ra.liate  fro,,,  the  disk  like  the  spokc-s  of  a 

'  <l.  ".-,  ap»„.  may  hay-  no  partic„lar  arrangement.     'I'he  retina 

.     s  il  ,"„      n  '"«'";'""""•"•     '^'i-'"'"  i^  -li».'l"l.v  rc-dnec-d.  l.ut  blindness 
."»(•>  II' I  iisiially  rc-snif. 

In  retm.ti8  punetaU  albescens  the  ntina  is  st.,.l,lc-d  with  small,  white 
(V  ^^  H.h  an-  niosl  nnn„-ro„s  arc,,,.!  the  .lisk  an.l  in  the  mac-nla.     The 
the"''  ''""'•^'■'•..'■*  ''■><""">■  "imffec(c-d.     Central  vision  is  reduml.  and 
nen    ,.,   so,ne.,mes  nyctuiopiu  unci  ri-diietion  of  the  peripheral  field 


MKaocorr  rbouition  tbt  chart 

(ANSI  ond  ISO  TEST  CHART  No.  2) 


1.0 


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644 


THE  RETINA 


SoUi  retiiiltii  is  the  result  of  expxsure  of  the  eyes  to  a  bnght  hght. 
There  is  found  a  central  seotouia  and,  later.  piKinentation  of  the  rnacula 

Pwaiites  -The  Cy.'iticercus  cdlidmv  has  l^-en  met  with  in  or  heiuutli 
the  re^a.  The  eondition  is  rare.  Separation  of  the  retina,  ch.u.hng 
of  the  vitreous  humor,  and  finally  atrophy  of  the  eye  result. 


■n-. 


:;#i 


RETROaSESSIVE  METAM0RPH0SK8. 

AtrODhy  and  Degeneration.-Atrophy  and  degeneration  of  the  retina 
oc^T  not  only  as  a  senile  change,  but  also  as  a  se<,uel  of  various  .lis- 
^e  presses,  among  which  may  l.e  m.utione*!,  hemorrhage,  s,  e  os.s, 
oHhe^^Ll  4s.sels,  vascular  obstruction  from  tlm.mlH^sis  or  embohsin, 
LpamUon  of  the  n«tina,  chronic  retinitis  and  neuron^t.mtis,  chron... 
ThSuis.  As  a  rule,  the  atn,phy  aflFects  chiefly  the  nervous  part  of 
theTucture,  while  the  stroma  aiul  pigmented  epitheliun.  are  no  m- 
S^Sy  h W'^stic.  The  nxls  ami  cones  at  first  show  sw.llmR 
S  rsume  ;  ch.l,-shape.l  or  pear.shape<l  appearance.  1  hey  usual  y 
ahoXgate  and  tend  to  split  at  the  ends,  becoming  conv.Tte.  into 
iimd^Sroval  masses.  The  nerve  cells  of  the  external  ami  intonml 
Sinukr  kvers.  as  well  as  the  gaMglion  cells,  may  ultimately  un.lerRO 
faTvTnd  colloid  change  and  .lisappear.  In  this  way  the  whole  nervous 
mKism  may,  at  times,  be  destroye<l  and  the  retina  n.>pla«Ki  l.y  a 
simnle  connective-tissue  membrane.  n       i        j 

iS  the  eN^s  of  old  people  the  vessels  of  the  retina  are  usuaV  .scl..n,sed, 
o„;i  the^  inav  l)e  cvstic  iegeneration  in  the  anterior  layers  of  the  retina. 
'    ttr;— n  tW^;  to  find  in  ch..roi.lal  and  rc-tinal  disease  n,arke.i 
chanl  in  Se  pigmenU-pithelium.     C\.rtain  of  the  ells  los,-  tlu.r  pig- 
ment  wWle  others  appear  to  take  up  more  than  the  norma    .u.nn^ 
KeSeneration  and  altemtions  in  the  pigment  layers  art.  not  in  n..ju..ntly 
fnnml  in  the  macular  n-gion  after  in  uries  of  the  eye  ami  in  old  af.r. 
X^aSSn  Of  the  Reka  (Amcio  E.tin»).-Normally.,  the  gnejU 
lav^r  of  the  n-tina  is  fairlv  firmly  attache<l  to  the  choroid.  ^^M.'  th 
Serior  portio^i  appears  to V-  merely  su,x.rimpose,l  upon  the  o.  ur  an 
hell   n  nosition  by  the  pressure  of  the  vitret)us  humor.     In  .I,. ...  huieii 
o    the  Sa    soi-alled.  the.s<.  two  layers  are  sepanUed,  the  p.,nu-ne 
kyer  Jng  ordinarily  left  iH-hind.     Sc-paration  of  the  retina  .Lh  JJ^ 
«iur  except  in  the  most  severe  afftK-tions  of  the  eve.  such  as  u.l  a  «^ 
mvoDia   severe  injuries.  hemorrhag.-s.  choroiditis,  iridoc-yc litis,  .  vstKv 
Tus  Ss    ami  inira-cK-ular  tumors.     Albuininuric  retinitis.  -  .-..-alb 
that  Lso^iate.!  with  pregnancy,  is  one  of  the  rarer  causes 
-  oaration.    The  condition  may  come  on  without  obvious  cuu> 
the  separation  is  recent,  the  retina  projects  forward  into  tii. 
ehaml^r  as  a  tremulous,  translucent,  K-y^^h-<-..lo,.d  rm-n^^ 
into  folds,  over  which  the  vessels  can  be  made  ou    taking  a, 
course     The  separation  temls  to  increase,  and  finally  In^-omc^ 
the  retina  remaining  attached  at  the  disk  ami  ora  ■'^•'•'•ata  ni  . 
a  plaited  funnel.    The  separated  retina  is  often  uKlematou, 


retinal 
When 
posterior 
.  thrown 
irre);ular 
.  miplete, 

form  of 
iiid  may 


GLIOMA 


645 


undergo  hyperplasia.  Calcification,  or,  more  rarely,  assification,  may 
.K-cur.  Ihe  hloaive.s.sel.s  finally  undergo  sclerasis  and  become  throm- 
bosed. 1  he  nervous  elements  atrophy  and  eventually  become  m  iterated 
and  disappear. 

PROGRESSIVE  METAMORPHOSES. 

Tumors.— The  only  benign  growths  which  have  lieen  found  to 
originate  in  the  retina  are  teleangiectatic  and  flbromatous  tumore,  which 
have  been  found  in  eyes  after  removal. 

OUoiM.— Glioma  'is  the  only  malignant  growth  which  is  primary 
111  the  retina.    Siiict  it  is  found  usually  in  early  infancy  and  never  later 

Fia.  176 


'■!■  "m  of  the  retina  (from  a  patient  of  Dr.  L.  Webster  F-.x  in  tie  Medico^-hiruigical 
College.  Philadelphia.)     (McFarland.) 

timn  .1,,.  twelfth  year,  it.s  development  seem.s  to  Ik-  dependent  on  some 
coMj;,  ,„tal  peculiarity.     This  view  is  supported  bv  the  fact  that  more 
man  ,.„..  of   the  same  family  may  be  attacked.    In  about  IS  n^r  ."ent 
otcuvi  both  eyes  are  involved.  * 


646 


The  OPfW  NERVE 


rr 


The  new-growth  l»egias  at  the  back  of  the  eye,  pushing  the  relina 
before  it  into  the  anterior  chainlier.  Comparatively  early  it  invades  the 
sheath  of  the  optic  nerve.  It  gradually  spreacls  to  the  ciliary  pnKiss 
and  iris,  and  may  eventually  infiltrate  the  whole  eye.  Iritis  and  uUhtu- 
tion  of  the  cornea  occur,  and,  finally,  the  tumor  penetrates  the  gloLe 
and  appears  externally,  where  it  may  attain  relatively  enormous  pro- 
portions. It  forms  a  soft,  fungating  mass,  which  is  necrosed  in  parts 
and  tends  to  bleed  readilv.  In  time  the  growth  may  involve  the  sclera, 
the  eyelids,  the  soft  parts  and  Ikjucs  of  the  face,  and  may  eventually 
reach  the  brain  by  way  of  the  sheath  of  the  optic  nerve.  Se<-omlary 
growths  may  be  found  in  the  regional  nodes,  the  parotid  and  submaxillary 
glands,  in  the  liver,  and  other  organs. 

Histologicallv,  the  growth  does  not  differ  materially  from  the  glioma 
occurring  in  the  brain.  It  consists  of  rumerous  closely  packed,  incmo- 
nuclear  cells,  emlx-dded  in  a  finely  granular  and  fibrillated  ground 
substance,  which  is  abundantly  provided  with  wide,  thin-walled  bi.KHl- 
vessels.  The  glioma  cells  are  round  and  contain  a  sinjile  nucleus  almost 
completelv  filling  up  the  cell  l)ody,  so  that  the  tumor  to  some  <xt<'nt 
seems  to  'l)e  made  up  of  granules,  recalling  the  granular  layer  of  the 
retina.  By  proper  methotls  the  peculiar  spidei-like  cells  of  gliomatous 
ti.ssue  can' be  detected.  In  some  specimens  pwuliar  rosettes  forimd 
of  rods  and  cones  have  Invn  found  and  such  tumors  have  l)cen  tirmeii 
neuro-epHheliomata.  Tin-  laver  of  nnls  and  cones  is  homologous  with 
the  cells  lining  the  central  neural  canal.  Flexner  would,  therct'ore, 
term  such  tumors  rpendymal  glwmuta.  Glioma  usually  starts  from 
the  outer  portion  of  the  retina,  the  granular  layers,  but,  more  rarely, 
may  originate  from  the  ner\e-fiber  layer. 


The  Optic  Nerve. 
CONGENITAL  ANOMALIES. 

Coloboma.— Ci>!oboma  of  the  sheath  of  the  optic  ner\e  has  already 
been  referred  to  (si-e  p.  608). 

OIBCULATORT  DISTURBANCES. 

(Edema  and  Congestion.— (Edema  and  congestion  of  the  optic  iierAc, 
either  in  the  papilla  or  in  the  papilla  and  la-hind  the  bulb  a-  well, 
are  found  in  the  eariy  stages  of  inflammation  of  the  ner\e,  or  as  a  result 
of  the  pressure  of  tumors  or  inflammatory  exudates  upon  the  ner^e 
trunk.  These  conditions  will  be  more  conveniently  treated  uii(i<r  the 
heading  of  inflammation. 

INFLAMMATIONS. 

Inflammation  of  the  optic  nerve  may  affect  the  retrobulbar  portion  of 
.6  trunk  (neuritis)  or  the  distal  extremity  (papilUtis).     inflanmiation 


PAPILLITIS  OR  CHOKED  DISK  547 

of  the  papilla— papilUtii— may  exist  per  se,  but  not  infrequently  is  due 
ti)  the  extension  of  an  infJummatory  process  from  the  retina  {iieuro- 
rcHniiis),  from  the  nerve  trunk,  or  from  the  brain,  by  way  of  the  nerve 
trunk  {descetiding  optic  neuritiii). 

Papillitis  or  Choked  Disk  (Stauungspapille).— PapilHtLs  is  com- 
monly the  result  of  meningitis,  sinus  thrombosis,  intracranial  tumors, 
and,  occasionally,  tumors  and  inflammatory  exudates  within  the  orbit. 
As  to  the  essential  natun-  of  papillitis  opinions  vary.  Some  interpret 
it  as  the  result  of  hydrops  ot  the  ner\'e  sheath ;  others,  as  a  true  inflamma- 
tion of  the  disk.  It  is  a  fact,  however,  that  any  condition  whicli  leads  to 
an  increase  in  intracranial  pressure,  such  as,  for  example,  a  new-growth 
or  meningitis,  results  in  forcing  an  increase<l  amount  of  cerebrospinal 
fluid  into  the  intervaginal  space  of  the  optic  ner\e.  This  induces  press- 
ure upon  the  central  artery  and  vein  of  the  retina  which  enter  the  nerve 
a  few  millimeters  Ix-hind  the  glol)e.  The  papilla  thus  liecomes  swollen 
and  a'dematous. 

The  ophthalmoscopic  examination  in  such  cases  shows  the  marein  of 
the  disk  to  be  blurred  and  the  retinal  zone  immediately  alwut  it  to  be 
dimmer  than  it  should  be.  The  papilla  itself  is  cloudy,  reddened,  and 
swollen,  particularly  in  the  nasal  portion.  The  veins  of  the  retina  are 
also  somewhat  congested.  In  the  more  intense  cases  of  papillitis  the 
infiltration  of  the  tissues  is  still  more  marked.  The  papilla  is  greatly 
swollen  and  so  cloudy  that  it  is  with  diflficulty  recognizable.  The  retinal 
veins  are  also  more  indefinite,  while  numerijus  small  extravasations  of 
1)101!-!,  arrangetl  in  radial  fashion,  are  to  \w  seen  in  the  gravish-red  nerve 
sul.s<!iKP.  In  purely  inflammatory  cases  the  turbidify  of  the  tissues 
IS  tin-  most  striking  and  characteristic  feature;  in  the  hydropic  form  the 
turbidity  is  not  so  great,  but  the  disk  is  enormously  swollen  and  the 
rt-tinal  veins  are  overfilled  and  distorted.  While  this  is  the  rule,  it  must 
Ik-  adinitted  however,  that  it  is  not  always  possible  to  determine  from 
the  ophthalmoscopic  examination  alone  the  true  nature  and  cause  of 
the  i)upillitis,  whether  due  to  pressure  or  to  inflammation.  The  form 
met  with  in  albuminuria  is  of  the  tv-pe  ot  a  neuroretinitis  (see  p.  641), 
Fapilhtis,  when  of  mild  grade,  may  pass  awav  leaving  the  disk  practically 
normal.  The  more  severe  or  more  prolon'ge<l  cases  usually  result  in 
loss  ot  vision.  This  is  due  to  atrophy  of  the  nerve-fiber^  from  the 
pressure  of  the  inflammatory  exuilate  or  of  newlv-formed  connective 
tissue. 

Histologically,  the  choked  disk  from  hydrops  presents  marked  oedema 
wlu(  li  IS  the  sole  cause  of  the  great  swelling,  but  .sooner  or  later  inflam- 
ma(..r\  iiihltration  is  superadded  and  a  picture  results  which  cannot  be 
dimivntiatt^  from  any  of  the  forms  of  true  papillitis.  'J'lic  tissues  are 
iimitiatcd  with  smal;  round  cells,  particularly  along  the  course  of  the 
vess,  U,  the  ner%'e-fibers  are  swollen  and  nodu'lar,  and  there  are  minute 
extravasations  of  blood  and  a  deposit  of  finely  granula-  detritus  l)etween 
tiie  tiiK Ts.  In  the  most  advanced  stages,  there  is  a  considerable  increase 
01  ti.nucctive  tissue  and  con.se<'utive  atrophv,  more  or  less  complete  of 
the  larve-libers.    In  the  letter  case,  the  papilla  is  sharply  defined.' on 


:  1!       t 
It      I 


648 


THE  OPTIC  SERVE 


ophthalmoscopic  examination,  of  a  dead  white  color,  perhaps  somewhat 
excavated,  and  the  retinal  vessels  are  shrunken  looking;. 

Inflammation  of  the  trunk  of  the  optic  nerve  {retrabidbitr  neiirltin) 
may  affect  the  pt-ripheral  portion  of  the  nerve  and  its  .sheath  (pni- 
neurUis),  the  axial  portion  rentrul  or  axial  neuritis),  or  various  anas 
scatteretl  through  the  ner\'e  (disseminated  neuritis).  The  parts  involved 
are  the  intervaginal  space  and  the  interstitial  fibrous  stroma  of  the  n»Tv»>. 
In  the  form  alxne  termed  perineuritis,  the  intervaginal  space  is  MM 
with  an  inflammatory  exudate,  ctmsisting  of  serum,  round  cells,  and  often 
fibrin.  I^ter,  the  endotheliai  ells,  covering  the  connecting  strands  lliat 
traverse  the  space,  pmliferatc.  Accompanying  this,  the  supporting 
stroma  of  the  nerve  may  be  found  infiltrated  with  similar  inflanuuatory 
products.  Later,  the  inflammatory  process  may  involve  the  ner\e-fil.ers 
proper,  so  that,  as  the  combined  result  of  pressure  and  disintegration. 
they  atr  ihy  and  finally  disappear.  The  nerve-substance  may  thus  l)e 
representiHlsimply  by  masses  of  fragmenting  myelin,  fatty  granules,  and 
the  so-called  amyloid  bodies.  It  is  possible,  too,  that  the  inflninnialion 
and  disintegration  of  the  ner\e-fil)ers  may  be  primary— newriV/a  medul- 
laris  (I^ber). 

Retrobulbar  neuritis  may  result  in  more  or  less  complete  loss  of  vision, 
according  to  the  amount  of  nerve-substance  that  is  destroyed.  Where 
there  is  partial  loss  of  vision,  the  condition  Is  known  as  scotoma.  We 
may  have  peripheral,  axial,  or  disseminated  scotomas.  Perhaps  in  the 
majority  of  cases,  lie  scotoma  is  situated  it.  o.  near  the  centre.  In  chronic 
tobacco  amblyopia  there  Is  a  central  scotoma  with  also  some  limitation 
of  the  peripheral  field  of  vision. 

Neuritis  of  the  optic  nerve  trunk  is  often  due  to  inflammation  in  the 
orbit,  the  extension  of  a  basal  meningitis,  or  an  intracranial  new-j^rowth 
Occasionally,  it  can  l)e  traced  to  a  .systemic  infection  or  intoxication 
In  the  toxic  forms  it  is  perhaps  a  question  whether  the  inflammation  it 
primary  in  the  nerve  trunk  or  whether  the  process  begins  in  the  retina, 
degeneration  here  leading  to  se<'ondary  a.scending  atrophy  of  the  fibers. 

Retrobulbar  neuritis  may  disappear  without  serious  damage  iK-ing 
done,  but  not  infrequently  atrophy  supervenes  with  more  or  less  loss  of 
visual  power. 

Tuberculosis. — Miliary  tuix'rclcs  have  l)een  found  affecting  the  sheath 
of  the  nerse.  Occasionally,  also,  the  nerve  has  Ix-en  destroyed  l)y  a 
diffuse  infiltration  of  its  .substance  with  tulierculous  granulation  li^^iie. 

Syphilis. — Syphilis  may  assume  the  form  of  a  simple  retrolmlhar 
nr>uritis  or  a  gummatous  infiltration  of  the  ner\e.  The  whole  traiik 
and  even  the  chiasm  may  be  involved.  Syphilitu-  neurorctiniii-  [i\.  v.) 
is  also  a  well-recognize<l  condition. 


RETB0ORES8IVE  MET1MOKPH08E8. 

Atrophy.     Atrophy  of  the  optic  npr\e  occurs  and  is  due  tn  :>  variety 
of  causes.    In  general,  it  may  be  said  that  any  condition  which  l:iierferes 


TVMORH 


64d 


with  the  nutntion  of  the  nerve-fil»ers  or  brings  about  destruction  of  the 
neurocytes  or  nutritive  nerve-centres,  is  competent  to  brine  about 
atrophy.  Pressure  upon  the  ner^e-trunk,  as  from  inflammatory  exudates 
connective-tissue  hyperplasia,  congestwl  vesseLs,  or  nev.'-growths  is  an 
important  caase.  Atrophy  of  the  neurocytes  in  the  retina,  from  inflam- 
mation.  vascular  disturlwnces,  or  other  causes,  leads  secondarily  to 
wasting  of  the  nerve-filiers  procee<ling  from  them.  Simple  atrophy  of 
tlu-  optic  nerve  occurs  in  tal)es  dorsalis  and  progressive  naralysis  of  the 
msane  The  cause  is  held  by  some  to  In-  a  primary  degeneration  of 
the  retinal  cells.  Ihe  various  toxic  amblyopias,  notably  that  from 
quinine,  are  probably  due  to  a  similar  condition,  resulting  from  the 
induced  ischemia  of  the  retinal  vessels. 


PKOORE88IVE  METAMORPHOSIS. 

Tumors.— Tumors  of  the  optic  nerve  and  its  sheath  are  rare.  They 
may  W  primary  or  secondary.  The  secondary  new-growths,  which  are 
of  course  ma  ignant.  usually  originate  in  other  parts  of  the  eyeball  or  in 
the  orbit  and  involve  the  nerve  by  direct  extension.  Taus,  glioma  of 
th(  retina  and  sarcoma  of  the  choroid  may  invade  the  disk,  and  carcinoma 
and  sarcoma  of  the  orbital  cavity  may  attack  the  trunk  of  the  nerve 
-Metastatic  carcinoma  has  also  been  reported. 

The  primary  tumors  may,  with  Ubcr,'  he  classified  into  those  affecting 
the  mtra-wular,  the  intra-ori)ital,  ami  intracranial  portions  ->f  the  optic 
nerve.  Ihey  may  further  Ik;  divide«l  into  tho.«e  that  spring  from 
the  (lural  covering  or  the  parts  immediatelv  adjacent  to  it-^xtradural 
new-growths,  and  those  originating  from  structures  within  the  dural 
sheath  and  for  a  time,  at  least,  bounded  extcrnallv  by  it— intradural 
new-growths.  ' 

The  vast  majority  of  primary  intradural  tumors  have  been  reported  as 
niv\.)inas,  fibromas,  san-omas,  ami  various  combinations  of  these 
elemental  types  occasionally  as  gliomas.  Many  of  these,  however, 
wer-  reported  before  microsconio  technique  was  as  perfect  as  it  is 
tcxlay,  so  that  Byers,  who  has  written  an  exhaustive  monograph  on  the 
sul.jeet,  ho  ds  that  nearly  all  of  these  growths  are  of  the  nature  of  fibroma. 
of  the  type  known  as  the  false  neuroma.  They  tend  to  involve  the  intra- 
cramul  as  well  as  the  intra-orbital  portions  of  the  nerve,  extending  some- 
nnts  into  the  chiasm.  Owing  to  the  wide  distribution  of  the  process. 
th..  association  of  the  fibrosis  with  the  lymph-channeLs,  the  Gedematous 
ap|.rMraiK-e  of  the  tissue  that  is  so  often  present,  Bvers,  further,  compares 
ine  ,  ondition  to  elephantiasis  an.l  suggests  the  term  fihronmUms  of  the 
o|>ti.   nerve  as  the  correct  designation  for  the  condition.     Such  tumors 


Hundb.  (ler  gesatnniten 


!'»■  Krankheiten  der  Xetzlmut  und  des  .Sehnerven. 
.^up-hi.ilkundi!,  Graefe  and  Saemisch,  5: 1877:910. 

,   '  ■'  ''""'•■!'•>•  I"tradural  Tumors  of  the  Optic  .\e.Ae.     Studies  from  the  Uoyal 
t. "  .  Hospital,  Montreal,  1;  1901:  Xo.  1. 


Vioto 


650 


THE  LENS 


occa-sionally  exhibit  a  limittil  tenilency  to  mali^nanry,  as  do  other  fihroiw 
growths.  These  new-gn)wthH  «Kf«ir  in  alwut  SO  per  cent,  of  the  cum's 
before  the  age  of  fifteen  years.  They  are  excessively  rare  after  twemy- 
five.  Females  are  slightly  more  often  attacked  than  males,  and  the  left 
eye  is  somewhat  more  often  affected  than  the  right. 

Fibromas  of  the  optic  nerve  start  fnim  the  arachnoidal  or  pial  covcrinj;, 
and  are  apt  to  extend  anterojiosteriorly  rather  than  laterally.  They  tciMJ 
to  compress  the  nerve  trunk,  which  early  undergoes  atrophy,  l^ws  of 
vision  and  proptosis  of  the  eyeball  are  characteristic  symptonis. 

A  few  cases  of  andothalioiu  have  Uhmi  reconlwl  (Alt,  Tailor,  Knit). 
These  have  l)een  (xrasionally  reconled,  though  incorrectly,  as  carciiioiiia, 
alveolar  san-oma,  or  fibnxsarcoma.  Ci'lls  of  flattene<i  appearance  and 
of  endothelial  tv-pe  are  found  aggregatwl  into  masses,  separated  one  from 
the  other  by  connective  tissue.  Occasionally,  the  characteristic  cells 
are  arranged  concentrically  or  in  whorls  alM)Ut  u  central,  clear,  refrintile 
body.  Such  forms  might,  therefore,  be  indud'Hl  under  the  category  of 
pununoout. 

One  case  of  nvnroin*  has  l)een  reported,  consisting  both  of  medulluted 
and  non-meduUated  filers. 

The  extradural  tumors  are  the  flbroiu,  endotheliomt,  and  sarcoma. 
They  originate  from  the  connective  tissue  of  the  structure  or  its 
endothelial  lining. 

The  Lens. 

OONOCNITAL  ANOMALISa. 

Several  forms  of  partial  congenital  cataract  are  recognized.  The 
opacity  often  assumes  geometrical  forms  and  usually  involves  Urth 
lenses.  Remains  of  the  hyaloitl  artery  may  Ik-  found  in  the  form  of 
fibrous  strpnds  or  membranes  of  the  posterior  surface  of  the  lens  (posterior 
polar  cataract),  or  on  the  anterior  surface.  Other  anomalies  tiiv  con- 
genital luxation  of  the  lens  and  coloboma. 


RETROaBESSIVE  METAMORPHOSES. 

The  anterior  surface  of  the  lens  is  covered  by  a  single  layer  of  epi- 
thelial cells  which  extend  backward  a  short  distance  l)ehind  the  (■|iiator 
of  the  lens  and  then  gradually  lK>come  converted  into  lens  fiUTs.  This 
epithelium  is  capable  of  overgrowth  and  may  undergo  a  thickeniii;:  known 
as  capsular  cataract.  The  transparent  fil)ers  of  the  lens  proper,  however, 
do  not  appear  to  lie  endowed  with  the  same  vitality,  and  are  disable 
only  of  degeneration.  Degeneration  of  the  fibers  gives  rise  to  lenticnlir 
cataract. 

Gapsular  Cataract. — Simple  capsular  cataract  is  usually  dm  to  the 
pressure  of  the  lens  upon  the  cornea  in  ciuses  where  the  couk  a  has 
been  {)erforated  and  the  acpieous  humor  has  drained  away.  Wt  ^<t'  'd 
therefore,  in  connection  with  «lccn»tion  of  the  cornea  and  in  ...meal 
staphyloma.    Occasionally,  a  central  capsular  cataract  is  foumi  m  con- 


it 


tSSTlCL'LAR  CATARACT 


651 


rHt'tion  with  ophthalmia  neonatorum,  even  where  there  is  no  corneal 
perforation.  Penetrating  injuri«'s  of  >\u-  lens  may  also  bring  about 
capsular  catarac-t,  but  this  Is  usually  usscKJated  with  lenticular  cataract. 

The  histolojjical  appearances  indicate  that  the  «-pithelium  of  the  cap- 
sule, usually  about  tlie  centre  of  the  anterior  surface  of  the  leas,  under- 
ffH's  pmliferation,  gradually  liecominjj  stratifiwi.  Kventually,  the  newly 
fornu'd  c-ells  are  convertt-d  into  spindles  and  later  into  dlv'Ts,  poor  in 
nuclei  and  resembling;  connective-tissue  KIkts. 

Lentiealar  Cataract.— Lenticular  cataract  is  often  found  in  connec- 
tiou  with  affectioRs  of  the  retina  and  choroid,  an<l  in  cyclitis.  Other 
well-known  forms  are  those  resulting  from  traumatism,  diabetes,  and 
old  u^e. 

Ill  injuries  to  the  lens  involving  penetration  of  its  capsule,  we  usually 
get  a  combined  form  of  cataract.  If  the  ruptun-  Ik-  slight  it  mav  be 
(•overed  by  the  iris  or  closed  by  the  formation  of  a  capsular  cataract. 
Thus,  a  small  localized  opacity  may  result  which  may  eventually  be 
ahsorlKil.  In  more  exteasive  injuries,  the  capsule  retracts  and  the 
atiueoiis  humor  soaks  into  the  substance  of  the  lens.  The  fillers  of  the 
lens  JK-gin  to  swell,  In-come  opaque  and  protrude  through  the  opening, 
.is  the  extruded  tissue  is  absorlicd  or  detached,  other  fibers  in  their  turn 
prolapse,  and  this  pnxrss  goes  on  until,  if  the  nucleus  Ihj  not  too  hard, 
the  whole  siilwtance  of  the  lens  is  absorbed.  Ix-iikocytes  may  pass  into 
the  lens,  also,  and,  later,  vascular  c(»nnective  tissue,  so  thai  we  get  a 
fibrous  cataract,  in  which  calcart-ous  salts  are  often  deposited.  A 
foriiiiition  of  bone  may  also  take  place. 

In  (lialx-tes,  the  acpicous  humor  apjH-ars  to  undergo  changes  in  its 
cheinical  composition  which  result  in  degeneration  of  the  lens  fibers. 
They  iK-come  granular  and  disintegrate  and  the  subc-apsular  epithelial 
ce'.s  (legenemte  and  atrophy. 

In  .smile  mtaract  it  is  U-fievetl  that  the  first  step  is  the  formation  of 

•^  •"    neir  the  equator  of  the  lens  owing  to  traction  on  the  peripheral 

.d  shrinkage  of  the  nucleus.     The  clefts  fill  with  liquid  and 

.  1  fillers  iH'gin  to  swell  up  and  InHome  vesicular  from  imbibi- 

■  fibers  next  present  small  globules  in  their  substance,  and 

.omogf   ( oils,  myelin  masses  and  fatty  globules  are  found  in  the 

tissue  spaces;      Later,  the  superficial  fibers  'iKtome  detached  from  the 

capsule  and  the  cortex  is  converted  into  a  soft,  pulpv.  or  semifluid  ma.ss. 

Ihis  IS  the  stage  of  tumefaction.     Next,  the  liquid  is  absorlied  and  the 

lens  ivtunis  to  its  normal  size.     The  cataract  is  then  said  to  lie  "ripe." 

llie  .lejteneration  may  go  on  farther,  and  the  cataract  is  then  said  to 

l»e  •ov,.r-ri|)e."    The  whole  of  the  .  ortioal  portion  mav  eventuallv  lie 

conv.ited  into  a  milky  litpiid  in  which  the  nucleus  floats  (Morgagnian 

catanirlu  or.  again,  the  liquid  may  U-  entirely  absorbed.  leaving  only 

the  iiiK  Iriis  within  the  capsule  {mcmhramms  cataract).    In  some  cases  of 

a<lvaM( ,  (1  senile  cataract  a  capsular  cataract  develops  also. 

In  ilie  so-called  lamellar  cataract  there  is  an  opaque  zone  between 
the  (■.(rr.v  and  the  nucleus.  The  condition  is  commoiiiy  met  with  in 
"cketv  children,  and  affects  both  eyes. 


^ 


652 


III 


THE  MTREOl'fi  HVMOR 


Tb«  l^tTMOi  Htunor. 


The  vifnous  Ixxly  Ls  an  avascular  Inxly,  like  the  cornea,  antl  like  it 
may  he  the  .seat  of  tin  active  iiiKltiation  with  celU  and  'nflaniinatury 
products,  derived  from  the  neinhlwrinK  vascular  structures.  Priirmry 
inflammation  of  the  vitreous  is  rare.  The  vitreous  Ls  also  liahle  to  undcr),^) 
fihrillation  and  liifuefaiiion  as  the  result  of  the  sli|{htest  lesion.  In- 
flammations extending  to  the  vitreous  from  other  parts  of  the  eye,  the 
milder  irritation  produtwl  liy  awptic  foreign  Ixxlies,  or  even  the  triHiiig 
changes  pres;?nt  in  myjipia  may  l)riiig  this  aitout.  The  vitreous  in  such 
cases  becomes  more  coarsely  fibrillated  than  normal,  the  fluid  portion  is 
to  some  extent  forcc<l  out,  ami  the  whole  IkkIv  contracts  ami  InHonies 
detache<l  from  the  ailjacent  structures.  Detachment  of  the  n-tina  may 
be  brought  almut  in  this  way. 

The  vitreous,  finally,  acts  as  a  passi\r  receptacle  for  pus,  blood, 
inflammatory  exudations,  and  fon-ign  iKnlies  generally. 

P«ruite>  and  Foreign  Bodies.  -The  chief  parasite  is  the  Fikrk 
tanguinia  hominia  which  has  In-en  found  Inith  in  the  anterior  clianilHT 
and  in  the  vitreous.  Cyaikrrcua  cysts  have  al.s«»  Ix^n  met  with.  All 
kinds  of  meidllic  and  minenil  substances  may  gain  an  entrance  into  the 
vitreous  as  a  result  of  injury. 


OLAUOOMA. 

Cilaucoma  is  an  affection  of  the  eye  characterized  by  an  incren-se 
in  intra-ocular  pressure.  It  may  develop  in  a  previously  heultliy  eve 
{primary  glnueomn),  or  in  one  that  is  already  the  site  of  gnjss  disease 
{aecondary  (/laucoma).  The  disease  often  begins  slowly  and  insidiously, 
but  may  also  set  in  acutely,  in  Inrth  cases  with  or  without  ass(Hiate<l 
inflammatory  disturbance.  The  cases  in  which  the  intra-ocuhir  prcsynre 
increases  slowly,  though  it  may  Ik;  intermittently,  without  i.  "  nini;  of 
the  eye,  are  known  as  aimple  glaucoma.  Tho.se  l)eginning  acimly  willi 
all  the  signs  of  an  ophthalmitis  are  calleil  inflammatory  glaiicoiiin. 

The  pathogenesis  of  glaucoma  is  not  altogether  understixxl,  for  it  is 
difficult  to  deci<le  what  are  causes  and  what  are  effects.  In  antral,  it 
may  l)e  .said  that  we  have  to  recognize  Inith  atrophic  an<l  inHiiimiiatoi^- 
changes.  We  have  definite  information  which  goes  to  siiow  that  if 
there  Ix;  any  impediment  to  the  outflow  of  the  a<|Ueous  humor  tlif  intra- 
ocular tension  rises  and  the  condition  of  glaucoma  is  initiated.  In  most 
ca.ses  this  impwliment  is  due  to  bl(K-kage  of  the  filtration  anulf  or  to 
incn'ase<l  viscosity  of  the  aqueous  hinnor,  whic-li  cau.ses  it  to  tili'r  with 
difficulty.  Thus,*  an  inflammatory  infiltration  in  the  neighli'i'icKxi  of 
Schlemiii's  canal,  which  leads  to  the  pnxluction  of  a  cellular  t  lulate  in 
Fontana's  space  and  on  the  anterior  surface  of  the  iris,  is  i  ptent 
caase.  In  fact,  any  condition  which  causes  the  periphery  of  ' '•  iris  to 
press  agaiast  the  cornea  may  set  tip  gliiucoma,  snrh  fvs  civ.w  -tion  or 
infiltration  of  the  ciliary  process,  the  traction  upon  the  iris  ■  \  rti-d  by 


TUMORS 


653 


an  anterior  symt-hia,  the  |)r»-.s.siin'  of  »hi'  aqtimiM  humor  iti  rase-,  of 
circular  inxsU-rior  MviHHhiu.  Ia'ss  often,  the  p«-rrneul>ility  of  the  filtration 
anjjie  Is  interf..e«l  with  hy  s<Ierofie  changes  in  the  peetiimte  ligament, 
ft-sides  the  factors  jiwt  descrilieil  as  the  causes  of  glaucoma,  thromlxjsis 
of  the  choroidal  veins  (Klel)s)  and  proliferation  of  the  en.lothelium 
lining  the  venie  vorticosae  (Birnlmcher;  Czermak)  have  Ikh  ii  regarded 
as  of  etiological  importanc  It  is  hard  to  say.  Ii<.wever.  whether  the 
rhimges  in  question  art'  no.  a.s  iik«>iy  to  lie  effects  rather  than  causes. 
The  etiok^y  of  simple  glaucoma  is  cpiite  obscun*.  'I'he  condition  iisuall  f 
(i.'vtiops  in  hyperopic  eyes  and  in  individuals  the  subject  of  arterial 
sc'lcriwis. 

In  a  typical  case  of  acute  glaucoma,  the  conjunctiva  Ls  reddened  and 
often  < edematous;  the  cornea,  c-loudy.  devoid  of  lustre,  ancl  with  an 
uneven  surface;  the  pupil  is  usually  "dilated.  The  faint,  gravish-green 
appearance  of  the  pupil  of  the  eye  suggested  the  term  glaucoma  for  the 
condition.  In  the  milder  forms,  the  increased  intra-ocular  tension, 
though  :t  may  c-ome  on  cjuickly.  is  ae-companied  hv  little  more  than  hard- 
ness of  the  eyeljall.  opacity  of  the  cornea,  and  slight  pericorneal  injection. 
The  more  severe  cases  assume  the  picture  of  an  ophthalmitis.  In  some 
inslancvs.  in  aeldition  to  the  conditioas  deseribed,  we  find  hemorrhages 
info  the  retina,  the  vitreous  humor,  and  the  anterior  chamlier— A<'mor- 
rhaiflr  glaucoma. 

As  a  n-sult  of  the  inflammation  and  the  inc-reased  tension,  widespre.id 
atrophic  changes  make  their  appe'ara:ice.  The  sclera  loses  its  elasticity, 
may  W-  thinsiwl,  and  may  bulge  at  certain  points.  The  lens  may  be 
cataractous.  The  iris  is  atrophic  and  its  pigment  may  be  gathered 
anmnd  the  pupillaiy  margin  on  the  anterior  surfac-e.  The  ciliary  Ixxly  is 
flattened.  The  retina  ancl  choroid  an>  atrophic  and  the  vessels  si-lerosed 
or  otherwise  oostructed.  The  optic  nerve  presents  the  picture  of  an 
asciii(lin)'  "neration  and  the  bulging  backward  of  the  lamina  cribrosa 
causts  tlie        ailed  cupping  of  the  disk. 

The  Orbit. 

nrrLAMMATIONS. 

InHuinmations  of  the  orbit  may  be  of  the  tv-pe  of  a  diffuse  ceiluUtis 
or  ol  abscesi.  Cellulitis  and  abscess  often  result  from  injury,  but  mav 
oe  spontaneous.  Inflammation  may  extend  to  the  orbit  from' the  face  in 
er}si|K.|as,  fron*  the  throat  in  tonsillitis,  or  from  the  socket  of  an  inflamed 
tooth,  or,  again,  from  >^e  lacryraal  gland. 


PKOORESSirr   METAMORPHOSES. 

Tumors.— Tumors  of  the  orbit  may  arise  primarily  from  the  loose 
conn.,  live  tissue  of  the  part,  but  much  more  frequently  originate  in 


'^ 


654 


THE  ORBIT 


somp  of  Ihf  f>«>iili);iioii.<t  .slnH-liin*.4.  'V\iv  In-iuku  tiimor!«  that  Imvf  iHcn 
olMenttl  an*  the  tngioiiM,  lymphkngioou,  oitMBu,  und  various  rorins 
of  tt>rutoi<i  iH-w  fonimtioas  mcIi  its  dtnnoid  cjrtti,  rhtbdonyonn,  ami 
myoatwoma. 

OtsU  of  various  kiiiil.s  arc  also  foiiiHl,  siuli  as  hv^roinu,  nuliicris, 
fatty  ami  oil  v\Ms,  ath«-n>n>utoii.s,  lu'iiiatonmtotiH,  and  .stcaloniaioiis 
cy.Ht.s,  many  of  which  art>  i-ongt'iiitul  and  pfrliu|>.<4  rt'lattil  to  the  d«>rniiiii|>. 

The  inoMt  c-ontinon  primary  mali);nant  ^niwth  of  the  orliit  is  ilif 
Mreoiu,  usually  the  round-  or  HiumUv-crlM  fonn.  (hieimtrcomii ,  iiiii.ro- 
mrromn,  cylindroma,  and  mifojibroxiirronut  an-  also  di-scrilH"*!.  Ohloroma 
iK-<'urs  and  appan-ntly  arises  fn)m  the  [>eriosteiiin.  Sareoinas  ami 
endotheiiomas  originatin);  in  the  antrum,  brain,  or  pituitary  fjland  may 
involve  the  orbit  se<-on<larily. 

F'o.  177 


]-]xupht))aliiios  frnm  tin  intru-orhitul  Krowlh.     (Krnni  llic  Optitliallniiloviciil  (  hr  i.  . 
Montrpiil  (ieiieral  HuHpilal.) 

Oaitinonu  is     '    ..vs  .sjH'ondary  and  oripiiates  from  the  cMliiN.  the 
episcleral  "issue,  .<r  tlu-  lacrymal  jjlan<l. 

New-growths  originating  in  the  orbit  may  lead  to  niiirkcd  (li-l'natioii 
of  the  eyeball  (proptimin;  cxophthalmon). 

iDJtiries.-  Kxtravasations  of   I>I(hnI  may  take  place  into  tli< 
tissue  as  a  result  of  contusions,  wounds,  or  fractures.     Friictin 
inner  wall  of  the  orbit  o|H'ning  up  communication  with  the  noM 
duct  often  lead  to  emphysema  of  the  t)rbital  cellular  tissue. 


(>rl)ilal 
i.f  the 
\-  iiusal 


OHAPTKK    XXX. 


THK  KAH. 
OOXaiHITAL  AVQMALIII. 

o  a  p„rt  ..f  It      MalforinH.i<,iw  of  the  •xJenml  nm'     .,MI..  ,.„>  „«!  „,.,„.,. 

ally  unilHtonil,  nm-iy  LiJah-ml.  .in.l  an-  ..ft.-n  a,ss,Kiat«i  with  other 

.l.v,.|..pmental  aiu.mahe.s.  siul,  as  han-li,..  eh-ft  palate,  clul,.f,K>t.  hernia 

persistent  l.ramliml  clefts,  an<l  faeial  hemiatrophy. 
C.miplete  »bMne«  of  the  anrielM  is  exciHKlinKlv'nire.    It  i.x  sai.l  that  in 
hinu  tuere  is  a  spj^H-s  .  '  .heep,  ,«||..,i  the  Vu.Vti.  in  whi.h  this  ptvu- 

liari  y  IS  of  iiormal  «r..:.en,e.     In  the  vasv  of  the  aiiri.le,  the  helix 

Sii;  '"■  I'Ti!  '""'■  '"  ''•'^•-••'^r-,"'-. ""•  «l'"l»'  ''tr.Ht.m.  is  stnnt^i 
(microti.).      In  other  ea.s«s  the  auricle  is  exc^MJin^lv  iarin.  (aiMsrotU) 

S^otli:/  Tl"     "'I'l'vP"'*/  "■■  '^r  "'">•  '"■  ^"FH'rnumr.ary  anriele!; 

poljotU).  Ihese  additional  auricles  an-  usually  unilateral,  and  may 
W-num  or  le.s.s  perftrt.  As  a  rule,  they  are  pn^auii.ular  apm-mlages' 
but  may  Ih-  found  on  the  n«k, clurk,  or  should.r.  Similar  pliuliaJK 
Mrii.  to  have  iH-en  known  from  remote  times,  for  ther.-  is  i„  the  British 
.Museum  the  head  of  an  .1<.Kipan  with  an  8eces.s.)rv  auricle.  The  Satvrs 
ar,.  a  >o   r;-pre,s«.,it.Ml    with  u-^t-'ike   ears.      Headers  of   Hawthorn'e's 

-Marljle  Faun  will  reinen.lH-r  the  inten-stiuK  wav  in  which  the  sf.ry 
is  made  to  centri-  ar.und  an  inherited  onialv  of  this  Mid  Sot 
.ufnM.unt  y.  small,  .scar-like  RrtKnes,  or  fix.,,  ,r,  discharK,  ,  cn-amv 
Huicl.  are  found  on  the  ear,  remnants  of  the  primitive  irill.<       s  (fMn 

Complete  .b.«ic,  of  the  oxtanul  auditory  mwt.'.-  ha-:  In-en  ohsened. 
It  IS  ..uenilly  unilateral,  hut  nay  Ik-  bilateral.  '!  ' .  .-ondition  is  no 
mrosarily  ass,K-iate.l  with  impairm  -  .,f  JH-arin;,.  The  site  of  the 
m.,  us  IS  sometimes  ,n.lic«t..l  hy  „  sh:  .■  «„K,ye,  Km  ,.ven  this  mav  1^ 
«ammj;  I  he  atresia  may  Im-  due  to  lume  or  menil.rane.  PaWial 
am  Ma  the  presence  of  <-(,mHrtive-tissue  Imnds  traversing  the  passage 
O--^;).  liour.gl«..s  constriction  of  the  cavity,  abnormal  wicleSesir 
«lu,. cation  o  the  passagi.  (Sc-hwartze),  have  Ikh-u  ohserve,!.  Is  a 
nik,  these  conditions  are  ttss,K-iate.l  with  other  defects  of  tl-  •  auricles 
meiiil.rana  tympani,  or  middle  ear.  "uncits, 

<|'n^.nital  anomalies  in  .levelopment,  configuration,  and  position  of 
"IP  III.  iiil)rana  are  fairlv  common  ' 

"" '""'"•"•>"  "1™'"-"  «'«!  tvmpanic  cavity.     Small  fissures  of  the 

'  Klinik  dor  Ohreiikrankhcitcn,  S/ 


I 


J  ? 


i  f^ 


666 


THE  EXTERSAL  EAR 


liili 


membrana,  often  bilateral,  are  occasionally  met  with  as  a  result  of  non- 
closure and  explain  how  certain  persoas  are  able  to  emit  tobacco  smoke 
from  the  ear. 

The  middle  e«r  witii  its  contained  ossicles  may  be  completely  absent 
or  radimentuy.  Atresia  may  be  present,  partial  or  complete  absenct;  of 
the  foramen,  abnormal  wideness  or  rctluplication  of  the  same.  Tlie 
incus  and  stapes  have  bei>n  found  to  be  fused.  In  such  cases  the  hearing 
may  be  practically  normal. 

The  luiUcUan  tube  may  l)e  absent  in  cases  of  defect  of  the  e.xternal 
ears  and  rudimentary  development  of  the  tympanic  cavity  and  labyrinth. 
KinUng  of  the  tul)e  or  abnormal  position  of  its  pharyngeal  opening  ure 
more  frequent.    Stenosis  is  rare. 

Congenital  malformations  of  the  internal  ear  are  occasionally  met 
with.  They  are  usually  bilateral,  and  may  be  associated,  though  not 
invariably  so,  with  other  developmental  anomalies  of  the  auditory 
apparatus.  The  labyrinth  may  Ik;  wholly  or  partially  defective,  the 
cochlf^a  may  be  undevelojHfl,  or  the  modiolus  or  lamina  spiralis.  'I'lie 
aqueducts  may  In*  dilated  or  reduplicated.  WTien  the  labyrintli  is 
defective,  the  auditory  nerve  may  also  l)e  absent  or  end  in  a  bulbous 
swelling  in  the  bone. 

The  External  Ear. 

ANOMALIES  OF  SECRETION. 


i.  'i  I 


-A 


Anomalies  of  swretion  of  the  sebaceous  and  ceruminous  glands  arc  not 
infri'tiueiitly  met  with.  Secretion  may  Ik'  scanty  with  marked  drvncss 
of  the  surface  of  the  canal.  This  is  seen  in  association  with  ccrlain 
affectioiLs  of  the  middle  ear  (chronic  sclerosing  otitis  media),  and  is 
apparently  trophic  in  character.  Hypersecretio:;,  with  its  innncroiis 
unpleitsant  accompaniments,  is  of  fre(|uent  ix-currence  esix'ciaily  in 
those  suffering  from  chronic  middlen'ar  disease.  Under  ordinarv  cir- 
cumstances, the  cerumen  is  gradually  r(>move<l  to  the  exterior  liy  tlic 
movements  of  the  jaw  ccjmmunicated  to  the  meatus,  and  by  the  imtnral 
e.xfoliaiion  of  the  epithelium.  In  certain  cases,  however,  favoivii  In 
excessive  priKluction  of  wax,  collapse  of  the  meatus,  or  change  in  tlic 
nature  of  the  swretion,  whereby  it  U-comes  tough  and  viscid,  the  (•<  riiincri 
accumulates  and  tends  to  Ixtome  impacted.  The  hyjH'rsi-cn  linn  is 
sometimes  excited  by  persistent  hyperemia  of  the  meatus,  but  in  otiur 
cases  apjx'ars  to  1r'  a  trophic  disturbance.  ShouUl  foreign  l)ii 
present,  such  as  hair,  epithelial  plugs,  cotton  wool,  etc.,  the  si 
will  tend  to  n-main  within  the  meatus  and  may  be  impacted 
diri-ctcd  efforts  to  remove  it.  The  prj'ssun-  of  impacted  wax  r 
ever,  causes  any  serious  disortler  of  the  auditory  canal,  althongli 
tion  or  inflammation  of  the  canal  and  niembrana  tympani  ai' 
infreijuent  (xcurrence.  When  enlargement  of  the  meatas  or  di 
of  the  drum  membrane  is  present,  this  is  most  probably  to  be  :i: 
to  antectHlent  suppurative  proces.ses. 


lies  be 
■rction 
niis- 
niy.if 
xcoria- 
M  not 
ruction 
•ilMitc<i 


OTHEMATOMA 


657 


Keratosis  Obtnraas.-Keratosis  obturans  (Wreden;  Burnett)  is  a 
rather  rare  condition  in  which  the  meatus  is  obstructed  by  a  material 
at  hret  sjght  not  unlike  impacted  cerumen.  The  substance  is,  however 
tough  and  adherent,  and  of  a  lighter  color  than  ordinary  wax  After 
rimoval,  which  is  difficult,  the  meatus  is  always  found  to  be  more  or 
I(^s  eroded.  The  material  in  question  is  composed  of  an  accumulation 
of  the  horny  elements  of  the  skin  lining  the  cavity  and  the  condition 
probably  results  from  a  chronic  otitis  externa.  The  condition  is  some- 
what similar  to,  if  not,  indeed,  identical  with,  the  soK^alled  cholesteatoma 
which  originptes  in  the  tympanic  cavity. 


OIROULATORT  DUTURBANOES. 

Hypereinia.-H%7M;remia  of  the  parts  may  be  due  to  inflammation 
or  trauma,  resulting  from  mcclianical,  thermic,  or  chemical  insults 
It  IS  seen  also  m  paretic  or  paralytic  conditions  of  the  sympathetic 
nenc  and  the  vasomotor  fibers  of  the  cer\ieal  plexus. 

Heinorrhage.-Hcmorrhage,  in  the  form  of  small  «eeh7moaeB  or 
Webj  m  the  skin,  occasionally  results  from  traumatism  and  occurs  in 
st'vcrc  inflammation  of  the  auricle  or  middle  ear. 

Othein»tom».-The  most  striking  form  is  the  extensive  extravasa- 
ion  of  blood  known  as  othematoma,  or  hanutoma  amis,  which  gives  rise 
to  a  bluish-red  fluctuating,  tumor-like  swelling.  The  effusion  takes 
p  are  iH-tween  the  cartilage  and  the  perichondrium,  or  into  the  substance 
of  «...  cartilage  itself.  Two  forms  are  known-the  traumatic,  due  to 
fra.lure  of  the  cartilage,  and  the  spontaneous.  The  latter  is  some- 
times bilateral  and  symmetrical,  and  is  found  with  most  frequency 
m  Ik-  insane,  although  it  is  also  met  with  in  severe  blood  dyscrasias 
such  as  leukemia.     Owing  to  the  fact  that  section  of  the  restiform' 

anri"'  Z  '''''lir^"*!  ''"'"I'^'"  ''  s«'»eti'"<-«  followed  by  hematoma 
a..r  >  Brown-S^uard'  would  rt^fcr  the  occurrence  of  spontaneous 
henialoma  to  lesions  at  the  base  of  the  brain.  Degenemtive  changes  in 
the  cartilage  and  the  formation  of  new  bloo«lvcsscls  is  suppo,sed  to  pre- 
d.siK.s,.  to  the  condition.  Cysts  have  been  known  to  deVelop  in  tl^ 
muscles  of  the  auricle  after  a  hematoma. 


\\\ 


RETROGRESSIVE  METAMORPHOSES. 

TIr.  degenerative  disturbances  are  not  many,  nor  are  thev  of  preat 

?;:":;; '"  n*  t-"*  r'"'*'^  ^'^p°-^'*«  ^^  umtic  Ss  k 

aR>  nnf  ..frequently  found  m  the  auricle.    Fisauring,  softening,  necrosis 
and  paitial  calcifieatioD  are  also  met  with.  ^^  ' 

,.,  '  BuH-  de  I'Acad.  de  M<:d.,  34. 


658 


THE  EXTERNAL  EAR 


PB00BI8SIVI  MBT1M0BPH08ES. 

Exostoses  and  Hyperostoses. — The  progressive  metamorphoses  are 
exostoses  and  hyperostoses,  and  various  forms  of  tumors.  Exostoses 
and  hyperostoses  may  arise  in  any  part  of  the  external  auditory  meat  as, 
but  frequently  grow  from  the  upper  or  posterior  part  of  the  canal  just 
in  front  of  the  drum-membrane.  They  form  single  or  multiple  growtlis, 
pedunculated  or  sessile,  and  of  a  spherical  or  conical  shape.  They  are 
composed  of  cancellous  or  compact  ivory-like  bone.  More  or  less  occlu- 
sion of  the  meatus  results.  These  growths  are  by  some  attributed  to 
preexisting  subperiosteal  abscesses  which  have  made  their  way  to  the 
meatus.  This  is  doubtful.  Others,  again,  think  that  they  are  dependent 
on  gout,  excessive  bathing,  or  hereditary  peculiarities.  It  is  possible 
also  that  they  are  due  to  anomalies  of  development. 

Poljrpi. — Polypi,  arising  from  exuberant  granulatioas,  are  rather 
common  in  the  meatas.  They  may  be  mucous,  fibrous,  myxomatous, 
and  angiomatous.  Some  contain  hairs;  others,  keratinous  masses  and 
giant  cells. 

Tumors. — Among  tumors  should  l)e  mentioned  the  fibroma,  liponu, 
osteoma,  angioma,  chondroma,  sarcoma,  and  carcinoma.  The  sttrcomas 
are  usually  spindle-celled,  occasionally  round-celled,  fibrmircomax,  and 
osteosarcomas.  The  chloroma,  a  rare  tumor  of  sarcomatous  type  and 
of  pale  green  color,  which  sometimes  originat<s  from  the  temporal  Iwne, 
may  invade  ihe  meatus. 

Sebaceons  and  Dermoid  Cysts.— Sebaceous  and  dermoid  cysts  have 
also  lieen  described.  Various  forms  of  warts  and  novi  are  found  on  the 
auricle  but  are  rare. 

INFLIMMATIONS. 

Inflammation  of  the  auricle  may  be  primary  or  secondary  to  lesions 
in  the  neighborhcKxl.  Practically  all  the  diseases  in  the  skin  may  lie 
found  affecting  this  part.  Mast  of  these  need  only  be  mcntioiie.l  lure. 
They  are,  the  acute  exanthemata,  erysipelas,  erythema,  ucne,  .  etlivma, 
eczema,  her}.>es,  impetigo  contagiasa,  psoriasis,  pemphigus,  sel.orrli(ra, 
pityriasis  alba,  lupus,  sj-philis,  actinomycosis,  lepra,  iclitlivoMs,  ele- 
phantiasis, sclerotlerma,  and  gangrene. 

Common  affections  of  the  auricle  are  chilblain  and  frostbite  i  jiernio). 
Both  conditions  have  this  in  common,  that  profound  circuliiiory  dis- 
turbances are  induced  as  a  result  of  various  defr  -es  of  colli.  In  the 
milder  form  the  auricle  is  swollen,  bluish-red,  ai,  1  very  iteliy  When 
actual  freezing  has  taken  place,  the  organ  is  much  reddened  ami  -"(>llen. 
intensely  painful,  and  may  l)e  covered  with  blebs  containing  a  rllowish 
or  bloody  fluid.  In  more  severe  cases  ulceration  or  even  gaii-'i  ne  may 
result,  and  more  or  less  tleformity  remains. 

Gangrene.— Gangrene  is  seen,  rarely,  in  erysipelas  and  tv]'!  '<!  'ever. 
Noma  may  occur  in  young,  debilitated  infants.  UrbantM !  ii>ch  has 
recorded  a  case  of  Raynaud's  disease  of  the  ear. 


OTITIS  EXTERNA 


669 


Pwichondriti8.-Penchondriti3  of  the  auricle  and  meatus  is  a  rare 
affection  It  gives  rise  to  a  fluctuating  tumor  on  the  concavity  of 
th«  auncle,  not  unhke  the  othematoma.  The  process  generally  begins 
in  the  external  auditory  canal  and  thence  extends  to  the  concha  and  other 
portions  of  the  auncle;  the  tragus  alone  escapes.    The  meatus  is  liable 

0  be  stenosed  from  inflammatory  oedema.    The  fluid  contained   within 
the  swelling  is  at  first  clear  and  serous,  sul)sequently  becoming  purulent 

1  he  periosteum  is  stripped  from  the  underlying  cartilage,  and  necrosis  of 
his  structure  may  occur.      Complete  restitution  to  the  normal  may 

h»^;ft^  i  f^  "  usually  some  shrinkage.  Ossification  occurs, 
but  M  rare.  The  left  auricle  is  the  one  usually  involved.  Some  cases 
rpcordH  by  Haug,  have  been  tuberculous.  ' 

Besiaes  these  fmnkly  inflammatory  disturbances,  there  is  another 
"fm  "  'I'.^V?''^"':^  be  mentioned,  characterized  by  a  painless  and 
afebrile  collection  of  a  clear,  yellow  fluid  between  the  cartilages  and 
perichondrium  After  evacuation  the  condition  readily  clears  up.  These 
cv.'^s  are  attributed  by  Hartmann'  to  previous  degenerative  softening 
of  the  part  and  formation  of  local  collections  of  fluid 

OtitiB  Externa  Circumscripta;  Furunculosis;  Follicular  Inflam- 
matlon.-Otitis  externa  circumscripta  is  a  fairly  common  affection 
of  the  meatus  in  adults,  though  much  rarer  in  chihlren.  It  is  usually 
cau.se.1  by  an  infection  of  the  sebaceous  and  ceruminous  follicles  with 
pyogt-nic  COCCI  but  occasionally  originates  in  the  cartilage  and  neri- 
chomlrium  1  he  direct  exciting  factors  are  trauma  of  all  Wnds,  chronic 
dLs,harges  from  the  ear,  and  chronic  eczema.  Anemia,  gout,  diabetes 
mdlitus,  and  disorders  of  menstruation  are  said  by  some  to  be  piedis- 
posiiig  causes.  Occasionally,  pathological  conditions  of  the  nems  of 
the  meatus  cause  a  trophic  or  soHJalled  "sympathetic"  furunculosis 

?  rt  r^tT"  ,'''"^  ^''"^•'T  ^  chamcter'i/d  by  the  pIZ^onTf 
uncles  or  boils   al,n,,st  invariably  in  the  cartilaginous  portion  of  the 

arrihc^Jh^  r""  ''  ""^y  "fP"*""  '"«"'''"'  °'  may  develop  one 
^m  .1    ti  TT  '""'^'  deep-seated  abscesses  mav  be  foVmed, 

ami  tlu.  tissues  around  the  ear  are  reddened  and  swollen.  The  neighbor- 
ng  I.vniph-glantk  are  commonly  swollen  and  tender,  and  even  the  parotid 
nav  be  invo  ved     Spontaneous  resolution  rarely  occura,  and.  as  a  rule 

t;;'r:i^rofr s™."^- ''''''''  ^^--^^'^  ^-'"-•>'  f«™ 

cimjr  ^r^  Difltusa.-C)titis  externa  diffusa  may  be  acute  or 
clironu  It  IS  rarely,  if  ever,  idiopathic,  but  can  usually  be  traced  to 
nons  traumatic  causes,  chief  amoig  which  is  the  instillation  of  Sng 
Hi  1>.  It  occurs  also  in  erysipelas,  acute  and  chronic  exanthemata 
."  :  'rrn  "T  "^^^X  .'l"*"'"- '«  "«*  uncommon,  espLia  ly 
1    ;     L  -^'  "T"f''*^'  ''"'•^"'"-     ^^^  '^"'"^'"°"  should  dlways 

sT  t  rP"'""  r  ^"'rr*^'^  disease.  The  part  affected  i 
M  the  osseous  portion  of  the  canal,  but  the  proces^s  mav  extend  to 
the  iu..,„brana  and  the  outer  parts.    The  lining  membrane  of 'the  meatu^ 

'  Zeitschr.  f.  Ohrenh.,.15: 156;  and  18:  4^. 


660 


THE  EXTERNAL  EAR 


t'-E! 


is  reddened,  swollen,  and  covered  with  discharge,  at  first  serous  but 
later  purulent.  Sometimes,  from  the  presence  of  secretion,  together 
with  exfoliated  cells,  a  kind  of  membrane  is  formed.  In  some  cases  the 
entire  epidermis  may  be  thrown  off  repeatedly,  leaving  each  time  a 
reddened,  moist  surface  which  quickly  becomes  covered  with  new 
epithelium  (otitis  externa  exfoliativa). 

Membranoos  Otitis  Externa. — Membranous  otitis  externa  is  rare 
as  a  primary  affection.  It  usually  arises  from  an  angina,  such  as 
that  in  scarlatina,  which  has  extended  to  the  middle  ear.  The  osseous 
portion  of  the  canal  and  the  membrana  tympani  are  first  and  chiefly 
involved,  but  the  process  may  gradually  extend  outward.  The  parts  are 
covered  with  a  dirty  white,  firm,  and  adherent  membrane,  which,  when 
removed,  leaves  a  bleeding  excoriated  surface. 

Diphtheria.— True  diphtheria  of  the  external  auditory  meatus  is  also 
rare  as  a  primary  affection.  It  has  been  observed  in  the  course  of 
epidemics  of  diphtheria  of  the  throat,  but  in  some  cases  there  has  Wn 
some  previously  existing  inflammation  or  excoriation  of  the  parts  which 
predisposed  to  infection.  Much  more  commonly  the  disease  is  secondary 
to  diphtheria  of  the  throat  and  middle  ear. 

PhlegmonoiU  Inflammation. — Phlegmonous  inflammation  of  the 
meatus  arises  from  septic  infection  through  a  wound  or  abrasion  of  the 
surface. 

Periwiitis  accompanies  all  forms  of  deep-seatetl  or  deeply  penetrating 
inflammation,  or  may  be  due  to  an  extension  of  inflammation  from  the 

middle  ear. 

TuberculOBis.— Tuberculosis  takes  the  form  of  a  nodular  periclioii- 
dritis  or  a  miliary  tuberculosis  of  the  skin.  The  first  form  is  found  in 
the  concha,  the  soft  tissues  of  which  are  reddened  and  afk-niatous. 
Small  nodules  form  resembling  fibromas,  which  grow  slowly  and  do 
not  tend  to  soften.  If,  however,  there  !>e  no  operative  inte^^(Mltlon, 
after  a  considerable  time  tul)erculous  ulcers  and  fistulae  form  iipon  the 
skin  and  portions  of  the  cartilage  may  l)ecome  sequestrat«  1.  The  neigh- 
boring glands  are  swollen  and  tender.  The  infection  i  said  l>y  Hang 
to  arise  from  the  practice  of  piercing  the  ears,  or  from  wearing  the  ear- 
rings of  a  tuberculous  person. 

Syphilis.— Pnmory  syphilis  of  the  auricle  is  rare,  but  has  l>t  i  n  de- 
scribed by  Zucker.  The  auricle  was  greatly  swollen  and  ul<(  is  were 
present  on  the  anterior  surface  of  the  tragus.  The  ncighborin;;  -lands 
were  enlarged.  Secondary  syphilitic  ulcers  are  much  more  loMiinon. 
They  form  by  preference  at  the  point  where  the  ear  is  pierced  for  an  ear- 
ring. Such  ulcers  are  deep,  crateriform,  with  sharp,  indurate.!  edges. 
In  tertiary  syphilis  gummas  form,  or  there  is  a  perichondritis. 

Parasites.— Otomycosis  is  a  parasitic  affection  of  the  exteniiil  audit- 
ory passage  produced  by  various  forms  of  moulds.  As  a  ride,  ilv  nsper- 
gillus  is  the  infecting  agent.  About  00  cases  of  otomycosis  aspergillins 
have  been  recordetl,  mostly  in  Germany  and  the  Uniteil  ^'  '"''■  " 
is  a  decidedly  rare  affection  in  Canada,  only  4  cases  hii\  nj;  been 
recorded  in  Montreal  in  many  years.    The  forms  usually  fom  >1  are  the 


OTOMYCOSIS  ASPEROILLINA  qq] 

Aspergillus  niger,  the  A.  fumigatus,  the  A.  flavus,  and,  exceedirur'y 
rarely,  the  A  glaucus.  A  case  of  the  last-mentioned  form  of  ihe 
affecton^has  been  recently  recorded  by  Dr.  H.  S.  Birkett  and  one  of  U5 

The  disease  is  most  common  in  adults,  and  is  liable  to  affect  those 
who  live  m  damp  houses  and  under  unfavorable  hygienic  renditions 
Inasmuch  as  it  has  been  found  irapo....ble  to  cultivate  these  onanisms 
in  the  healthy  ear,  it  is  improbable  that  the  disease  is  ev  r  spontaneous 
but  more  likely  that  some  disease  has  preexisted.  Moisture  and 
warmth  appear  to  be  the  two  essential  factors.  Maceration  and  loosen- 
ing  of  the  superficial  epithelium,  with  the  formation  of  a  neutral 
or  slightly  acid  medium,  such  as  is  produced  by  dermatitis,  eczema, 

Fio.  178 


Asix-rnillus  ni  'icam  fmm  tli-  ....■i.,u:i.  ^, 
B.  Iiypha;  C,  sporangium  with  ripe  .pores 
wiin  spores.     (Politier.) 


■■atu».     A.  mycelium  covered  with  numer«u.  fallen  apon.- 
'Pe  -pores;    B\  hyph.  ;    D.  receptaculum  :  E.  aterS 


and  psoriasis  soKialled,  provide  the  most  favorable  condition-^  In 
ecfion  probably  fakes  place  through  the  instillation  of  substenc^s  such 
Z  f  '"'r'^r^r^^i^.  ^''«,''P«'*«-  '^he  mycelium  of  the  fuZ!\^ws 
wh  r/t  \''P'^''-"  ""^'^  '^'^"^"^  P^"«"-'^tes  the  deepeJTucK 
^11.-  the  hyphie  project  into  the  cavity.  Owing  to  the  fuLs  extenS 
0  he  sensitive  parts,  or  poasibly  from  the  presence  of  som^Lln  S 
tio...  and  a  certain  amount  of  inflammation  result 

(...  examination,  upon  the  walls  of  the  meatus,  or  ever  on  the  drum 
men„.ra„e  {v^ynngomycosU  a.pergihlna,  Wreden),  can  L>e  seen  mem 
bramms  patches,  or  the  meata,  is  filial  with  a  <  -ty  de  rit^of  waxv" 
E'l' r*  ''''%d-^»«"?*'«K  epithelium,  covere.l-'w1  ^  nodd   Tl 
Wa<k-l,rown  or  dull  gray.sh-green  color,  according  to  the   nature  of 

0  t      SdfeT"'    i"  T'""'  '^'  ^°"'^'  ''^^  disease  hL  ."p7ead 
,n.ddle  ear,  and  in  two  was  apparently  the  cause  of  perforation 

.  i^^.tl  lifS^""'  °''""''^''' """'  *°  t'"^ Asper^ilh.  Glaucus,  Montreal  Med. 


III 


ti62 


THE  DRUM-MEMBRANE 


■'' 


in 


f  -■! 


f.  -.  i 


(PoUitzer,  Bezold).  Among  the  rnrer  fungi  that  have  been  found  in  tlie 
ear  may  be  mentioned  the  Mucar  mucedo,  Mucor  ci  rymbifer,  Tricho- 
theceum  roseum,  Ancophma  elegant,  Otomycea  purpureua,  Ptiyriaiiia 
versicolor,  and  the  Oidium,  albicans. 

roreign  B'Wiies.— A  great  variety  of  substances,  provitW  only 
they  be  small  enough,  may  be  found  in  the  auditory  card,  ouch  are 
seeds,  peas,  nut-shells,  beads,  buttons,  cotton,  wo.Vi,  sand,  gravel. 
Matches  or  toothpicks,  which  have  been  inserted  to  relieve  itching, 
have  been  broken  off  and  portions  left  behind.  The  larva  of  flies,  or 
even  a  living  fly,  have  beei;  found,  as  has  also  the  Acarus  foUiculonm. 
Animal  parasites  are,  however,  much  more  common  in  the  lower  animals. 
Concretions  of  carbonate  or  phosphate  of  liu.e  are  also  met  with  somewhat 
frequently  in  the  lower  animals  but  rarely  in  man. 

Foreign  bodies  of  all  kinds  are  liable  to  excite  congestion  i^nd  inflam- 
mation, and  may,  by  pressure  upon  the  sensitive  structures,  give  rise  to 
marked  symptoms.  Some  of  these  are  of  reflex  character  and  affect 
the  fibers  of  the  trigeminus  and  vagus  ne-'es.  Epileptiform  convulsions, 
vertigo,  mental  depression,  neuralgic  pa.ns,  and  lary-igeal  cough  have 
all  been  found  resulting  from  this  condition. 

The  Drum-membrane. 

The  drum  membrane  forms  the  boundary  between  the  external 
auditory  meatus  and  the  middle  ear.  On  the  outer  side  it  is  covered 
by  a  thin  layer  of  cutis  continuous  with  the  epidermis  of  the  meatus, 
and  on  the  inner  side,  by  the  mucous  membrane  of  the  tympanic  cavity. 
As  will  be  readily  understood,  from  its  position,  it  is  especially  liable 
to  be  involved  in  disease  of  either  of  the  before-mentioned  cavities. 
Primary  lesions  are  rare. 


OntOULATORT  DI8TURBAN0E8. 

Hyperemia.— Hj-peremia  may  affect  the  external  epidermal  layer, 
the  mucous  surface,  or  both.  In  milder  grades  the  vessels  arc  seen 
to  be  large  and  distende.!,  while  in  the  severer  forms  the  memiirana  is 
diffu.  ely  reddened. 

Hemoirhage.— Hemorrhage  into  the  membrana  occurs  on  tiilier 
surface  and  takes  the  form  of  punctiform  or  linear  ecchymoses.  Tiiose 
on  the  cuticular  surface  tend  to  spread  upward  and  posteriorly  Knvanl 
the  periphery.  They  result  frequently  from  traumatism.  In  ty|.hoi(i, 
variola,  endocarditis,  and  scurvy,  bluish-red,  sharply-defined  cl(  vations 
may  be  found  on  the  mucous  covering. 


imrLAMMATIOHS. 

Myringitifl.— Inflammation  of  the  tympanic  membrane  (myringitis'i 
is  acute  or  chronic.    The  membrane  is  rarely  involved  alone,  liit  may 


MYRINOITIS 


663 


l)e  inflamed  from  injury,  or  by  extension  from  the  middle  ear.  Sea- 
bathii^,  foreign  belies,  and  careless  instrumentation  may  produce  it 

In  the  acute  form  the  membrana  is  congested  and  swollen,  and  on  ex- 
amination the  handle  of  the  malleus  and  the  short  process  can  no  longer 
!«  seen.  Later,  the  superficial  epithelium  becomes  macerated  and  is 
cast  off.  Microscopically,  all  the  layers  are  swollen,  oedematous.  and 
mhltrated  with  round  cells.  The  mucous  membrane  is  especially  con- 
gested and  greatly  thick«-»d  from  the  exudation  of  inflammatory  prod- 
ucts. In  certain  cases  of  intense  inflammaf;on,  localized  collections 
of  pus  are  found  m  the  cutis,  giving  rise  tc  small,  yellowish  dots  and 
streaks  {inierlamellar  abaceaaea). 

In  chronic  myringitU  the  membrana  is  swollen  and  infiltrated  the 
vessels  much  congested  and  varicose,  whih-  the  surface  is  covered  with 
small  papillary  or  polypoid  granulations  (myringUia  viUoaa). 

TuberculoMS.— Myringitis  may  be  due  »lso  to  tuberculosis,  in  cases 
of  tubercu  osis  of  the  middle  ear.  Small,  miliary  foci  may  be  seen  or  a 
more  rapidly  caseating  and  destructive  ulceration. 

Syphflfa.— Com/y/offi<M  and  gummas  have  been  observed  on  the  drum- 
meinnrane.' 


BETROORE88IVE  METAMOBPH08K8. 

Atrophy.— A ;-upi,y  of  the  drum-membrane  may  result  from  severe 
aiK  loiig-conl...ue«l  pressure  upon  '.  This  mav  be  cau-.-d  by  foreign 
bo,lR-s  or  accumulations  of  uetritu*  in  the  external  au.laory  canal,  or 
l.y  the  pressure  of  the  external  air  in  cases  of  obstruction  of  the  Eustachian 
canal.  1  he  part  chiefly  affected  is  the  lamina  propria.  The  membrane 
btromes  thin,  more  or  less  transparent,  and  sinks  inward,  or  project, 
externally  like  a  bladder.  *^    •' 


PROGRESSIVE  BIETAM0RPH08ES. 

.Among  the  progressiNc  disturbances  mav  be  mentioned  the  polypoid 
outgrowths  that  sometimes  form  on  the  cuticular  or  mucous  surfaces. 
ih.....  are  largely  the  result  of  chronic  inflammation.  Localized  over- 
Rrmvths  of  the  epidermis  of  the  outer  surface  are  met  with  (comua 
cutanea),  or  small,  pearly  nodules  the  size  of  a  pin-head 

A  rare  and  interesting  growth  is  the  cholesteatoma,  which  is  found  on 
the  inner  surface  of  the  drum-membrane.  It  forms  a  tumor-like  ma.-v'^ 
co,„,,os«  of  more  or  less  concentrically  arranged  .scales  and  plates  sur- 
rouM, ,  ,1  by  a  thin,  va^ular  capsule.  WV.en  of  lai^e  size  such  growths 
m. .^  lead  to  atrophy  of  the  bony  n..is,  so  that  the  auditory  canal, 
l>n.  uuK-  cavity,  and  mastoid  celU  are  thn.wn  into  one  large  cavity 
ill.,  exact  nati      of  this  growth  is  still  in  dispute.    Virchow  consider«i 

•  Baratoux,  Bull,  et  mita.  de  la  Soc.  d'OtoI.,  2:2. 


664 


THE  EUSTACHIAN  TUBS 


it  to  be  a  true  heterologoas  tumor;  others  refer  it  to  a  developmental 
defect — branchiofjenic  clefts.  Leutert  believes  thai  t  is  a  retention-cvst, 
the  squamous  epithelium  of  the  meatus  or  tympanic  membrane  having 
passed  through  a  perforation  and  developed  into  an  encapsulated  mass. 
Hednew  believes  in  a  variable  etiology,  namely,  that  some  of  these  growths 
are  true  tumors,  while  others  are  epithelial  cysts,  retained  masses  of 
tissue,  or  hyperplastic  epidermis. 


TKAUMATIBM. 

Sapture. — Rupture  of  the  drum-membrane  may  arise  from  direct 
or  indirect  violence,  as,  for  instance,  from  the  introduction  of  pointed 
instruments,  condensation  of  the  air,  concussion  and  fracture  of  the  skull. 
In  the  cases  due  to  the  first-mentioned  cause,  the  perforation  is  usually 
in  the  superior  posterior  quadrant.  In  those  due  to  condensation  of 
the  air,  as  from  boxing  the  ears,  concussions,  explosions,  working  in 
caissons,  pulling  the  auricle,  fractures  of  the  skull,  sneezing  or  coughing, 
the  rupture  is  in  the  anterior  quadrant.  Some  few  cases  are  dependent 
on  the  weakening  of  the  membrane  from  pressure  atrophy.  Perhaps 
the  most  frequent  cause  is  necrotic  inflammation  of  thedrum-mt.  nlirane 
secondary  to  otitis  media.  Only  rarely  does  the  form  of  inflammation 
restricted  to  the  membrana  (interlam/Uar  abscess)  lead  to  perforation. 
The  membrana  becomes  eroded  and  infiltrated  and,  either  bv  direct 
extension  of  the  destructive  process,  or  from  the  pressure  of  contained 
fluid,  or  both,  finally  gives  way.  Any  part  of  t'le  structure  may  lie 
involved.  There  may  be  only  one  perforation  or  several,  varying  in 
size  from  one  extremely  minute  to  destruction  of  the  whole  strut  ture. 
In  the  milder  cases,  the  tear  may  heal  without  any  obvious  alteration  in 
the  part,  but  if  extensive  a  scar  is  formed.  The  lamina  propria  in  such 
cases  is  not  restored.  Large  scars  may  sink  inward  and  luiume 
attached  to  the  wall  of  the  labyrinth.  Occasionally,  calcihcatiiMi  of 
the  membrana  results,  and  rarely,  ossification. 


I 


The  Eustachian  Tube. 

Owing  to  the  close  relationship  existing  between  the  Eustacliiau  tulie, 
the  nasopharynx,  and  the  tympanic  cavity,  affections,  esptn  ially  the 
inflammatory  ones,  of  these  cavities  are  particularly  liable  to  involve 
the  tube  by  extension.  Primary  involvement  of  the  tul)e  must  U-  rare,  if 
indeed  it  occurs.  The  most  important  conditions  met  with  arf  various 
alterations  in  the  lumen,  such  as  kinking,  stenmis,  and  dihtatuin. 

One  of  the  common  causes  of  obstruction  is  the  presence  of  t! 
pharyngeal  or  Luschka's  tonsil.  The  presence  of  this  outgrow  t 
voung  child  may  prevent  the  proper  development  of  the  tube,  a ; 
individuals,  owing  to  its  close  proximity  to  the  nasopharyngt ;; 
of  the  tube,  may  grow  direc-tly  over  it.  In  many  cases,  from  y^ 
contact,  or  from  Uie  formation  of  inflammaKry  adhesions,  u'.' 


na50- 
\n  the 
in  all 
irihce 
iiged 
ikes 


HYPEREMIA 


66fi 


place,  leading  to  traction  upon  the  tubal  lip  and  more  or  less  kinking. 
In  advanced  cases,  the  obstruction  may  become  even  more  extreme, 
inasmuch  as  the  traction  is  gi-eatly  increased,  owing  to  the  fibroid  involu- 
ton  which  the  hypertrophied  tonsil  inevitably  undergoes.  Again,  any 
obstruction  in  the  nasal  cavities  which  limits  the  supply  of  air  to  the  naso- 
pharynx, will  tend  to  produce  a  partial  vacuum  in  that  cavity.  Chronic 
congestion  and  more  or  less  hyperplasia  of  the  mucous  membrane  in 
the  lower  portion  of  the  tube  is  thas  induced  and  brings  about  stenosis. 

\anou3  inflammatory  processes,  both  within  and  without  the  tube,  or 
the  presence  of  tumors,  may  lewl  to  obstruction.  Vegetations  and  polypi 
in  the  middle  ear  may  press  upon  and  occlude  the  upper  end  of  the  tube. 

\\'here  stoppage  is  complete,  the  air  in  the  middle  ear  Ls  gradually 
absorbed,  the  tympanic  membrane  is  sucked  in  and  thus  rendered  more 
tense,  so  that  deafness  results.  In  other  cases,  the  tube  is  so  large  that 
its  lumen  is  constantly  patent,  with  the  result  that  passage  of  air  into 
the  middle  ear  produc-es  autophony,  and  sudden  concussions  of  the 
air  may  lead  to  deafness  and  even  rupture  of  the  membrana  tympani. 
Atrophy  of  the  mucous  membrane  is  a  chief  cunse  of  this  state  of  affaire. 

Inflammation.— Catarrhal  and  purulent  inflammation  of  the  tube 
are  not  uncommon  as  a  result  of  nasopharyngeal  catarrh  and  otitis 
media  and  as  complications  of  certain  infectious  fevers,  prominent 
among  which  are  scarlatina,  measles,  diphtheria,  influenza,  and  typhoid. 
The  lining  membrane  of  the  tulje  becomes  h\peremic  and  swollen,  so 
that  the  lumen  is  more  or  less  completely  obstructed  and  there  may 
be  abundant  exudation. 

Syphilis,  varioU,  and  tabwrcaloaii  nay  also  produce  lesions  in  the  tube. 
Prolonged  inflammation  and  congestion  will,  in  time,  lead  to  hyper- 
plasia of  the  mucous  membrane  and  the  submucous  connective  tissue 
and  stenosLs.  ' 

Foreign  Bodies.— Foreign  bodies  in  the  tube  mav  also  cause  obstruc- 
tion. The  condition  is  rare.  A  bougie  may  break  off  in  the  course  of 
lastrumentation.  Pias,  wire,  and  particles  of  food  have  also  been  known 
tu  enter  the  tube. 

The  Middle  Ear. 

The  t\Tnpanic  cavity  is  so  closely  connected  by  contiguity  and  the 
ana^omosis  of  blood  and  lymph-ves.sels  that  it  is  particularly  liable  to 
be  involved  in  any  disease  processes  affecting  the  neighboring  parts, 
snth  as  the  external  auditory  meatus,  the  nasopharvnx,  labyrinth,  and 
craniiil  cavity. 


OIROULATORT  DISTURBAKOES. 

Hyperemia.— Active  hnMremia  of  the  mucosa  is  met  with  in  the  early 
stu;;.    ,f  inflammation. 

Pa.=3ive  hyptramia  may  be  found  in  general  systemic  congestion,  such 
as  t    y  occur  in  the  course  of  cardiac  and  pulmonary  disease,  or  as  a 


600 


THE  MIDDLE  EAR 


local  effect  of  pressure,  for  example,  in  the  case  of  tumors  about  the 
head  and  neck. 

Btmorrhafes.— Ilemorrha|(es,  either  petechial  in  character  or  u 
free  effusion  of  blood,  may  (xrur  spontane«>usly,  or  as  a  result  of  eoiiciis- 
sion  or  fracture  of  the  skull.  They  may  aUo  ite  caused  by  the  sev»nr 
forms  of  otitis  nuHlia  arising  in  the  course  of  diphtheria,  Hright's  dis<>tis<', 
or  leukemia, and  by  eml>olisra  of  the stylomastoiil  artery.  Hemorrhups, 
so  extreme  that  the  blood  escapes  externally  through  the  meatus  or  Kiis- 
tochian  tul»e,  are  met  with  in  severe  traumatism  to  the  temporal  Umv, 
the  spontaneous  separation  of  polyps  and  in  carious  processes  which 
cause  erosion  of  important  vessels,  such  as  the  carotid,  the  jugular  vein, 
the  transverse  and  superior  petrosal  sinuses. 


nrTLAiiiiATioira. 


Otitis  M0diA.~C)titLs  media  u  of  fairly  frequent  occurrence  niul 
arises  fnmi  a  great  variety  of  causes.  It  may  be  divided  into  sim])le 
catarrhal  (non-suppurative),  suppurative,  and  specific,  or,  acconliiig  to 
its  course,  into  acuie  and  chronic. 

Among  the  primary  causes  may  l)e  mentioned,  trauma,  climatic 
changes,  various  forms  of  inflammation,  and  circulatory  disturb,iiices. 
Perhaps  in  the  majority  of  ca.ses  microorganisms  are  at  work  as  well. 
The  chief  traumatic  causes  are  direct  or  indirect  injuries  to  the  ilriim- 
head,  as  from  careless  instrumentation,  forcible  syringing,  concussion 
and  condensation  of  the  air,  local  irritants,  contusions,  and  fraotiins  «>f 
the  skull.  Expasure  to  wet  and  cold,  sea-bathing,  the  aspiration  of 
water,  medicinal  solutions,  or  infected  secretions  through  the  Eastac  liian 
tube  should  also  be  mentioned.  External  otitis  of  all  forms,  inipat  tmi 
wax,  and  foreign  Ixxlies  may  cause  an  inflammation  that  may  extend  to 
the  middle  cir.  Infective  secretions  from  the  accessory  cavities  of  tl.e 
nose  and  n^'sopharynx  may  reach  the  cavity  through  the  Eustadiiaii 
tube.  The  pus  from  a  retropharyngeal  abscess  has  l)een  kiio\Mi  to 
burrow  its  way  along  the  sheath  of  the  tensor  tympani  aral  info  t  tlie 
cavity.  In  children  perhaps  the  most  frequent  predisposing  cause  i«  ilie 
presence  of  adenoids.  >Iany  cases  also  are  dependent  on  certain  of 
the  infective  fevers,  such  as  scarlatina,  measles,  variola,  iiitluriiai. 
whooping-cough,  and  cerebrospinal  meningitis.  Gout,  sypliiii>.  imi 
tubcKulosis  are  also  of  importance.  Some  ca.ses,  finally,  apjxar  \'<  \<e 
due  to  obscure  circulatory  disturbances,  pn  bably  reflex  in  natur. 
the  vast  majority  of  instances  liacteria  are  present  from  the  lx>.'i; 
or  make  their  appearance  sooner  or  later.  No  particular  genu 
regarded  as  the  specific  caiLse  of  otitis  media,  but  nearly  all  tin  i 
pathogenic  bacteria  are  capable  of  exciting  it.  The  infection  ■ 
mixed  or,  again,  one  form  may  die  out  and  be  replaced  by  anoth' 

With  regard  to  the  frequency  of  the  various  forms  of  micnui  . 
Orne  Green's  analysis  of  101  cases  may  be  cited.    He  found : 


.     In 

I  ling. 
Ill  1* 

;  iiwn 

.>ms 


I   -■'f.^ 


ACUTE  SUPPURATIVE  OTITIS  MEDIA 

SUphytoeoeoui  (bU>uii,  H;  auraua,  0;  notiipeeifled,  10)      .      .  3A 

Streptocuccua .19 

I*neuroocucGiu  |0 

Bocillua  pyucyanoiw  3 

A  cipaulitteU  bacillur 3 

Hacillua  diplitheriu! 2 

Mixed  infection 28 


067 


In  many  cases  the  infet-tive  aKents  reach  the  middle  e»r  through  the 
Eustachian  tulie,  l)eing  introduced  into  it  by  the  acts  of  ci.jj^hing,  sneez- 
in>r,  or  gagging.  When  the  drum-head  is  perforated  the  organisms 
may  enter  from  the  external  audiforv  meatus.  In  the  case  of  the  infect- 
ious fevers,  even  in  diphtheritic  and  sc-ariatinal  angina,  the  invasion  is 
most  probably  through  the  blood  stream. 

Acute  OatairiMl  Otitii  Madia.— In  acute  ca'arrhal  otitis  media  the 
mmous  membrane  is  reddened  and  swollen,  while  the  submucous 
connective  tissue  is  infiltrated  with  inflammator)-  proilucts.  The 
cavity  is  more  or  less  fille<l  with  a  serous  or  more  viscid  mucinous 
sefTction,  containing  desquamated  epithelial  cells  with  a  few  mucous 
cells  and  leukocytes.  Examination  of  the  drum-membrane  in  the  early 
staj.'ps  will  show  congestion  and  beginning  infiltration  at  the  peripherv, 
espwiaily  the  upper  part  and  near  the  manubrium  mallei.  I^ter  on, 
small  blebs  containing  serum  or  hUnnl  niay  l>e  seen  in  the  epidermis 
near  ."shrapnell's  membrane.  In  other  cases  the  drum-men  '>rane, 
paniiularly  the  posterior  portion,  may  bulge  considerably,  and  even 
perfiiration  may  occur. 

Chronic  Oatanhal  Otitia  Madia.  — In  the  chronic  form,  the  mucous 
mfnil>rane  is  thickened,  firmer,  of  a  gravLsh-white  color,  and  presents 
here  and  there  nodular  and  villous  granulations.  The  thickening 
may  affect  the  mucous  membrane  as  a  whole,  or  may  \te  confined  to 
certain  localities,  as  the  drum-membrane,  the  ossicles,  the  orifice  of  the 
Eu>!af  hian  tube,  or  the  labyrinth  fenestrum. 

(lironic  catarrhal  otitis  media  fre(|uently  super\enes  upon  an  acute 
prix »— ,  or  may  be  chronic  from  the  start.  Most  of  the  causes  pro<lucing 
the  unite  form  are  competent  to  produce  the  chronic.  Some  cases  of 
the  rlh  nlc  disease,  however,  originate  independently  in  those  of  a  gouty 
or  rhciini.  tic  tendency  or  who  have  syphilis.  The  constant  jarring 
froiii  Ixiid  noises  may  also  produce  it.  In  such  cases  the  lesion  usually 
beji,!-^  in  the  neighborhood  of  the  tubal  orifice.  In  other  instanced 
the  :ir'f<  tion  begins  alwut  the  l»ase  plate  of  the  stapes  and  apparently 
(let)*  K  on  vasomotor  conditions.  In  some  it  is  said  to  be  hereditary. 
t>ei  u 'atiiip  diseases  play  a  part. 

Acute  SuppDiatiTe  Otitia  Madia. — Acute  suppurative  otitis  me<lia  occurs 
chit^n    ;:i  the  course  of  the  acute  infective  fevers,  as  scarlatina,  measles, 
'iiphtheria  and  t}-phoi<'.    It  is  not  always  easy  to  draw  a  hard  and 
l«etween  the  catarrhal  and  the  suppurative  forms.    Undoubtedly 
i-*s  of  the  latter  originate  in  simple  catarrhal  inflammation, 
luuc-osa  is  greatly  swollen  and  congested,  while  the  cavity  is 


fast '.; 
man. 


6A8 


TUB  MIDDLE  BAH 


filknl  with  a  pimil(*nt  or  iiuu-opuruk*tit  rxutlutinn,  lomrtiinra  niixtni 
with  liloml.  I1ie  tlruiii-nu'tiiliraiie  iMfDinrK  iiifiltrutnl,  .v)ft(>iH'«i,  aiid 
enxieti,  no  that  perfimition  is  (HMnnMHi.  It  is  not  tuiul  for  iimr''"! 
ulcrratiuii  of  the  mucoas  membrane  to  oecur  except  in  diaea.ie  of  the 
most  violent  .neptic  nature,  hut  in  .iiK*h  fnM>.t  the  oMirkn  ami  wall  of 
the  tyniimnic  ravity  may  liecome  necrosed  and  the  infection  extt'iul  tu 
the  cranial  cavity,  where  it  muy  lead  to  extmdiirai  absces-i,  nieniiipiU, 
and  thromlioMinUHiti.t.  Thw  Is  |iartictdarly  liable  to  ocur  in  childrt-n  in 
whom  the  petriMos<|uamoHal  suture  not  infrequently  remaias  patent  for 
a  long  time,  thus  exposing  the  dura,  which,  furthermore,  may  dip  down 
after  the  fashion  of  a  hernia  througli  the  fissure,  'l^e  inflanniiatort' 
exudate  tends  to  gravitate  to  the  Imttom  of  the  tympanum,  although  ca.'fM 
are  met  with  where,  owing  to  aHitnm  of  the  mucosa,  the  fluid  remains  |>ent 
up  in  the  attic.  Ilern-e,  it  may  dU.s«>ct  its  way  along  the  upper  wall  of 
the  meatus  and  make  its  appearance  externally  l>ehiiHl  the  ear.  In  such 
cases  the  mastoid  cells  are  almost  invariably  involved  as  well.     , 

Ohnmie  loppantiT*  Otltii  Madia.— Chronic  supp  tive  otitis  nuslia  a 
invariably  the  result  of  a  previous  attack  or  reneati  attacks  of  the  acute 
form.  Here,  the  thickness  of  the  lining  membrane  .s  greatly  incrcaM-d, 
owing  to  round-celletl  infiltration,  congestion  of  the  vessels,  with  liy|H>r- 
plasia  of  the  tissue,  chiefly  of  the  sul>epitlielial  layer,  and  new-furnialion 
of  bliwdvessels.  The  secretion  varies  in  amount  and  is  u  iially  foul- 
smelling,  mixed  with  blood,  and  of  u  dirty  brown  color.  When  the  y-  -^ 
tion  is  retained,  as  it  usiully  is,  for  this  Is  one  of  the  most  frequent  caiiiies 
of  an  acute  l)ecominp  a  chronic  pnx-ess,  it  l)ecomes  iasplssated,  and,  Ix^ing 
admixed  with  cast-oiT  epithelium,  forms  a  tough,  cheesy  mass,  possessing 
a  peculiar  laminated  structure,  known  as  cholesteatoma.  The  drum- 
head is  perfonitt'd,  more  or  less  destroyed  and  deformed,  and  what  re- 
mains of  it  niu^t  lie  gredtly  thickened  and  etudded  with  grantdutit)iis.  In 
certain  cases  the  epidermal  layer  of  the  drum-memi»rane  [K'nttnites 
through  the  perforation  and  tends  to  involve  the  cavity.  Wlurc  the 
ciliated  epithelium  has  l)een  exfoliateil,  the  expos«sl  surface  of  the  mem- 
brane is  dark  reil  and  octively  secretes  pus,  while  here  and  there  it  is 
dotteil  with  fungoid  or  villous-like  granulations.  These  may  pmliferate 
to  such  an  extent  that  opjwsite  masses  of  granulations  may  fii-e  and 
give  rise  to  cystic  cavities  or  loculi  lined  with  epithelium. 

Sooner  or  later,  the  destructive  inflammation,  which  has  leil  to  emsion 
and  even  ulccnition  of  the  mucosa,  extends  to  the  l)ony  part-  .\iii(h 
l)ecome  carious  and  n«'<Tosed.  The  incus  Is  usually  first  ottucked.  a^  it  is 
somewhat  imperfectly  supplie<l  with  blood.  Next,  the  malleus  is  i 1 1\ . ilved, 
and  later  that  portion  of  the  tympanic  ring  on  which  the  hem  I 
malleus  abuts,  as  well  as  the  inner  end  of  the  Eustachian  tulx'. 
the  wall  of  the  tympanic  cavity  is  affected  the  course  is  iLsiia' 
marked  at  the  tegmen.  The  wall  of  the  labyrinth  may  Ix'  i 
so  that  the  Fallopian  canal  and  the  cavity  of  the  labyrinth  av^ 
up,  leading  to  paralysis  of  the  facial  nerve  and  sometimes  int' 
the  cranial  cavity.  The  lower  part  of  the  tympanic  cavit^ 
anterior  wall  of  the  labyrinth  are  not  so  often  involved. 


..f  the 

Wlien 

'  most 

ivafied 

;TjT!eil 

•ion  of 
:nl  the 


CHRONIC  aCLEROSISa  OTITIS  MEDIA 


M9 


In  my  (wvere  fomw  of  inflammation,  surh  a.i  thnae  whioh  in  ohiblKn 
e-..ii.pli«iite  the  inrwtive  fwew,  exteniiivK  nrrnMis  and  .<tw|uestntion  of 
flu-  bone  may  lake  plat-e.  'Vhe  owirlcji  may,  owing  to  necitMM  ami 
IfMis^-ning  of  their  attathmenti,  lie  vhM  ufl  ami  appear  in  the  iluchar({e 
fn)tn  the  roeatiia.  'Vhe  foot-plate  of  the  stafiefi  iwiially,  however,  resi.iU 
the  proress.  From  the  adjoiriiiift  nernwinj?  infliinimation,  together  with 
the  presence  <>f  retained  secretions,  the  cavity  of  the  middle  ear  Incomes 
(•"fisiderably  enlarged.  In  course  of  time,  eiwing  to  the  stimulas  of  the 
inflammatory  process  on  the  periosteum  and  the  iwne-inarrow,  hyper- 
wtuwes  ami  exostoses  are  formed,  usually  on  the  promontory,  the 
fenestrum  rotuiMium,  or  the  eminentia  pyramidalis.  >Iuch  more  rarely, 
they  form  upon  •he  ossicles  and  orifiie  erf  the  Eas  ichian  tulie.  In  this 
way  the  cavity  may  in  the  end  t)ecome  notahly  diminished  in  size.  In 
.fline  ca.ses  the  ossicles  ainl  other  Ixjny  |>late»' Ijecfune  sclerosed  rather 
than  necrosed.  Invasion  ot  the  niHstoid  antrum  is  not  infre(|uent  in 
casfs  of  chronic  sujipurative  otitis  mwlia,  and  is  alwavs  of  serioas 
import,  as  it  may  lead  to  extensive  necrosis  of  the  tone  ami  infection  of 
the  cranial  cavity,  or  to  .septic  thmmlKwis  of  the  lateral  sinus.  If 
unreiievwl,  or  if  operative  measures  Ik;  undertaken  tiK>  late,  the  jugular 
vein  may  become  thromlnwed  for  a  ctjasiderable  distance  and  the  patient 
die  fri)tii  general  sepsis. 

Bfsi<ies  the  simple  and  suppurative  forms  ..f  chronic  otitis  just 
destriM  there  are  others  of  great  practical  import? :kc,  the  etiol»>gy  of 
whuii  is  not  quite  clear.     These  are  the  adhnive  ami  ncle.wiing  forms 

Chronic  AdhMiT*  Otitii  Madia.-In  chronic  adhesive  otitis  media 
there  is  a  slowly  progressive  inflammati.m  which  lea  '.s  to  thickening  and 
proliferation  of  the  miicoas  nieml>rane  lining  the  tympanic  cavity,  and 
the  formation  of  bamls,  membranes,  ami  other  ad'hesiorw  binding  the 
drum,  the  <«sicles,  and  the  tensor  temlon  together,  or  t<»  the  tvmpanic 
*hII.  or,  again,  traversing  the  cavity.  'I'he  adhesioas  are  composed  of 
iixiv-.  avascular  connective  ti.s.sue,  covereil  with  epitheliuii 

Chronic  Belaroting  OtitU  Media. -(  hronic  sclerosing  ot:.;^  media  is 
perhaps  ,,f  greater  iniix»rtance.  In  some  ca.ses  there  is  a  transformation 
of  tin  infiltrated  and  h\T)eremic  mucosa  into  dense,  scar-like  tissue.  In 
other  ( ases  it  is  the  deeper  or  periosteal  portion  of  the  mucasa  that  is 
St  ero>«l.  In  stil!  other  cases  there  may  be  a  granular  deposit  of  lime 
salt'  .11  the  submucous  ti.ssue  or  in  the  drum-memSraiie.  These  changes 
niuv  atftvt  the  whole  lining  membrai.c  of  the  cavitv,  or  certain  structures 
uiav  l„.  more  particularly  alTecte«l,  such  as  the 'drum-membrane,  the 
o^^l.  1,  ~,  the  promontory,  and  the  wimlow  of  the  labvrinth.  Naturally, 
whei.  these  lesions  become  pronounce<l,  ankvlosis,  more  cr  less  complete 
take,  place  between  the  assicles.  Most  fluently  the  attachment  of 
the  ';  p,.s  to  the  fenestrum  ovale  is  involved,  or,  more  rarelv,  the  articu- 
Setween  the  malleus  and  incus.  Ankylosis  of  the  stapes,  which  in 
iH-s  IS  congenital,  is  due  either  to 'caleifiuation  of  the  annular 
f  attaching  it  to  the  fenestrum  ovale,  or  to  cartilaginous  or  l>onv 
•th-\  The  ankylosis  leads  to  pressure  upon  the  endolymph  of 
,  rinth  and  serious  interference  with  the  circulation. 


lati'i 
soni. 
lipai: 
outi;: 

the!. 


P 


670 


THE  MIDDLE  EAR 


■fi 


Diphtheritic  Otitis  Media.— Diphtheritic  otitis  media  is  usually 
secondary  to  diphtheria  of  the  nasopharynx.  It  probably  arises  bv 
way  of  the  Eustachian  tube,  owing  to  the  aspiration  of  infective  materiai. 

Tuberculosis.— Tuberculosis  of  the  middle  ear  is  now  a  well-recog- 
nized affection.  It  is  probably  never  primary,  but  usually  occurs  late 
in  the  course  of  tulwrculosis  in  some  other  part  of  the  body.  It  is  thought 
by  some  that  infection  takes  place  through  the  Eustachian  tube,  altliotigh 
it  is  not  improbable  that  some  cases  are  hematogenous.  It  is  character- 
istic of  the  affection  that  it  is  insidious  in  its  onset  and  of  slow  progression, 
so  that  the  disease  may  exist  for  some  time  before  symptoms  arise  to 
draw  attention  to  it.  The  first  sign  is  a  discharge  from  the  meatus, 
and  in  a  short  space  of  time  the  membrane  is  completely  destroyed. 
Then  the  cavity  of  the  tympanum  is  found  to  be  lined  with  an  exuberant 
granulation  tissue,  secreting  acrid  pus,  a  contlition  which  may  persist 
for  months.  In  other  cases,  when  the  patient  lives  long  enough,  or  the 
disease  is  more  severe,  the  ossicles  are  loosened  from  their  attacliiiients 
and  cast  off  in  the  discharge,  while  large  portions  of  the  bony  wall 
become  carious,  or  even  large  sequestra  may  \ye  formed.  The  micro- 
scopic appearances  of  the  diseased  parts  do  not  differ  materially  from 
those  in  other  forp's  of  destrui  tive  inflammation,  save  that  in  tlie  (lcej»er 
layers  of  the  mucous  membrane,  giant  cells  and  patches  of  caseation 
with  bacilli  can  be  seen.  It  is,  however,  a  curious  circumstance  tiiat 
tubercle  bacilli  fretiuently  cannot  l)e  discovere<i  in  the  discharge.  How- 
ever, the  fact  that  there  are  advanced  tuberculous  lesions  in  other  jmrts 
of  the  body,  the  insidious  nature  of  the  otitis,  and  the  rapid  destruction 
of  the  tissues,  is  practically  conclusive  of  the  nature  of  the  disease.  In 
the  severe  forms  where  there  is  much  destruction  of  bone,  meningitis 
may  develop,  or,  rarely,  a  local  brain-abscess. 

Sjrphilis. — Syphilis  gives  ri.se  to  forms  of  acute  and  chronic  otitis 
clasely  resembling  tho.se  arising  from  non-specific  causes.  .Xciiralgia 
of  the  tympanic  cavity  is  also,  rarely,  observed.  Most  auth()ritic^  .ippear 
to  l)e  agreied  that  in  .syphilis  there  is  a  special  tendency  to  iin])hcation 
of  the  auditorv  ner\e. 


PROGRESSIVE  METAMORPHOSES. 

Tumors. — Hyperplastic  outgrowths  and  tumors  are  foiiinl  more 
frequently  in  the  middle  ear  than  in  other  parts  of  the  Miiditory 
apparatus.  They  may  arise  from  any  part  of  the  tymjtanii  (avity, 
but  generally  spring  from  the  wall  of  the  labyrinth,  the  attic,  or,  i.nasion- 
ally,  from  the  membrana.  The  majority  of  these  form  polypi  >iil  masses, 
either  pedunculated  or  sessile,  of  a  globular  or  nodular  shajH",  .mii'I  having 
a  smooth  or  papillary  surface.  They  may  attain  such  a  size  ii-  u\  com- 
pletely fill  the  tympanic  cavity  and  even  appear  externally,  liny  art 
of  importance,  since  they  tend  to  perpetuate  any  suppurativr  ])r(K'ess 
that  may  be  going  on  and  to  retain  the  secretion.  Occasionally,  ,i  urowih 
of  this  kind  may  be  separateil  from  its  base  and  give  rise  to  >c!!i>us  and 
even  fatal  hemorrhage. 


TUMORS 


671 


These  polyps  are  composed  of  a  central  core  of  varying  nature,  covered 
by  ciliated  epithelium,  stratified  columnar  or  squamous  cells.  Many 
of  them  are  of  the  nature  of  inflammatory  hyperplastic  new-formations, 
while  others  are  more  truly  tumors.  Among  the  various  forms  may 
be  mentioned  flbronuu,  angioflbromu,  maeous  and  adenonutoua  polypi, 
ugiomu,  and  myzomu,  which  are  rare. 

Mucous  polyps  are  soft,  vascular  growths,  usually  lobulated,  resemb- 
ling the  mucous  membrane  in  structure,  but  more  cellular  and  containing 
gland-tubules.  ** 

Angiomas  form  red,  slightly  vascular  growths,  which  may  pulsate  in 
accord  with  the  radial  pulse. 

Myxomas  are  supposed  to  be  derived  from  the  remains  of  the  mucoid 
substance  which  normally  fills  the  cavity  of  the  ear  in  the  foetal  state. 

OholestaatODu  has  already  been  referred  to  (p.  6()3). 

Sarcoma,  oiteosarcoma,  and  carcinoma  have  been  described,  but  are  rare 
Most  frequently  they  are  secondary  to  malignant  disease  elsewhere 
-Malignant  growths  from  the  brain  or  dura  may  invade  the  ear.  They 
may,  however,  be  primary,  and  when  this  is  the  case,  they  can  be  traced 
to  a  chronic  or  neglected  suppurative  process  in  the  tympanic  cavity, 
or  to  necrases  in  the  temporal  bone.  Large  portions  of  the  temporal 
hone  may  be  destroyctl.  Meningeal  and  brain  symptoms  may  result, 
or  hemorriiage.  In  advancetl  eases  there  mav  be  paralvsis  of  the  facial' 
abducens,  and  the  first  division  of  the  fifth  nme.  '  ' 


■;  I-  ' 


The  Internal  Ear. 
OIRCTTLATORT  DISTURBANCES. 

Anemia.— Anemia  of  the  inner  ear  mav  be  present  in  cases  of 
gineral  anemia,  and  in  all  conditions  which  lead  to  an  imperfect  supply 
of  l)l()od  to  the  parts,  such  as  endarteritis  or  embolism  of  the  arteria  audi- 
tiva  interna,  tumors  pressing  on  it,  or  aneurisms  of  the  basilar  artery. 

Hyperemia.— Active  hyperemia  is  found  in  cases  of  early  inflamma- 
tion of  the  parts  and  inflammation  of  the  associated  cavities'. 

Passive  hyperemia  arises  from  generalized  blood  stasis  in  the  head,  as 
from  heart  and  lung  diseases,  or  struma.  Local  causes,  such  as  tumor 
of  the  base  of  the  brain  or  skull  and  sinus  thromlwsis,  may  also  lead  to 
thr  condition,  owing  to  interference  with  the  free  outflow  of  blood. 

Hemorrhages.— Hemorriiages,  either  punctiform  or  extensive,  readily 
fo  low  upon  hyperemia  and  inflammation.  Large  doses  of  quinine  and 
siilirvlic  acid  lead  to  hyperemia  and  hemorrhages  in  experimental  animals 
(<-iiiiiert;  Kirchner'). 

1 1  use  minute  hemorrhages  may  he  confined  to  certain  parts  of  the 
c<K  iil.a  or  vestibule,  or  may  be  more  extensive.  They  are  seen  particu- 
lar,  III  severe  otitis  media  and  many  of  the  infective  fevers,  such  as  typhoid, 

'  Hcrlin.  klin.  Woch.,  1881:  49;  725;  u.  Monatssch.  f.  Ohrenheilk.,  1883:  5. 


672 


THE  INTERNAL  EAR 


:IV 


variola,  septicemia,  acute  tuberculosis,  and  mumps.  They  may  also  l)e 
caused  by  intracranial  aflfections,  such  as  meningitis  and  hemorrhufjic 
pachymeningitis,  and  occur  in  severe  blood  dyscrasias,  such  as  per- 
nicious anemia  and  leukemia.  The  more  copious  extravasations  are 
due  to  trauma,  as,  for  example,  concussion  and  fractures  of  the  skull. 
Such  extravasations  may  become  completely  absorbed  in  time,  or 
become  organized  or  infiltrated  with  lime  salts.  The  resulting  struifiire 
is  usually  colore»l  by  altered  blood  pigments.  Even  moderate  hemor- 
rhages may  lead  to  deafness,  notwithstanding  that  in  time  they  become 
more  or  less  absorbed.  This  is  due  to  the  fact  that  inflammation 
frequently  supervenes,  leading  to  atrophy  and  degeneration  of  the  con- 
nective tissue  and  nerve  filaments.  If  infection  occur,  suppurative 
inflammation  may  set  in  and  be  communicated  to  the  cranial  cavity. 

Inflammation. — Inflai""aation  of  the  labyrinth  is  rarely  primary, 
being  much  more  commonly  derived  by  extension  from  tlic  middle  ear 
or  the  cranial  cavity.  From  the  middle  ear  the  infective  agents  invade 
the  parts  by  means  of  the  blopdvessels  in  the  wall  of  the  labyrinth, 
through  fistulous  op.uings,  or  through  the  fenestrum.  In  the  earlier 
stages  we  see  congestion  and  oedema  of  the  labyrinth  with  round-celled 
infiltration.  Later  on,  in  the  more  severe  infections,  the  cavity  i>  lille<l 
with  pus  and  the  membranous  structures  are  destroyed.  In  time  tlie  jtus 
may  become  inspissated  and  the  process  be  limited  through  the  fornui- 
tion  of  adhesions  in  the  porus  acusticus  internus;  or  the  pus  may 
burrow  its  way  along  the  sheath  of  the  acoustic  nerve  to  the  brain 
cavity. 

In  cases  originating  in  the  cranial  cavity  the  inflammatory  {inness 
extends  along  the  sheath  of  the  auditory  nerve,  or  through  the  a(|Ue(liKt 
of  the  cochlea,  or  boti..  Epidemic  cerebrospinal  meningitis  plays  an 
important  nile  in  this  form. 

Here,  in  the  earlier  stages  there  is  hyperemia  and  hemorrhage  into  the 
labyrinth  with  more  or  less  necrasis  of  the  membranous  striu  tiirei. 
I^ater  on,  the  softer  parts  are  completely  destroyed;  the  jHTiostriini 
is  stripped  from  the  unflerlying  bone,  and  the  cavity  is  filltnl  with  \>\\> 
and  granulation  tissue.  Should  the  patient  sur\'ive,  this,  in  time.  l>e- 
comes  organized  into  connective  tissue  or  even,  in  parts,  into  \<i>w. 
The  intensity  of  the  inflammatory  process  is  most  marked  in  the  vc-tiliule 
and  semicircular  canals  and  l)ecomes  less  extreme  towanl  the  cix  lilta. 
As  a  result  of  the  process  we  get  in  addition,  atrophy  and  degent  niiioii 
of  the  membranous  structures  and  of  the  nerve-fibers, cells,  ami  jriiiylia, 
while  the  cavity  is  filled  with  altered  pus,  detritus,  cholesterin,  .i'hI  \nfi- 
ment.    Thus,  the  whole  auditory  apparatus  may  become  disorpiiiztfl. 

The  productive  or  hyperplastic  type  of  labyrinthitis  is  ficin-ntly 
associated  with  syphilis. 

In  Meniere's  disease,  an  affection  in  which  there  is  deafn< 
severe  vertigo,  there  is  a  hemorrhagic  exudation  into  the  semi 
canals  and  vestibule,  hut  it  is  not  ijuite  clear  whether  here  wt 
do  with  simple  blood  extravasation  or  with  inflammation. 


and 

■iilar 
..;  to 


i^ 


TUMORS 


673 


Deaf-nratUm  is,  by  some,  attributed  to  an  internal  otitis  in  early  life 
originating  in  meningitis  which  has  extended  along  the  aqueduct' 
Others,  again,  associate  it  with  defects  of  the  auricle,  atresia  of  the 
meatas,  immobility  of  the  tympanic  fenestra,  and  acciuired  lesions  of 
the  acoustic  nerve. 

The  Acoiutic  Nerve. 

Atrophy.— Atrophy  of  the  nerve  is  frequently  the  result  of  pressure 
exerteti  upon  it.  as  by  internal  hydrocephalas,  tumors  of  the  brain  or  base 
of  the  skull,  fractures  of  the  petrous  Ixine,  or  hyperostosis  about  the 
poms  acusticas  internus.  It  may  also  be  caused  by  hemorrhage 
and  inflammation  (neiu-itis).  Cerebral  causes,  such  as  aijoplexy  and 
encephalitis,  involving  the  nucleus  of  the  nci  ve,  may  also  be  at  work 
According  to  Erb,  atrophy  occurs  also  in  tabes  dorsalis.  Atr.>phv  from 
mlnbition  of  function  (atrophy  of  inactivity)  seems  to  Ije  rather  rare 

Tumors.— Primary  tumors  of  the  acoustic  nerve  are  excessively  rare 
and  our  knowledge  of  them  is  strictly  limite.!.  According  to  Viithow' 
li'  .ever,  this  nerve  is  more  fretjuently  the  site  of  tumor  growth  than' 
aiiv  other  cranial  nen'e. 

Fibrom,  myxoma,  pummomt,  and  sarcoma  have  been  re<or(Jetl 

As  a  rule,  the  malignant  growths  originate  in  some  of  the  neighboring 
parts,  usually  the  bram  or  dura.  Pollitzer  reports  a  case  of  secondary 
CMcinoma  originating  in  the  mastoid  region.  Burkhardt-.Merian'  reiwrts 
a  fibrosarcoma  originating  in  the  inferior  petrosal  sinus,  and  Mrxls '  a 
spindle-celled  sarcoma  connected  with  the  cerek-llum  which  had  invaded 
the  acoustic  nerve. 


'  Arch.  f.  Ohrenheilk.,  12. 


'  Ibid.,  4. 


i:i 


SECTION  V. 
THE  DUCTLESS  GLANDS. 


CHAPTER    XXXI. 

THE  FUNCTIONS  OF  THE  U'{ TLKSS  GLANDS  AM>  THEIR 
WSTURBAXCES. 

THE  DUCTLESS  GLANDS. 

In  our  first  volume  we  have  di.sfu.s.sed,  to  some  extent,  the  .subject  of 
e  .„ ternal  secret. oas.  and  the  influence  e.xerted  by  iurea.se  or  .1  m  n 
.on  of  the  same  upon  the  organism.     It  is  not  n«.essarv.  therefore    o 
mn.'  forward  at  th..s  point  the  evidence  that  has  been  acrumu  a't« 
.  .-.onstratrng  the  existence  of  internal  .se<-retio:,s.     Su.h  sec-retL  s  7 
..V  be  re<.all«l,  are  affor.l«l  In^th  by  t^pical  glandular  organs  prc^ 
.■<  Iw,  h  ducts  such  as  the  liver  and  pancreas  (although  in  connecC 
uth  the  latter    here  are  tho.se  who  hol.l  that  the  specific  internal  sLT 
■on  ,s  denml  fn,m  cell-ma.s,ses  unprovi.led  with  ducts- ttS-uTsTf 
Lan,,.rha.«)  and  again  by  atyp.Val  ami  .luctlcss  glandular  orgal  v    1 

P'Ms  which,  having  no  .lucts,  must,  if  they  be  f.inctionallv  a'tive' 
absra.t  certain  substances  from  the  circulating  1,1,^x1  aiul  lynmn  ■  5' 
as  tiu.  result  of  their  metabolism,  must  discharge  the  -.k  u ctTof"  £ 
;;;v;-v  int.,  the  same.     The  organs  usually  classified  under   1  ^  h  a    n^ 

m  .,      ^    ^r".   ^^        °^^  pos.se.ssing  M      'r  or  cell-masses  „f  ,l,e 
«    .f.  glandular  type,  name  y.  coiiec-tio,  ||s  of  fair  si.e  and  rela! 

I  ab  ndant  cytoplasm,  of  a  cubical  .,  .lyhedral  form.  re.  a  Hi  r 
hp  ot  he  salivary  glands,  liver,  etc'.;  (2)  tia.se  po.ssessi„g  chromaffin 
elK  :„„!  other  elements  which  we  nt.w  regani  as  ,lenve<l  from  d.e 
;;--  system;  and  (.3)  those  compos«|  in  The  main  of  lymphoid  Z 

S,„l,  M  classification  is  unsatisfactory  l^^-ause  not  a  few  of  these 
n^Z^fjrT  "^uT  "^  "T  *'^""  """  "f  'hese  <.ateg',l^ 
sn^oni      i  1^>       r"i''  n'""*^'  '"^  *''"  ^""^  '>!>*••  '»'•-  '"eclulla  to  the 
n",       fi^     T"       '■'  ?"''■''*'  ^"'"""'"^  '''*''»*'"'^  '-'<'"Ki"K  to  both 
1    i  >    «»t<'K''"es  the  tliymus.  while  mainlv  form..!  of  the  third 

CO  t.  .  ,„  „.s  Ha..saJ's  corpuscles,  elements,  rudimentarv,  it  is  true     f 
"P'th.  U  ongm.     It  .s,  however,  difficult  to  suggest  any  other  dassifi^a 


676  THE  THYROID  AND  PARATHYRC     3 

tion.  or  perhaps  it  is  more  nt-curate  to  say  that  we  here  p«up  tonetlitr 

orf?ans  so  widely  different  histol«KiraIly  that   they  defy  <la.s.sifi<ati<)ii. 

save  as  a  group  passessing  the  one  common  feature  of  l)eing  ductless. 

At  mast.  Gaskell,  in  his  remarkable  ami  strikingly  suggestive  work  on 

the  Origin  of  the  Vertehmiea,^  traces  the  whole  group  of  these  ductless 

glands— pituitary,  tonsils,  thyroid,  thymus,  lymphatic  glands,  and  adrenals 

—to  a  common  origin,  as  one  and  all  mo.    'icd  representatives  of  what 

were  primarily  duct-bearing,   "coxal"   glands,   or  excretory  or>;aiis, 

situated  at  the  bases  of  the  segmental  appendages  of  the  protostracaii 

forms,  which,  he  holds,  gave  origin  to  the  vertebrates  as  well  as  to  the 

crustaceans  and  arachnids.    While  we  gladly  accept  the  results  of  his 

long-continued  studies,  as  throwing  light  upon  the  peculiar  structure  and 

components  of  the  pituitary  botly,  adrenals,  anil  thyroid,  we  confess  to 

a  difficulty  in  regarding  the  thymus  and  lymph-glands  in  general  as 

metamorphosed    "lepidic"    structures,    an<l    that    l)ecaase    lymphoid 

tissue  is  so  widely  ami  irregulariy  dLstributetl  throughout  the  organism 

that  it  seems  impossible  to  regard  it  as  the  representative  of  an  original 

chain  of  small,  paired  organs  situated  in  each  segment  of  the  ImhIv.    In 

fact,  the  tendency  nowadays  is  to  deny  to  the  spleen  and  lympli-follir  les 

the  right  to  he  termed  glands.    Their  cells  are  neither  of  the  uceepted 

"  glandular"  form,  nor  do  they  show  any  trace  of  the  characteristic  j;laiid- 

ular  arrangement  into  cluste'rs  of  the  lepidic  type.     Conformablv  with 

this  tendency,  we  have  treateti  them  apart  and  in  connection  with  the 

vascular  svstcm.    Yet  another  organ,  this  time  of  the  true  ductless  f;lan(l 

type,  namVlv,  the  corpus  luteum,  we  discuss  elsewhere;  it  is  botli  more 

rea.sonable  and  more  natural  to  deal  with  this  in  connection  with  the 

genital  sv>uin. 

Let  us,'  then,  as  briefly  as  possible,  sum  up  what  we  know  regarding'  the 
functions  of  the  remaining  "ductless  glands,"  and  of  the  effects  u|)on  tiie 
organism  of  disturbances  of  these  functions. 


THE  THTROID  AND  PAEATHTROIDS. 

Embryology.— We  have  here  full  evidence  that  the  thyroid  orii:inates 
as  a  median  and  two  lateral  (ducted)  depressions  from  the  liooi  .jf  die 
embryonic  mouth,  and  in  the  frerpient  persistence  of  a  processus  pyrauii- 
dalis  passing  upward  from  the  gland  toward  the  hyoid  bone,  and  die 
rarer  appearance  of  a  persistent  thyrolingual  canal  or  fistuhi  jeadnif; 
down  from  the  forumen  cecum  of  the  tongue,  as  again  of  llivimd  cysts 
in  the  substance  of  the  tongue  and  median  line  of  the  neck,  see  .,  imiants 
of  this  order  of  development. 

Function.— The  vesicles  are  lined  by  r.n  epithelium  of  <ul.i.  d  ^'laml- 
ular  type,  and  are  surrounded  by  an  abundant  network  botli  <'f  ••I"*"' 
capillaries  and  lynipli-ve.ssels.  The  cells  tlischargc  their  MvVyi^.n  mto 
the  vesicle,  amfthis  tends  there  to  become  inspissated  (colI'Md).    Hut 

'London,  Longnmiis,  (ircen  &  Co.,  1908:  418. 


THYROID  INCOMPETEUCE 


GTl 


apparently  there  is  also  external  ilLscharRe,  for  although  its  significance 
lure  IS  <lispute«l,  colloid  matter  has  been  detectwl  in  the  surrounding 
capillanes  and  lymphatics.    There  is  evidence  that  this  colloid  material 
contains  the  specific  secretion  of  the  gland.     From  the  organ,  Baumann 
and  others  have  isolateil  a  globulin  having  iodine  in  direct  combination 
(i(Klothyrin).    This  IkkIv  is  by  most  held  to  be  the  active  principle  of  the 
Sland.     It  is,  however,  to  l>e  noted  that  the  amount  of  iodine  present 
ill  the  organ  shows  wide  variations  and  that  the  activity  of  the  gland 
extract  has  not  been  clearly  prove<l  to  \ye  related  to  the  amount  of  ioiline 
pn-sent,  although  this  view  has  l)een  strongly  supporteil  bv  Oswald  and 
Held  Hunt.'    It  is  quite  likely  that  this  is  not  the  only  active  principle; 
in  treatment  iodothyrin  has  l)een  found  less  effective  than  the  «lrie«l  gland.' 
i'lie  simplest  hypothesis  to  aciount  for  this  peculiar  histological  arrange^ 
iiK-nt  IS  that  the  thyroid  cells  are  capable  of  a  reversible  action,  and  so 
noriiially  regulate  the  amount  of  active  principle  present  in  the  circulation ; 
tliat  when  the  active  principle  of  the  gland  or  its  precursors  are  present 
in  the  blood  in  excess,  these  are  taken  up  by  the  thvroid  cells  and  store<l 
in  the  vesicles  in  a  convertetl,  less  soluble  state;  when,  on  the  coiitrarv, 
these  have  become  used  up  in  the  blood,  and  there  is  defect,  now  the 
ceils  alisorb  the  active  principle  from  the  vesicles,  and  discharge  it  into 
the  hl(KKl.     On  the  one  hand,  we  may  find  the  contents  of  the  vesicles 
small  ill  amount  and  distinctly  fluid,  with  extensive  congestion  of  the 
oiyaii,  suggesting  that  the  spet-ific  secretion  is  Ijeing  discharged  into  the 
blood  rather  than  into  the  vesicles— as  in  ordinarv  exophthalmic  goitre, 
or  tlie  regenerative  hyperplasia  that  follows  removal  of  part  of  the  gland; 
on  (he  other,  as  in  colloid  goitre,  the  vesicles  mav  l)e  found  hiigelv 
(listciided.  with  dens*',  solid  colloid,  suggesting  that  the  cells  are  dis- 
charging into  the  vesicles  with  little  reverse  passage  into  the  blood.     It  is 
interesting  to  note  that  in  advanced  stages  of  this  condition  we  are 
apt  to  get  symptoms  of  myxcedema— of  absence  of  thvroid  se<Tetion 
( ?  through  compression  atrophy  of  the  vascular  epithelium'),  and  contrari- 
wise, when  by  operative  handling  of  such  an  enlarged  thvroid,  a  con- 
Cesiioii  of  the  gland  is  induced,  symptoms  of  exophthalmic  goitre  are 
apt  to  siiow  themselves.     It  is  eminently  probable  that,  as  indicated  bv 
l.m  kc,  the  activity  of  the  secretion  is  controlled  by  the  iier\-ous  svstem" 

Effects  of  Ablation  and  of  Atrophy.-These  are  well  known  and 
liave  ii (ready  l)een  discussed.  In  the  former  case  a  condition  of  carhrxlii 
xtn,nn,,nrn  may  supervene  (Heverdin.  K(K-her)  identical  in  character 
vvith  Hie  myxcedemu  which  Ord  lia<l  noted  as  assoc-iated  with  atn)phv 
J'f  the  ;;land  and  with  Vn\\\\  crdinoid  cachexia,  in\\\  noting  the  resein"- 
I'laiic  e  l...tweeii  the  symptoms  of  the  atrophv  of  the  thvroid  in  adult  life. 
and  liiose  of  cretimgm  in  the  young,  ass(K-iated  with  'congenital  lack  of 
niiKiin,,  of  the  gland.  We  shall  revert  to  the  effects  of  ablation  when 
"^cn^Miij,'  the  function  of  the  parathyroids. 

Thyroid  Incompetence.  r«//j/«(//<(/  a(r„ph,f  of  the  gland,  or  other 
tiiMM..    Msstxiatetl  with  arrest  of  function,  shows  itself,  as  in  cretins, 

'  Hulletin  47,  Hygienic  I.iil)orati>ry,  WiisliiiiRton,  MIOS. 


:   ■• 


1^ 


<l 


Jl 


678 


TIIK  TIIYROin  A\'n  P.\H\TnYHOIt>S 


more  especially  by  «lelaye<l  growth  of  the  Injnes  and  tissues  in  Keiurul. 
by  non-development  of  the  genitalia  at  pul)erty,  sterility  in  adult  life,  ami 
by  arrested  mental  development.  O-curring  in  later  life  the  iiicom- 
jH'tence  is  acTompanied  by  depresstnl  metabolism,  heat  pnxluetion,  and 
((aseous  inten-haiit^-,  slowed  mentality,  and  listlessness.  The  hair  tciids 
to  drop  out,  the  skin  is  thickened  as  thou(;h  infiltrated  by  a  firm  utlcitia. 
IflMti  of  Admlniitration  of  Ihyroid  Iztract. — Metal>olism  is  marknllv 
accelerated  by  nivinp  raw  thyn)id  of  the  domestic  animals  by  the  niDUlli. 
or  administerinjr  extract  of  the  gland.  The  heart  rate  is  increased,  llicrc 
is  a  tendem-y  to  ner\()us  excitement  with  muscular  tremcirs.  Tin-  fats 
of  the  organism  In-comc  use«l  up,  anil  eventually  there  is  evidciKc  of 
increaseil  bn-aking  down  of  the  proteins.'  This  Is  in  striking  coiiirast 
to  the  loweretl  mctalwilism  and  nervous  depression  of  the  myx(Jwleniatoiis 
state.  That  this  lowcre<l  metalM>lism  is  d\ie  to  the  lack  of  thyn)i(i  dis- 
charge  is  demonstrated  by  the  disappearance  of  the  myxtiMlematoiis  and 
(•retinoid  conditions  when  thyroid  extract  is  administered. 

The  Parathyroids. — The  (piestion  of  greatest  present  interest  in  this 

connwtion  is  the  relationship  of  the  parathyroids  to  the  thynml  and  to 

morbid  states  of  the  organism.     And  here  there  is  wide  diversity  of 

opinion.     There  is.  on  the  one  hand,  evidence  that  in  a  certain  luinilHT 

of  casis,  lM)th  in  man  and  in  the  animals  of  the  lalx^atory,  if  the  tliyroid 

Ih'  removed  and  the  parathyroids  be  left,  few  ill  results  enstie,  wlnn-as 

if  iMitli   thyroid  and   parathyroids   In*   removetl,  symptoms   of  tttanv 

are  liable  to  supervene,  citiier  rapidly  or  within  a  few  days,  willi  fatal 

result.    Tiiis  tetany  may  l>e  indiiceil  if  the  parathyroids  alone  l>e  niniivc<l. 

There  is,  thus,  a  tendency  to  regard  the  parathyroids  as  all  iin|Miriaiit, 

the  thyroid  as  of  subsidiary  importance — at  least  in  regard  to  tlic  |)r('- 

veiitioii  of  tetany  and  rapidly  fatal  effects.     But,  on  the  other  liaiid.  it 

is  to  be  noted  that  not  all  of  Ueverdin  and  Kcx-her's  cases,  in  wlii(  li  they 

cxtirpate<l   the  whole  of  the  thyroids  and   the  attacheil  parathyroids, 

were  followed  by  tetany  and  dcatii  within  a  short  pericMl.    ( )ur  coihafiiic, 

Dr.  .Sheplienl,  who  has  a  large  experience  in  the  operative  trtatininl 

of  various  forms  of  goitre,  assures  us  that  he  has  repeatedly  icniovi-d 

tiie  whole  organ  without  leaving  the  parathyroids,  and  never  once  has 

he  seen  tetany  supcr\ene.     It  has  been  urge<l  that  in  sudi  cases  acrts- 

sory  detacliHl  parathyroids  have  been  present  and  have  l>ecii  left  liiliind. 

Now,  it  is  true,  as  we  have  observed  from  the  studies  of  Dr.  I'lKuhnaii 

in  our  laboratory  at  the  Royal  Victoria  Hospital,  that  tiieic  i    a  \*V 

wide  variation  both  in  the  iiuml)er  of  parathyroids  in  normal  i.  Iition- 

shij)  to  the  larger  gland,  and  in  these  accessory  jmrathyroiils.    >\valf 

\  iiicent,^  who  reconls  a  remarkable  lack  of  after  effwts  from  i>  nioval 

of   the   thyroids  ami   parathyroids  in  monkeys  (contrary  to   Knrsley, 

Murray  and  Kdnninds,  he  never  obtained  myxdnlema  in  tlu-sc  ;miiiialsi, 

states, "  however,   that   he   made  a   more  careful   search   for    i  '  rssory 

paratiiyroitis  in  his  animals,  and  never  cnconntere<l  thtui.       •     :i:'^''' 


'  Scliorn.lortT,   I'fliiftcr's  Arch.,   <)7:   1S97:  Xi'i. 
'  Science  I'rogress,  3:  January,  1!)09. 


EMBRYOWnWAL  COXSinHRATIOXS 


079 


ill  short,  with  the  pnrathyruids,  miwli  tht-  suine  prohlein  that  confrorjt.s 
ii-i  ill  connection  witli  the  Islumis  of  l4in)(erhan.s  in  the  [mncreus.  Hoth 
Imve  iin  einbryoiiic,  imperfec-tly  ilevelo|)etl,  or  latent  apiwurance.  With 
Ixilh  there  is  evi<lence  |N)intin}r  to  tiie  assumption  under  certain  coiulitions 
of  an  a»lult-«levelope(l  state.  The  luiinan  parathyroids  frefpiently,  in 
nliice  of  the  groups  of  cells  (resembling  those  s<'attere»l  throu(;h  the 
uiliiit  thyroid  lietween  the  vesicles)  that  are  the  comintm  features  of  the 
litnlies.  exhibit  well-formed  vesicles  filled  with  colloid;  and  in  animals 
fntin  which  the  thyroid  has  iieen  removed,  the  parathyroids  assume 
tliyniid  characteristics.  This,  however,  is  <leni»'<l  by  the  upholders 
of  tlie  specificity  of  function  of  these  iMxlies,  who  also  rejjard  the  colloid 
vesicles  encountered  in  certain  apparently  normal  parathyroids  as  dis- 
tiii>;iiislie<l  from  those  of  the  thyroid  pro|>er.  Save  for  the  small  size  of 
tlu  fonner,  we  personally  have  lieen  uiiai>le  to  recognize  any  histological 
•iifrcrence  lietween  the  two.' 

Without  denying  specific  function  to  the  parathyroids,  we  are  iiu  lined 
to  (lemaiid  clearer  and  more  certain  evi<lence  liefore  accepting  that 
tlu'v  are  absolutely  distinctive  organs.  Amid  the  many  coiitradictorv 
oliscrvations,  we  are,  however,  impresse<l  by  the  fact  that  these  bodies 
arist'  from  an  aiiluge  (the  epithelium  of  the  thini  and  fourth  branchial 
clifis)  closely  allied  to,  but  nevertheless  distinct  from  the  lateral  thyroid 
iwliKjrii,  as,  again,  that  the  symptoms  of  tetany,  as  shown  by  MacCailum, 
can  lie  ameliorated  by  injecting  emulsions  of  the  parathyroids. 

Tlic  most  n-cent  work,  it  may  be  remarked,  in  conclusion,  stronglv 
points  to  the  im|M>rtancc  of  the  parathyroids  in  regulating  calciuiii 
iiu'titbolism. 


!i 

If 


THE  ADRENALS. 

Embryological  Considerations.— The  embryogeny  of  the  adrenals 
is  nut  a  little  remarkable;  the  cortex  and  the  iiiediilla  have  wiiollv  dif- 
ftnnt  orij'ins;  and,  in  fact,  in  certain  lower  vertebrates  (elasiiiob'rancli 
tisli.,1  constitute  distinct  organs.  This  suggests  diversity  of  functions, 
even  if  the  eventual  fusion  suggests  also  that  the  two  "are  intimately 
(itlH  iideiit  the  one  on  the  other.  The  cortex  in  different  animals  is", 
111  lai  t,  (leriv«Hl  from  the  mesonephric  or  pronephric  excretory  organs; 
llif  imdiiilii  has  a  separate  origin  from  the  sympathetic  nervous  svsteiii. 
Wliilf  the  cortex  is  formed  of  columns  of  cells  of  glandular  fy|M'  in  iiiti- 
matf  assiKiatioii  with  a  system  of  capillaries— so  intimate  that  in  places, 
a(<ni,lii,(,r  to  some  authorities,  the  cells  actually  abut  upon  the  IiKmhI 
strriiiii  with  no  intervening  endothelium  -the  medulla  is  characterized  by 
an  iiliMiice  of  gland-cells  proper  and  presence  of  certain  remarkable 
ehromajUn  cells.  Such  chromaffin  cells  are  widely  distributed  through- 
out (lie  IxHly.  They  owe  their  name  to  their  affinity  for  neutral  salts  of 
flirr..|;i(   uiul,  a.s.suming  with  these  a  stniiig  yellow"  or  brownish  color. 

'  \m  ..liniralilo  presentation  of  the  case  for  the  (iistinotion  between  tlie  two  organs 
IS  zr  ,  ,  l.y  Ddoli  i„  Osier's  Modern  .Medicine,  .l:  1!M)<»:  ;{.S2. 


680 


THE  ADRESALS 


'Iliey  nre  «leriv«l  frrnn  the  nervoai  system,  and  from  one  ponion  of  this, 
the  symniithetk-  .system.  'I'hev  are  to  U>  found  in  the  sympathetic  anug- 
lia,  in  tne  pituitary,  the  carotid  glands,  and  the  organ  of  Zuckerkuridl, 
iiituuteil  at  the  origin  of  the  superior  me.senteric  artery,  ami,  acfonji-  • 
to  .some  authorities,  in  the  rot-cygeal  gland,  but  are  present  in  gn-  ot 
ahundaiuf  in  tiie  adrenal  medulla.' 

Tunction.  —  Th«  Madnlla. — ITie  oljservatioas  of  recent  years  have 
demonstrated  that,  judge«l  from  the  effects  of  their  extract,  these  (rlls, 
wherever  present,  have  the  .same  properties.  That  extract  has  a  iH)\vc.fiil 
action  up4iii  the  arteries  an<l  arterioles,  leading  to  ctmtraction  of  the  sunie, 
and  temp<»rary  pronounce<l  rise  of  the  blood  pressure.  'ITicse  pn>|MTtifs, 
us  first  noted  by  C)liver  and  Schttfer,  are  particularly  marked  in  coimcc- 
tion  with  extracts  of  the  adreiul  medulla.  The  active  principle  hiiviii); 
these  effect^  ha.s  lH>en  isolated  in  a  crystalline  form  by  Tukuiniiie  iitid 
Aldrich  inde|)endently,  and  by  Aliel.  It  Ls  generally  known  as  adrenalin, 
the  name  given  to  it  by  Takamine,  but  as  his  substaiK-e  has  liecoine 
proprietary,  Scliiifer  proposes  adrenin  as  a  more  ethical  name.  It  lias 
an  action  u}M)n  skeletal  and  cardiac  mu.scle  as  well  as  upon  the  plain 
muscles  of  arteries.  Limgley'  has  enunciated  the  view  that  in  all  itlls 
a  cliicf  sub.stance  is  present,  to  which  is  owing  the  chief  function  of  the 
cell,  and  a  more  uastable  intennediate  or  receptive  btxly,  which  sets 
the  chief  suhstatice  in  action  when  it.self  actc<l  upon  by  nervous  and 
other  stimuli.  The  action  of  adrenin  appears  to  l)e  identical  with  that 
of  the  sympathetic  nerves,  and  Ijaiigley  suggests  that  adrenin,  taken  up 
by  the  cells,  has  the  .same  effect  on  the  receptive  substance  as  havi-  siimiili 
reiiciiing  it  through  the  sympathetic  nerve  endings.  Stoltz  ami  oilurs 
have  prepared  a  synthetic  adrenin  having  the  .same  coniptisition  ami 
eff«H"ts  as  adrenin,  but  optically  inactive,  instead  of  l>eing  levoiot^itorv, 
and,  acrording  to  Cushing,  not  .so  powerful  as  the  natural  siili>t.  iwe. 
Adrenin  is  .soluble  in  water,  and  dialyzable,  uiiaffe<'te<l  by  lM>ilin<;,  Iml 
insoliil)le  in  alcohol,  and  non-acted  upon  by  the  giustric  juice  a  mi  hv 
acids. 

The  Cortex. — Very  little  definite  has  I)een  determined  M'ganlinj;  tiie 
functions  of  the  cortex,  though  there  have  l)een  not  a  few  theories. 
Uollcston'  brings  forwanl  .some  evidence  in  favor  of  a  relatiniisliip 
between  the  cortex  and  the  .sexual  powers.  The  abundance  of  jicithin 
and  IxKlies  of  the  nature  of  myelins  is  suggestive  in  coiiiie<ii.in  with 
re<ent  studies  upon  the  importance  of  the.se  bodies  in  rehitinn-liip  to 
the  I)I(kk1  serum  and  the  pnKluction  of  immunity. 

The  Relationship  between  Adrenal  Function  and  Disease.— 
Adrenal  Incompetency. — To  repeat  what  was  stated  in  our  first  Mijnnie, 

'  I'or  a  study  of  the  "('liromnflin  System,"  see  Ciierke,  Lubnrsch-OstcrlML'  -  \.rt\\<. 
(ler  allg.  Pathol.,  .luhrR.  10:  MMM  to  liKLi:  .'>()2;  ami  Wiesel,  Iiilernat.  Cliiiio.  -'  HflJ; 
2HS. 

'  .If.iir.  of  I'hysiol.,  ;«:  190r)  to  1<»0C:  374. 

'.Montreal  .Mc<l..Iovir..li»()7;orIjjncet, London, 2:1907:S".5;.seeal.'«>Sil  t.  K"r 
the  fullest  collection  of  data  hearing  uj)OU  adrenal  function,  see  .Sijoiis.  11;.  l.i'  ni.il 
S'cretions,  1 ;  l!t()2,  ami  2:  1S)07. 


KELA  TIOSSIIIP  BETWEEN  A  DKENA  L  FUNCTION  A  ND  DISEA  flE    OH  1 


«'xtea«ve  diseaw  i»f  the  ailrpnab,  or  etn)piiy  of  Ihe  .sainf,  in  acrom- 
(Miiiecl  hy  the  symptoim  nt  Ad<lw«in'.sclisea.ie— great  muiw-ular  weakiies.s, 
with  low  bIfNNl-prefMiire  ami  soft  pulse,  amirexiu,  with  f^stric  iliw-om- 
fort,  and  n(x>a.sii>nHl  voinitin);,  cerebral  diitturlwnces  of  a  mil<l  ty|»e,  and 
uUwe  all,  piKincntulion.  The  va-srular  symptoms  and  lark  of  iiiusrular 
tin>  the  very  opposite  of  the  result  of  injections  of  adrenin,  and 

thu  lie-  generally  accepte«l  view  Is  tliat  normally  the  adrenal  medulla 
atords  the  active  prim-iple  to  the  bloo«l  whereby  the  vascular  and 
iniiscular  tone  «)f  the  Uxly  is  maintainetl.  The  Frewh  .s"»iool,  under 
Alielous  and  I^anglois,  uphold  rather  a  the<)ry  of  auto-intoxication, 
firi<ling  the  l>loo<l  of  animuls  depnvetl  of  their  ca|Mules  to  jiossess  cunire- 
like  pn)perties,  they  regard  the  gland  as  removing  or  neutralizing  this 
siilwtance.  These  two  the«>ries  are  not,  it  may  lie  note<l,  al^iliitcly 
(i|)|Kxse<l;  it  is  quite  |>assible  that  adrenin  may  Ixit'h  neutralize  the  paretic 
uctiiin  of  such  a  substance,  and  itself  a<'t  directly  upon  the  muscle. 

What  has  until  nov,  Wii  u  difficulty  in  understonding  the  relalioaship 
Ix'tween  the  adrenals  and  Addison's  di.sea.se,  is  the  existence  of  a  certain 
simill  numlier  of  cases  in  whicif  either  one  or  Ixith  adrenals  and  their 
iiHtliillas  nre  ap|iarently  unaffected;  and  of  another  series  of  ca.ses  in 
wliiih  there  might  lie  complete  replacement  of  the  adrenals  by  new- 
ffnittth  with  no  signs  «if  Addison's  disease.  Many  years  ago  it  was 
sii^tgcstetl  by  Uolleston  and  others  that  in  these  <a.ses"  not  the  glands,  but 
the  nearby  .semilunar  ganglia  and  .solar  plexus,  wen'  involve<l.  \'ery 
nmiicmus  ner^■es  pa.ss  fnim  these  to  the  adrenals— and,  indeed,  Insides 
c  iiroinaffin  cells,  the  me<lulla  contains  ordinary  .sym|Nithetic  nene  cells, 
'riiiis  some  have  held  that  nervous  disturliances  might  lead  to  arrest  of 
ailrciial  function.  The  recent  .studies  upon  the  chromaffin  cells  have 
iiironieil  a  |Mi.ssible  explanation.  Here,  Wiesel's  ob.ser\ations  are  <if 
(listiiict  in)(>ortance.  In  seven  cases  of  the  disea.se  he  has  e.xamine<l, 
Tint  merely  the  adrenals,  but  the  whole  chromaffin  .system— adrenals, 
the  cliains  of  sympathetic  ganglia  and  plexases,  Zuckerkandl's  organ, 
tl( .,  and  he  has  found  a  general  alwence  of  chromaffin  cells,  altlougli 
ii<>w,  as  a  compeasatory  prcKcss,  the  .sympathetic  ganglion  cells  may 
CIV.  the  chromaffin  reaction.  If,  as  in  the  cases  of  cancer  aliove  nien- 
tiiiiicd,  the  adrenals  alone  are  destniyed,  the  chromaffin  cells  elsewhere 
iii:i\  k'  adequate  to  prevent  disea.se,  or  there  may  lie  extensive  destrnc- 
tinii  of  the  clmimaffin  cells  in  other  areas,  leading  to  symptoms  of  the 
•iiMiisc,  without  extensive  adrenal  disea.se.  .\s  a  matter  of  fact.  Heitzke 
liii-  r(|)()rte(i  a  ca.se  of  cancer  involving  the  adrenals,  without  Addison's 
tli-iasc,  in  which  he  found  the  chromaffin  cells  intact  eLsewlicre.  Fur- 
'hi  cDiifirmation  is  needed  of  these  most  suggestive  ob.ser\!itii)ns. 

lint  neither  Wiesel's  nor  other  studies  upon  ablation  of  the  medulla 
Ijiiv.  ilirown  lifrlit  upon  the  specific  pigmentation  .seen  in  .Addison's 
liiMiir.  In  th.  first  volume  (p.  893)  one  of  us  brought  together  the 
evi.l,  n.  e  that  cell-pigment  of  the  mUm-  of  melanin  i.s  a  prwluct  of  the 


''/■■■■I.  I.  Heilk.,  24:  liXI.J;   Pathol.  Anat.,  .M>t    No.  4;  ami  Interna!,  (linics,  2: 
l'«i'    1.0.  cit. 


(W2 


THK  ADRKSALI 


ili.iintcf^tiim  of  pmti'tns,  ami  i.H  an  oxidation  pnNltict  of  iNNlifx,  like 
(vriMiii,  of  the  unmuitic  .st'ric'*,  anil  Halle's  olM«*n-ution  that  in  the  luin'mil 
tynMin  Ih  t-onvrrtnl  into  oiirrnin  thniiif(ti  thi*  action  of  an  tMi/vinr. 
Now,  us  rxtnictH  of  ull  the  tif^sues  c-ontaininK  chnimaffin  ivIIh  have  like 
t>ff<t't.H  ii|Miii  till'  vi-smIh,  wt'  nuiy  assiiine  that  adrt'iiin  U  prt>Nt>nt  in  all, 
uikI  is  similarly  priMiucetl.  Tims,  if  ilalk*  Im*  rnrri'ct,  tni>  aKsi'iict-  nf 
clininuiffin  tissnt*  nui.st  tend  to  Ih>  a(rompani«Ml  hy  an  a«-«'inniilitlii>ii 
in  tln'  tissues  of  members  of  the  aromatic  series,  which,  nnder>.i>iii;,' 
oxidittion,  Itecome  pigmented  iNNlies  of  the  ruture  uf  melanin,  iiittcail 
of  undergoing  «-«Hiversion  into  adrenin.  Along  thes«'  lines  of  rlin)- 
niatiin  inude(|uacy,  with  heaping  up  of  nu-mlier!!  of  the  aromati<-  sirirs, 
the  pigmentation  gaias  a  plaasihie  explanation. 

'rhen-  is  still  confesseiily  much  to  Ik*  nc«'omplishe«l  liefore  wc  have 
a  thorough  understantling  of  the  Itearing  of  adrenal  changes  upon  (lit- 
whole  series  of  symptoms  of  Addison's  dis«'as«'.  Vet  the  last  few  vtarH 
ap|>ear  t«»  have  carrieil  us  forwanl;  the  theory  of  adrenal  or,  more  accii- 
ralely,  of  chromaffin  ••ell  inadetpiacy  would  seem  to  Ik*  estahlishiiig  ii>«lf, 

KxetuiTt  ▲dmal  Fnnction.-  We  said,  in  connectii>n  with  the  riivroiil, 
that  excessive  pnMlcction  and  <lischargi'  of  tfie  tliyroid  M-crelion  Icil  to 
a  very  definite  syn<lrome.  Is  a  like  condition  of  excessive  prcMliicticin 
of  the  adrenal  sii-retiim  to  Im"  detemiiiMtl?  We  of)served  tluir  iliat 
feeiling  or  injec-ting  thyroid  extract  lirought  alniut  a  series  of  syin[)tiiiiis 
(hyperthyroidism)  re.seml)ling  in  many  respects,  though  not  in  all.  the 
symptoms  of  (Jnives'  dis(>a.se  (vol.  i,  p.  ."12")).  Is  there  any  morliiil  >talt' 
resemhling  in  its  .symptonts  the  n>sults  of  admini.stering  adrenalin  i>r 
adrenin  to  man  or  the  lower  animals?  As  we  have  statwl,  tlic  most 
.striking  feature  of  such  administration  is  rise  of  hlood  pressuif  .\< 
a  matter  of  fact,  fiy|)erpiesis,  »)r  pronounced  and  continued  rise  of  MoihI 
pressure,  is  not  uncommon.  Is  there  atiy  'I  lur  .  'o  !«■  of).  tmmI  in  tin- 
adrenals  in  this  condition?  It  may  Im*  ol>jecte<l  liiut  the  adinini^iiation 
of  adrenin  leads  hut  to  a  transient  rise  of  hlcKxl  pressure;  l)Ut,  on  the 
other  hand,  we  mu.st  take  into  ac<'ount  that  a  difference  is  to  Ih-  <\()ii  ted 
lietwwn  the  effects  of  experimental  inoculation  froni  time  to  tiim  .  and 
the  steady  outjxmring  of  the  active  principle  fnim  an  ovenictivr  ulainl; 
further,  if  exjM'rinientally  we  give  repeate<l  dcwes,  each  is  folloudl  li.v 
its  ri.se;  there  is  no  accustomance.  It  is  in  connection  with  <  hronir 
Miterstitial  nephritis  that  we  most  fre<{uently  eiicoimtc  tills  rniiijiiioii 
hyperjjiesis,  and  here  Vacquez  and  Auliertin,  Aschoff  ..  "I  I'ljivc,' 
'  put  on  reconl  tlie  oh.servation  that  in  a  series  of  aut«)i»i<  -  upon 
riiLsclerosis,  more  particularly  when  accompanied  hy  clironii  intcr- 
.stitial  nephritis  and  hyjK'rtrophy  of  the  left  ventricle,  the  atln  ii:il-  are 
distinctly  larger  than  normal,  with  distinct  increase  in  the  si/i 
medulla.  Dr.  Klotz,  in  our  lalM>ratory,  has  called  our  attcn 
the  same  noticeable  hyjK'rtrophy.  Whether  this  is  primary  or 
ary  must,  for  the  present,  lie  left  an  open  rjucstion.  as  also  '' 
determined  whether  lM)tli  states  are  to  lie  encoimtereil ;  a  scric^   ; 


of  the 

oil  to 
idllll- 
i^    !10t 

wliich 


.lour,  of  Kxp.  Mel.,  10:  1(108:  735  (with  bihliograplivK 


KMBRYOLnt;ir.\L  COSSITiKHA TIOSS 


tlK.1 


iln>  liyptTtrofilu'  uimI  iiH-n>u.sn|  .wrplion  Is  (he  priiimry  liMtiirlmiKf; 
iiriothfr,  ill  wlik-li,  I'hlHT  thniUKh  the  nip-iM-y  of  the  tH>r>-ua>*  system,  or 
tlirongli  the  alM(>q>tioii  of  f<NNl.s,  etc.,  acting  liy  (heir  iliaiiiteKmtion 
|»;iMhi<in,  irKTea.ie<l  |>nNhK'tioii  ..f  lulrenin  is  hroiif^ht  ulniut.  The  rarity 
of  hi);h  I>IihmI  pressure  niwl  of  hy|>ertrophy  of  tlie  iiietiiilla  in  early  life  U 
oitiiieHhat  UKHiii'it  the  fonner.  It  has  .still  to  lie  iletennineil  whether  this 
<  iiliirp'inent  of  the  ^luiiil.s  is  purely  Mss(K-iate<l  with  the  arterioM-lerotic 
or  with  all  ty|H's  of  i-hmnie  interstitial  nephritis,  a.s  also  how  far  it  is 
rcittltsl  l<»  arterioscler«>ti<-  states  in  (reneral.  It  will  lie  reealle«l  that 
ii(lri-iiin  ill  itself  leails  to  arteriosclerotic  manifestations,  ainl  also  that  not 
all  discs  of  this  comiition  are  associatetl  with  \\\[i\\  McnmI  pressun*.  It 
will  thus  lie  seen  that  much  ha.s  still  to  lie  piriiereil  liefore  sure  coiH-lusions 
•  an  U'  laid  down.  We  have  thought  it  worth  while  to  im>ntion  these 
iiiiiiicrs  as  an  iiiilicution  that  the  .study  of  [MMsililc  conditions  of  excessive 
Hiln-iial  ac-tivity  is  not  lieiiif;  wholh    e);le<-t(sl. 

THB  PITUITAKT  BOOT  (HTVOPBTIII  OIUBRI). 

This,  like  the  adrenal,  is  fornifsl  of  a  combination  of  );landular  and 
nervous  elements,  tiic  former  approximating  in  tyjie  to  what  Ls  seen  in 
the  thyroid. 

Embryological  Oonsidentions.  The  infundihulum,  to  whose  a|Nx 
is  iiilH(li»sl  the  pituitary,  represents  the  old  channel  of  communication 
lift « ecu  the  neural  ifiial  and  the  mouth.  If  (ia-skell  lie  rij{ht— and 
it  is  dilKcult  to  controvert  the  extraordinary  voiutne  of  evidence  iic 
lias  l)roiij;lit  forwani  in  favor  of  his  contention— that  neural  canal  repre- 
MiiH  the  original  alimentary  cliaiinel  of  the  invertebrate  ancestors  of 
till-  vcrtebrata.  hike  the  thyroid,  embryolo};ical  studies  (Bela  Ilaller) 
sjiiiw  (hat  the  glandular  jKirtion  is  originally  of  a  tubular  ty|K';  (Jp'-kell 
holds  thill  these  tiiltnlcs  repn-sfiit  tli-  coxal  ;,'la!ids  .situated* at  the  Im.ses 
of  ihf  appendages  (eiidognalhs)  oripnally  present  around  the  orijjiiial 
nioiiih.  Ill  the  prinrss  of  r«liiction,  the  nervous  elements  of  the  old 
'  -ophiijreid  tiilie  and  the  surnMii'diii;;  ring  of  jfland-substarice  l)e<-ome 

liiiiatcly  intemii.xe<l.     In  the  cat  the  infundibular  pr(Kes.s  retaiiw  its 
1  iiiial  cavity  and  is  liiicsi  by  ependyma  cells.     The  central  canal  dis- 
a|)|M'ars  in  other  higher  vertebrates. 

i'liiis,  in  the  fully  devehijHHl  pituitary  we  re<oj;nize  three  aretis:  (1) 
.\ii  anterior,  glandular,  containing  granular  <ells  in  .solid  columns,  with 
nlaiiycly  large  intervening  bliKxl  capillaries;  (2)  a  "pars  intermedia" 
loniaiiijng  dear  cells,  intermingletl  with  neuroglia  fibrils.  The.se  ceils 
ar.  i.f  epithelial  fvjie,  and  discharge  a  colloid  mati  rid,  vV.ich,  as  shown 
l>.v  Srhiifer  and  Herring,  passed  into  the  lymph  spaces  i m  channels,  and 
tliei '  !•  backward  into  the  cavity  of  the  infundil)iduni,  and  so  into  the 
(en  l,i(„[)iiiul  fluid;  ('A)  the  posterior  nervous  po-  '  !i  is  made  up  of 
n^ii  M-!ia  cpIIs  and  ribtr.s,  without  true  iierve-<elts,  though  there  are 
indi.  .lions  that  .sympathetic  fillers  pass  in  along  the  bl<x)dve.s.sels.  There 
Ilia  lie  fKcasional  islets  of  epithelial  cells  which  have  gniwn  back  into 
tlii-  I. "'ion. 


Ill' I 


I! 


-.  / 


C84 


THE  PITUITARY  BODY 


Functions. — No  effects  have  h°en  noted  as  following  injet-tioiis  of 
extracts  of  the  anterior  glamhilar  portion,  hut  the  intermediary  and 
nervous  portions  have  i)een  disc«)Vf  red  to  contain  a  Inxly  reseinljlinj;  In 
action  adrenin.  There  are  indications,  indeed,  of  the  presence  of  more 
than  one  active  principle.  Tiius,  Scliiifer  and  Herring'  found  that  a(|iif- 
ous  extracts  had  oppcxsite  effects  upon  the  hlcxKlvessels.  In  the  first 
injections,  tlie  pressor  or  vasoconstrictor  effects  predominate;  in  .sul)sf- 
(jueiit  injections,  the  depressor  effet-ts  l)ecome  manifest.'  So,  also,  tlic 
.same  olxservers  have  tliscovered  that  from  the  posterior  jKjrtion  a  siili- 
stance  can  l)e  obtained,  .soluble  in  water,  and  uninfluence<l  l»y  hoiliii);, 
having  a  .specific  effect  upon  the  kidney,  e.xerci.sing,  indeed,  a  diiirHlc 
effect  more  powerful  than  that  of  any  known  substance. 

Relationship  of  Morbid  Disturbance  to  Disease.— It  is,  however, 
difficult  to  a.ssociate  the.se  experimental  results  with  the  data  of  discasf; 
in  fact,  we  are  but  at  the  l>eginning  of  a  knowledge  of  the  function  of  the 
organ.  One  outstanding  fact  there  is,  that  the  remarkable  condition 
of  acromegaly  is  intimately  tLss(K-iatetI  with  overgrowth,  either  simple  or 
adenomatous,  affecting  more  particularly  the  glandular  portion  of  the 
organ. 

Uriefly,  the  morbid  changes  in  this  rare  di.sea.se  are  that  it  shows  itself 
in  the  swond,  or  more  often  in  the  third,  tlecade,  le.ss  often  in  the  fourth, 
as  a  pn)gre.ssive  enlargement  of  the  l>ony  .skeleton.  All  the  bones  are 
affecte<l,  but  most  strikingly  tlio.se  of  the  extremities  and  craiiiiini,  and 
more  especially  the  lower  jaw,  whi<-li  l)ecoines  enlarge*!  in  all  dinH'lions, 
while  the  sella  turcica,  in  which  the  enlarged  pituitary  is  lodged,  nmler- 
goes  atrophy  of  its  bony  walls  antl  great  increase  in  its  cavity.  .\\m\^ 
with  this  there  is  a  thickening  of  the  sulxtitaneous  tissues,  wliitli,  iii  a 
case  of  pituitary  tumor  descril)e«l  by  one  of  us,  was  the  most  ni:iike(l 
feature,  the  <-ondition  approximating  more  to  my.xoHlema  than  to  mnt- 
mepdy.  The  liver  and  sj)leen  are  often  noticeably  enlarged.  I'he 
testes,  ovaries,  and  uterus  often  exhibit  atrophy  or  hypoplasia,  ahlioiii;li 
the  external  genitalia  may  Ih'  hyjiertrophied. 

The  pituitary  in  the  majority  of  cases  is  greatly  enlarged,  eitiier  from 
a  pHK-ess  of  simple  hypertrt>phy,  or  by  neoplasia  of  the  glaiiduiar  iHniioii. 
simple  or  malignant  adenoma,  or  even,  according  to  .some  iiutlii>iiiies,  a 
reversion  to  a  .sarcomatous  type  of  growth.  Henda,  in  four  eases,  nc  ords 
a  marked  increa.se  in  chromaHin  cells.  With  the.se  changes  llniv  may 
be  nervous  .symptoms  (blindness;  paralysis  of  the  (K-idomotor  iihimIis; 
deafness,  due,  apparently,  to  pressure  effects  in  the  cranial  (•a\ii> ;  .iiiil 
others  that  cannot  .so  surely  be  ascribed  to  pressure,  such  as  de|)ii-ii)n, 
I0.SS  of  memory,  homicidal  in.sanity, etc.).  (ilycosuria  is  not  miroinnioii. 
(This  has  In-en  oKser\e«l  in  connection  with  other  tumors  of  (he  I  icof 
the  brain  and  cerebellum.)  Polyuria,  with  or  without  glyeosm,; may 
Ix?  a  prominent  .symptom,  a  fact  which  is  suggestive  in  comiei  11  ■!  "ith 


'  Phil.  Trans.  Hoy.  Soc.  Lond.,  lS!«i,  H. 

'The  studies  of   I'rofesHor  and  .Mi.s.s   .Mellzer  [xiint   to  the  existciifi' 
deprcHHor  xiihNtanceH  in  thynmi  extract. 


niihir 


THE  THYMUS 


685 


tlie  existence  alxwe  noted  of  an  acu.e  principle  promoting  diuresis  in 
llie  n«)rmal  organ.  We  here  would  seem  to  see  olxscurely,  as  in  connec- 
tion witli  lK>tli  the  thyroid  and  the  adrenal,  some  relationship  l)etween 
the  activity  of  the  epithelial  elements  of  the  organ  and  metabolism,  and 
more  particularly  the  development  of  the  proper  organs  of  sex.  Here, 
again,  as  in  connet-t'c  ■  v  ith  the  adrenal,  it  cannot  lie  said  that  the 
t'xhil>ition  of  the  r'ive  t.\tr;i<'t  i.?  the  gland  has  brought  almut  any 
uniform  results.  '  hat  <H-ca.si(iiiallv,  'lOth  in  Addison's  disease  and  acro- 
megaly, it  is  folic   -t-il  \>y  inarkrtl  amelioration  of  symptoms,  indicates 


us  suggested  by 


iiuNle  of  dasage  and  adminiaii';^.t<V  n. 


that  we    lave  not  as  yet  conquere*!  the  right 


M 


THE  OAKOTID  BODIES,  OOOOTOEAL  GLAND  AND  ZUOKEBKANDL'S 

ORGAN. 

'i'hese  may  l)e  dismissed  briefly.  All  are  organs  of  insignificant  size, 
intimately  ass(X'iate<l  with  the  vascular  system  on  the  one  hand,  with  an 
ahiMulant  sympathetic  network  on  the  other,  and  exhibiting  columns  or 
clusters  of  cells  iKmlcring  iipcm  the  walls  of  an  abundant  capillary 
network.  These  cells  in  the  csi.se  of  the  first  and  third  are  certainly  of 
the  chromaffin  type;  as  n'gards  the  c<R'cygeal  gland,  the  observations 
arc  not  so  clear.  The  carotid  gland  in  man  is  situated  in  the  posterior 
aspect  of  the  bifurcation  of  the  common  carotid  artery;  Zuckerkandl's 
orjraTi  is  closely  attached  to  the  advcntitia  of  the  origin  of  the  sufwrior 
niesenteric  artery;  and  the  cot-cygeal  gland  lies  close  to  the  tip  of  the 
(MH'cyx.  Little  is  to  l)e  said  in  addition,  save  that  these  bodies  may  [te 
the  seat  of  tumors,  gn)wfhs  of  peritheliomatous  type  (.see  vol.  i,  Fig.  272, 
p.  7.')(>,  and  Fig.  277,  p.  767). 


THE  THYMUS. 

it  is  so  usual  to  consi<ler  the  thyroid  and  the  thymus  in  succession, 
iliMi,  although  personally  we  reganl  the  latter  organ  as  belonging  to  the 
lymphatic  system,  we  have  not  venture<l  to  depart  from  custom,  and, 
tlniffore,  mast  here  note  what  is  known  regarding  its  function. 

Embryological  Oonsiderations. — From  their  embryogeny  there  is 
iiii<l(>ul)te(lly  groiuui  for  discussing  these  two  glamls  together.  Both 
<iiii;inalc  as  segmental  organs,  as  downgrowths  of  tubular  type  from 
ilir  mouth,  or,  more  accurately,  from  the  branchitc,  from  the  epithelium 
lii.i'i^'  the  original  gill-cleft.s.  Originating  thus,  the  thymus  undergoes 
ii  Modification  very  similar  to  that  .seen  in  the  faucial  tonsils,  which, 
ii( .  '(ling  to  (laskell,  are  of  like  origin,  the  epithelial  cell-nests  (Hassall's 
(..'i.n-cles)  Ix'ing  the  rcniaiits  of  the  original  epithelial  <lowiign)wths. 
Til  matter  of  the  origin  of  the  vertebrate  leukwytes  is  still  in  di.spute. 
I.I  Heard  wa.s  too  re-strictetl  in  regarding  them  as  clerived  primarily 
ai;i!  .  -sentially  from  the  thymus  epithelium,  must,  we  think,  be  generally 


6S() 


THE  THYMUS 


aci-epte*!.  (laskell'  giithers  to){ether  much  evidence  showiiij;  that  in 
lower  forms  the  segmental  tulies  (nephridia)  throughout  the  ImmIv 
may  become  mcxlified  into  a  lymphoid  and  phagcx-ytic  tissue.  On  the 
other  hand,  the  view  is  very  widely  held  that  lymphoid  tissue  is  essenliallv 
mestxiermal  and  not  hy[M>l)lastic  or  epiblastic.  The  matter  must  Ik' 
left  open. 

Certain  it  is  that  the  thymus,  when  fully  developed,  prior  to  the  •  ml  of 
the  second  year,  Ls  essentially  a  lymph-glandular  organ,  and  that,  so  far, 
no  specific-  active  principle  has  l)een  isolated  from  it,  or  recogni/«(l  as 
existing.  later,  the  cells  undergo  a  characteristic  fatty  change,  and 
in  addition  come  to  contain  hyaline  droplets;  and  with  this  there  is  a  slow- 
progressive  atrophy,  until  the  gland  is  representee!  merely  by  fatty  tissue 
with  occa.sional  small  collec-tions  of  lymph-cells. 

It  is  interesting  to  note  that  there  is  an  increasing  tetidency  to  ascrihe 
the  origin  of  the  not  uncommon  mediutinsl  sarcomas,  or  lymphosarcomas, 
to  overgmwth  of  this  lymphoid  tissue  of  the  thymus.  Weigert,  in  aildi- 
tion,  has  promulgated  the  hypothesis  that  the  condition  of  myasthenia 
gravis  is  intimately  relatetl  to  neoplasia  of  the  thymus.  In  an  aiitopsv 
upon  a  case  of  this  remarkable  state  of  progressively  increasing  nniscular 
weakness,  he  found  present  lymphosarcoma  of  the  tliynnis,  and,  wjtli 
this,  scattered  accinnulations  of  lymphoid  cells  In'tween  and  witliiii  the 
skeletal  muscle  fil)ers.  These  he  regarded  as  metastases.  Kciciit 
workers  have  confirmed  the  frequent  presence  of  these  "lyinpln)ri'ha;:('s" 
in  the  muscles  and  other  organs  in  myasthenia,  but  only  in  10  'nit  of 
ISO  cases  of  the  disea.se  have  disturbances  of  the  thymus  been  r('|)orttHl. 
Obviously,  therefore,  thymus  neoplasia  has  no  necessary  connei'tion  with 
the  condition,  althougl  it  may  \w  present  along  with  other  changes  in  the 
lymph-glandular  system. 

Ihymic  Asthma. — The  one  severe  condition  in  which  we  may  npird 
the  thynnis  as  primarily  at  fault  is  thymic  asthma,  a  condition  of  i^rave, 
rapidly  pn)gres.sive,  and  fatal  dyspud'a  in  children,  associated  with 
hypertrophy  and  congestion  of  tliis  organ.  To  this  we  have  alicadv 
referred  (p.  242).  Hut  here  if  the  gland  be  at  fault  -which  sonic  still 
strenuously  deny — it  is  not  i)y  any  internal  secretion,  but  i)y  the  |(liyMeal 
agency  of  its  enlarged  state  that  sym|)toms  are  produceil.  Wiesei  jioints 
out  that  in  two  cases  examine<l  by  him,  in  one  of  which  (an  a  iidn  the 
thynuis  was  the  size  of  an  apple,  there  was  an  accompanying  hy]iii|i|;isia 
of  the  chromaffin  system  in  the  adrenal  medulla  and  elscwiiciv,  and 
to  this  rather  than  to  thymic  enlargement  he  is  inclined  to  axiilif  the 
sudden  death. 


'  1,110.  cit.,  p.  -12.5. 


CHAPTER    XXXII. 

THE  THYROID  AND  THYMCS  GLANDS. 

THE  THTBOID  OLAND. 

The  tliyroid  f^land  is  composed  of  two  lateral  lol)es,  situaiol  one  on 
cacli  side  of  the  larynx,  and  fonnecte<l  by  an  isthmus.  The  averaj;e 
wii};ht  in  the  adult  varies  l)etween  twenty-five  and  sixty  grains. 

The  organ  is  envelope<l  in  a  fibrous  capsule  sending  projongation.s 
inward  to  form  the  stroma,  which  contains  numerous  bloodvessels, 
lyiiipliatics,  and  nerves.  The  vascular  anastomoses  are  very  abundant 
and  the  larger  lymphatics  have  valves  like  the  veins.  Eml)edded  in  this 
stroma  are  numerous  acini  that  vary  .somewhat  in  apj)earance.  Acconl- 
in;;  to  Wolfler,  a  cortical  and  a  meihdlary  zone  are  to  \te  differentiated. 
Till'  former  contains  .solid  bands  and  gniups  of  cells;  the  latter  is  made 
ii|>  of  closed  vesicles  lined  by  a  single  layer  of  cubical  or  cylindrical  cells, 
uriil  filled  with  a  homogeneous  gluey  substance  or  t-olloid.  The  cells 
may  contain  minute  drops  of  colloid  or  larger  masses  that  force  the 
nucleus  to  one  side. 

riif  colloitl  substance  seems  to  be  a  secretion  of  the  s{)ec-ific  cells, 
lint  in  some  instances  the  cells  .seem  to  be  fmnsformed  into  colloid, 
ai)|)iirently  as  ii  —  .te.ss  of  degeneration.  Colloid  t>ccasionally  also  has 
ixtn  ol>ser\e(.  -troma  and  lymphatics.     It  is  by  no  means  certain 

liuu  tlie  coilo  !  the  lymphatic  ves.sels.     Sonie  believe  that  the 

follicles  open  c  „\  into  the  lymphatic  vessels,  while  others  think 
that  there  is  no  direct  connec-tion,  but  that  the  fluid  parts  alone  reach  the 
lyniphalii  ^. 

Hitwfen  the  follicles  containing  the  colloid  material  may  be  observed 
t:ruii|)s  and  rows  of  epithelial  cells  which  are  considered  by  Wolfler' 
to  !»■  cnil)ryonic  " cell-re.sts"  which  have  not  developed  into  the  normal 
adili  They  are  esjiecially  (-ommon  in  the  newborn.  Embryonic  cells 
nia\  also  l)e  present  in  the  capsule. 

A  word  or  two  .should  lie  said  about  the  so-called  parathyroids  of 
.SiiHUtroin'  or  '  epithelkorperchen"  of  Kohn.'  According  to  Kolin, 
til"  iv  are  four  of  these,  an  outer  epithelial  btxly,  at  the  side  of  each 
1,1..  .1  |„i^  ^„j  ^„  j^i^pp  yjjp  QP  pi^pj^  mesial  surface.  Functionally, 
)odics  are  to  .some  extent  distinct  from  the  thyroid  gland,  since, 
s  of  atrophy,  as,  for  instance,  in  myxcedema,  the  epithelial  bodies 

'  Arch.  f.  klin.  Chir.,  29:  1.S85. 

'  I'psala  I.Akertoreningen8  Forhandlingar,  1880. 

'  .\rch.  f.  mikrosk.  Anat.,  44:  1895:  366. 


tlx 
ill 


n 


688 


THE  THYROID  GLAND 


remain  intact.  Apparently  they  have  to  do  with  the  control  of  calciiini 
metabolism,  as  MacCallum  and  Voegtlin'  have  shown  recently. 

Microscopicn'.iy,  they  consist  of  a  network  of  broader  or  smaller  rows 
of  cells  or  of  fairly  refj'ular  lobules,  which,  however,  bear  ordinari  y  little 
resemblance  to  the  colloid-pnx)  tcing  celb  of  the  thyroid  proper. 

Kmbryologically,  the  thyroid  is  developed  from  three  gertninal  cenircs. 
two  lateral  and  one  medial.  The  n>edian  portion  takes  its  orijjin  in  a 
diverticulum  from  the  fl(K)r  of  the  [,iiaryn.\  lietween  the  bases  of  tlic  liiM 
and  second  branchial  clefts.  The  lateral  portions  develop  as  evajji nations 
from  the  posterior  aspect  of  the  fourth  branchial  arches.  The  fusion  of 
the  three  parts  usually  occurs  at  about  the  seventh  week.  Orijjiiiully,  tlit- 
middle  IoIh-  was  ccmnected  with  the  pharynx  by  a  duct  calle<l  the  tliyro- 
plossal  duct.  As  a  rule,  this  disapjH-ars  after  the  eighth  week,  but  may 
persist  more  or  less  completely  for  many  years  in  the  form  of  a  fibrous 
band  or  a  small  cyst  which  may  discharge  externally  so  as  to  form  a 
median  fistula.  Vt.  E.  Armstrong'  and  A.  T.  Hazin'  have  both  dcscrilKil 
cases  of  this  nature  in  young  lM)ys  that  were  successfully  operated  upon. 
I'sually  all  that  remains  of  the  duct  is  a  small  depression  on  the  surface 
of  the  tongue,  known  as  the  foramen  cum.  Not  infrequently,  liowever, 
ju'^ing  from  our  postmortem  exj)erience,  there  is  a  pyramidal  proionjia- 
■  HI  upward  of  the  middle  lol)e  representing  an  accunnilation  of  tliyroid 
substance  about  the  former  duct. 

The  most  common  and  important  condition  that  we  have  to  deal  with 
in  •<se  of  the  thyroid  is  the  so-called  struma  or  goitre.  Tliese  terms,  of 
o.irse,  strictly  sjK'aking,  apply  solely  to  increase  in  size,  but  have 
been  so  l(K)sely  employeil  that  much  <onftLsion  has  resulted.  Tlic  wore! 
"goitre"  has  lieen  use<l  indiscriminately  for  any  enlargeinciit  of  ilie 
gland,  whether  due  to  hyperemia,  hypertrophy,  cystic  dilatation,  filiroid 
induration,  hyperplasia,  or  tumor-formation.  Thus,  anatomicahy 
speaking,  the  term  is  objectionable,  for  a  great  variety  of  cliohiuicilly 
differing  com'itions  are  arbitrarily  grouped  together,  nor  is  it  Iwttcr  from 
a  clinical  standpoint,  since  widely  differing  symptoms  arc  assixiated 
with  enlarged  thyroid.  The  size  of  the  thyroid  is  the  least  important  of 
its  characteristics  and  is  only  of  significance  in  those  few  «as(s  where 
nuH'hanical  pressure  is  exerted  on  tlie  air  passages.  It  woidd,  thrn  fore, 
contrilmte  to  acjiiracy  if  the  terms  "goitre"  and  "strmna"  cou'il  lie 
dropptnl  from  our  nomenclature.  For,  it  is  certainly  more  scicniilir  to 
discuss  enlargements  of  tiie  glands  in  tiio  light  of  the  etiologii..l  causes 
or  anatomical  jR-culiaritics. 


OONOENITAL  ANOMALIES. 


Complete  or  unilateral  defect  of  the  thyroid  is  rare.     More  fr(  lucntly 
there  is  absence  of  the   isthmus.      Occasionallv,  abnormal  lobulation 


Mohns  Hopkins  Hosp.  Hull.,  19:  liKXS: 
'  .Mont.  Med.  Jour.,  28:  1899: 85;j. 


191. 


3  1!,; 


h:i 


HYPEREMIA 


6S9 


is  observed  and  the  or^n  inay  be  divided  into  several  parts  lield  together 
by  bloodvessels  and  connective  tissue.  Very  rarely,  the  isthmus  passes 
l)etween  the  oesophagus  and  the  trachea.  Aceeuoiy  thyroids  are  not 
infrequently  met  with,  and  may  be  found  at  a  considerable  distance 
from  the  parent  glan  1,  viz.,  near  the  hyoid  bone,  liehind  the  pharynx, 
within  the  larynx  or  trachea,  at  the  superior  clavicular  groove,  anil  at 
the  aorta.  Accessory  thyroids  in  the  base  of  the  tongue,  situated  along 
tlie  course  of  the  thyroglossal 

duct,    have    given     rise     to  fio.  170 

tumors.'  Osier  mentions  hav- 
ing found  acces.sory  thyroids 
in  the  pleura. 

Premature  atrophy,  or  pos- 
.sil)ly  hypoplasia,  is  the  card- 
inal feature  of  cretinism. 

Congenital  enlargement'  is 
important  as  it  may  lead  to 
death  from  pressure  on  the 
air  passages.  Not  only  may 
the  normal'-y-situated  gland 
undergo  this  increase,  but  also 
the  accessories.  The  causes 
arc  very  various,  and  include 
liyiHTcniia,  hj-pertrophy,  telc- 
anjiifctasis,  cysts,  fibrous  pro- 
liferation, and  adenoma. 

.\  stninge  anomaly  is  one 
Micntioned  by  Wolfler,  who 
found  utriatcd  muscle  in  an 
oi'icrwise  normal  gland. 


CiaCULATORT  DISTURB- 
ANCES. 

Hyperemia.— Owing  to  the 

fin  at  vascularity  of  the  thy- 
niiil,  ( irculatory  disturbances 
arc  ipt  to  l)e  l)oth  frOTjuent 
and    jirofound.       Hyperemia 

tn;i\ 


Kxophthmlmio  goitre,  or  Graves'  diaeane.     (Fn>iii 
the  Medical  Clinio  of  the  Montreal  General  Hospital.) 

kI  to  a  surprising  en- 
lar;;.  .iicnt  of  the  gland.    Passive  congestion  is  met  with  in  valvular  and 
"till    iicart  affections,  in  suffocation,  and  in  ol>struction   of  the  veins  of 
tlic  ]■■   k  from  whatever  cause. 


Kii 


I        Warren,  .\mcr.  .Jour.  Med.  Sci.,  lOl:  1S92:  377. 

lie  literature  on  conj«"ital  gtriinm,  see  Demnie,  Oerhardt's  Handbuch  dcr 

.  :i:2. 


ogo 


THE  THYROID  GLAND 


Of  mufh  interest  is  the  congestive  h\-peremia  of  neuropathic  oiif;iii. 
tlitit  is  s.jpposc<l  by  many  to  \w  the  essential  lesion  of  (iraves'  disca^f. 
Tlie  enlargement  of  the  thyroid  Ihat  occurs  in  females  at  pulierty,  diirin;; 
menstruation,  and  pregnancy  is  probably  to  be  placed  in  the  siiiiif 
category  (Mruma  hyperemica). 

Dilatation  of  the  bloodvouela  {struma  vaaculosa)  is  met  wit.i  in  two 
forms,  an  aneurismal  and  a  varicose.  In  the  former  the  arteries,  nut 
only  within  the  gland  but  on  its  surfai-e.are  dilated  and  tortuous,  nsciiil)- 
ling  a  cirsoid  ameurism ;  in  the  latter  the  veins  and  capillaries  are  affccttd. 

Hemorrhage.— Hemorrhage  is  frequent,  especially  in  cysts  and  tumors, 
or  when  the  vessels  are  dilated.     It  may  also  be  due  to  trauma. 


INFLABflMATIONS. 


Inflammation  may  affect  the  otherwise  normal  thyroid  (thyroiditis), 
or  one  that  is  chronically  enlarge*!  (stmmitis).  The  latter  event  is  ilu- 
more  common.  The  wliole  gland  or  any  part  of  it  may  be  involvcii. 
Uotli  exudative  and  pnxluctive  forms  are  recognized. 

Acute  Exudative  Inflammation.  —  Acute  exudative  inflaniniaiion  is 
rarely  primary,  but  is  due  to  disease  elsewhere.  It  follows  tramnatisni, 
or  is  a  complication  of  alfei'tions  like  puerperal  infection,  typlioid  IVvcr, 
angina,  septicemia,  Bright's  disease,  pneumonia,  ulcerative  cndcwaicliiis, 
an<l  acute  rheumatism.  The  bacteria  found  include  the  strc])t(H(M<iis 
and  Staphyl(X'(K-cus  pyogenes,  the  Diplococcus  pneumonia*  and  tlif  15. 
ty|)iii  alxlominalis. 

The  affected  gland  is  swollen,  hard,  and  painful.  Resolution  niav 
rapidly  take  place  or  tiie  condition  may  go  cm  to  absccss-fonnalion. 
Large  areas  may  undergo  purulent  softening,  and  if  cysts  hv  i)r(stMt 
tlu'y  may  fill  with  pus. 

On  account  of  tiie  proximity  of  the  large  veins  of  the  mtk  ilicn' 
is  great  danger  of  thrombophlebitis  and  general  septicemia.  Tlif 
abscesses  may  rupture  into  the  mediastinum,  the  most  frei|ii(iii  (vciit, 
or  into  the  larynx,  trachea,  or  (esophagus.  When  healing  takis  i)l:i(i' 
fibrous  .scars  may  result,  or  the  abscess  may  l)ecome  encapsnlaicii,  ilif 
contents  inspissated  and  infiltrate<l  with  calcareous  .salts. 

Chronic  Productive  Inflammation. — Chronic  productive  infianiniatioii, 
or  interstitial  "brous  hyperjd.isia ,  is  quite  rare,  except  in  tiic  form  tliat 
attacks  a  previously  hyperplastic  thyroid  {struma  fibrosa). 
is,  however,  a  more  common  event  as  a  .sequel  of  diffuse  < 
thyroiditis  or  ab.scess. 

Tuberculosis. — Tul>erculosis  of  the  normal  or  enlarged  tli; 
invariably  .secondary  and  is  due  to  hematogenous  inftH'tion.  I  li 
lion  is  more  common  than  has  Ijcen  supposetl.  According  to  Iv  I  i 
it  is  usually  present  in  general  miliary  tul)enidosis.  Uolli  nh';. 
caseoMiKlidar  forms  are  de.scril)ed. 


ilirosis 
iidativf 

I'oid  is 

.■  atfiH- 

..•iikel' 

rv  aliii 


'  Virchow's  .\rchiv,  l(t»:  18K(i;  58. 


PROdRESSlVE  MET  A  MOHPIIOSES 


cm 


Syphilis.  —  Syphilis  is  ext-essively  rare. 

Parasites. — Kchinocorcus  cysts  are  rare.  They  may  disfhurj;c  into 
tlie  trachea. 

Actimnnycosis  of  the  thyroid  due  to  extensi'-n  of  the  disease  from  tiie 
neck  has  l)eeii  observed.     Occasionally,  it  is  t-aiised  by  metastasis. 


RETR0ORE8SIVE  METAMORPHOSES. 


Atrophy.  -  Simple  atropliy  is  a  common  condition  in  old  ape.  Here, 
tlic  acini  are  wasted,  the  interstitial  tissue  is  relatively  increase«l,  and  the 
vessels  are  sclerosed.     In  st)me  cases  the  atrophy  is  unilateral. 

Two  special  fom.  i  of  atro|)hy  call  for  mention,  namely,  that  due  to 
tlif  continued  exhibition  of  small  doses  of  iodine  and  that  found  in  myx- 
ndcma.  The  explanation  is  by  no  means  clear.  In  the  former  case, 
it  would  seem  that  io<]ine  interferes  in  some  way  witli  the  nutrition  <»f 
tlic  cells,  so  that  they  liecome  unable  to  assimilate  fcHnlstuffs  and  thus 
undci'jto  atrophy.  With  n-jjanl  to  myxtedema  there  are  not  wantinj; 
those  who  lcM)k  upon  this  disease  as  primarily  a  neurosis,  for,  as  is  well 
known,  there  is  a  close  relationship  l)etween  the  nervous  system  and 
the  thyroid  jrlaiid.  It  is,  however,  difficult  as  yet  to  de<'i(ie  whether 
till"  atrophy  in  this  case  is  a  primary  or  secondary  manifestation. 

Degenerations.— The  various  forms  of  degeneration  affect  the  thyroid 
liiit  arc  most  commonly  fotmd  in  association  with  other  pathological 
coiKlitions  of  the  gland,  .\mong  them  may  l>e  mentioned  fatty  degenera- 
tion (if  the  glandular  epithelium,  coagulation  necrosis,  hyaline  degeneration, 
anil  calcification. 

Amyloid  disease  is  met  with  under  the  usual  conditions,  but  it  is 
interesting  that  it  may  affect  "goitrous"  niMlules  to  a  greater  extent  than 
tile  rest  of  the  gland. 

Colloid  degeneration  is  <lescribed  as  (K-curring  in  the  thyroids  of  old 
people.  In  some  cases  it  appears  to  Ih*  a  true  colloid  degeneration  of 
the  ( ills  which  are  small  and  tend  to  disappear,  but  in  others  it  is  sinjply 
an  arrest  in  the  development  of  a  colloid  struma. 


Ill  I 
tneni- 

"lirnli 
lll:i 

^laiM 
tiiin  ,. 
tion. 
tive. 

of  till 

Geriii. 


PROGRESSIVE  METAMORPHOSES. 

Ills  category  we  place  for  convenience  tumors  and  all  those  enlarge- 

i)f  the  thyroid  commonly  known  as  "goitre,"  "strinna,"  and 

'  hiK-ele,"  with  the  exception  of  those  due  to  simple  hyperemia. 

'iiuch  as  our  knowledge  of  the  growth  and  overgrowth  of  the 

I-  still  somewhat  defective,  it  is  impossible  to  a<lopt  a  classifica- 

'  the  progressive  metamorphoses  that  is  entirelv  free  from  objec- 

I  hat  adoptnl  here  must,  therefore,  be  regardetl  as  merely  tenta- 

i  he  subject  is  still  further  complicated  by  the  conflicting  views 

•  lifferent  pathologists,  as  well  as  by  their  loose  use  of  tenns.    The 

I"  school  for  instance,  .speak  of  "benign"  and  malignant"  struma, 


662 


TUH  THYROID  GLAND 


mpuning  hy  the  former  all  simple  forms  of  eiilarjtenwnt,  whether  due  to 
hy|jereinia'  hyj)erplHsiu,  or  ^hindulur  excess,  wliile  under  the  latter  tlicy 
iiu-hide  can-inoma  and  san-oma.  It  wouhl  l)e  In-tter,  however,  in  (li>- 
eassinfj  "struma,"  to  keep  in  our  minds,  when  possible,  the  various 
etiological  factors,  and  draw  a  clear  distinction  Itetween  vascular  dis- 
turlmnces,  hy|)er])lasia  and  hy|HTtn)phy,  and  true  tumor-formatii  i. 

Ooitre.— In  attempting'  any  classifii-ation  of  the  goitrous  enlarjjenKiils 
of  the  thyroid,  we  art  met  at  the  outset  with  the  old  difficulty  of  decidiiij; 
what  enlargements  are  tumors  (a<lenomata  et  al.)  and  what  are  ni'  r-ly 
hy|)erj)la.stic  overgrowths.     Wtilfler,  iti  his  classical  s(u<lies  on  this  miI(- 


I'la.  IM) 


Pariiuliyiiiatuus  (jiiitre.     (Dr.  Shepherd'H  case.  .Montreal  General  Hos|iil:il 

ject.  attempts,  and  rightly  so,  to  make  this  distinction,  hut  his  < 
tioii  is  in  several  points  ojm-ii  to  criticism.     He  divides  "goii 
hypertrophic  and  adenomatous  forms.     In  the  first  group,  wlii. 
he  more  cormtiy  styled  "iiyjHTplastic,"  he  puts  all  those  <ii- 
hirgeinent  due  to  increase  of  the  specific  glandular  elements  ;in 
or  to  increase  in  tlieir  contents ;  in  the  .swond,  thase  forms  wli<n 
long,  l)raiicliiiig,  cellular  priKcsses  of  emhryonal  ty|H',  wliii  li  i 
as  epithelial  new-formations.     His  cardinal  point  is  that  thr 
are  derived  from  the  activity  of  the  inleralveolar  embryonicc 
It  is  ccrtiiinly  incorrwt  to  call  a  simple  collection  of  colinii! 


,i-~ifica- 
;i"  into 
!■  would 
-  of  eii- 

icsicles 
!  tTt'art' 

i<-j.'anl.s 
;.  nomas 

liliiii  the 


i|W* 


HYPERPLASIA 


093 


vi-sicles  an  hy|)ertn>|)h,v,  iis  Wolfler  iloes  (hvptTtniphia  >;elatin(»sa). 
Apiiii,  it  is  liy  no  mwms  (rrtuiii  that  wf  are  jiistiKitl  in  making;  the  Aide 
^'tneralization  tiuit  ailcnonms  ar»'  always  derivjHl  from  enihrvf/nic  celLs. 
More  ret-ent  oi)ser\ers,  notaliiy  Hitzij{,'  U-lieve  that  new-.ormations 
resembling  adult  tissue  are  to  Iw  referred  to  the  overgrowth  of  previously 
existing  adult  eelis. 

ByptrpUiia.— Hy|)eq)lasia  and  regeneration  of  tissue  are  not  infre- 
(|Mentiy  found  in  the  thyroid.  When  a  portion  <  the  glan«l  is  removed 
or  is  functionally  useless,  ('oini>eiLsatory  hyperplasia  occurs.  In  such 
eases,  as  Ilalstead'  has  shown  experimentally,  there  is  metamorphosis 
of  die  lining  epithelium  of  the  acini 

into  cylindrical  cells  that  tend  to  *"•"•  i»* 

iissuine  a  ptpilltiry  arrangement, 

while  the  colloid  material  l)ecomes 

more  mucoid. 

I  lyiM-rplasia  may  affect  the  gland- 
ular elements,  the  stroma,  or  hoth, 

iinil  leads  to  considerable  enlarge- 

iiient  of  the  organ.     How  to  class 

this  form  of  goitre  is  difficidt,  for 

it  is  not  always  possible  to  draw  a 

iiiird  and  fast  line  lietween  hyj)er- 

phisiii  and  adenoma.     The  over- 

;;ro\vtli  may  In?  diffuse  or  nodular; 

l>(i>sil)ly  the  latter  variety  is  more 

(orifctly   to   Ih,'   placed   with   the 

aileiHimas. 
Tlie  first  form  to  be  noticetl  is  that 

called  by  Virchow  xtriima  hijper- 

l>liislir(i  pdreiicliymdUuKi,  where  the 

(tverjirowth  is  confine<l  to  the  acini. 

Tin-    jjrowth     is    often     ntNluhir, 

faiily  well  defined,  and  of  a  soft, 

yellowish-gray  ;    pearance. 
Microscopically,  it  is  compose*!  of 

iipiiiid, oval, and  elongatetl,  branch- 

iiit;  alveoli, often  containing  colloid. 

Ill  (idler  cases  there  is  an  increase  of  the  fibrous  stroma  with  atrophy  and 

fait\  (lei;eneration  of  the  secreting  cells — .struma  hyprrplantica  fihntsa. 
Colloid  Goitre. — Another  and  one  of  the  most  fretpient  and  important 

foiiii-,  is  the  .ilrumd  (fphtinonii  or  colloid  (joltrr.     Of  this  there  are  two 

son  -     ( )ne  is  said  to  \w  due  to  the  simple  accumulation  of  colloid  within 

llic  vol,  les  which  are  not  abnormal,  except  from  pressure.     The  exact 

iiin,!,  of  origin  is  doubtful.    The  affection  might  perhaps  be  correctly 
rc^  v.!..,!  jis  a  form  of  reient ion-cyst.     It  is  significant  that  in  other  ca.ses 


Colloid  atriima.  Ihe  thyroid  i-.  ilivided  ver- 
tically and  the  anterior  portion  turned  upward. 
(From  the  Pathological  MuMum  of  McGill  Uni- 
versity.) 


'Arch.  f.  klin.  Chir.,  47:  lSi»4:4(M. 
'.Johns  Hopkins  Hosp.   Itep.,  1:  1896;  373. 


094 


THE  THYROID  GLASD 


vas<iilur  clmnjfes  liuvf  \wv\\  •lescrilH'*!.  Tin'  iirterit's  show  thickoiiiii;;  of 
tin*  inliiiia  iiiul  deRenenitioii  i>f  the  eliistH-  filirilhi'.  In  .s«>iim'  iiistuiiccs  ilir 
lyinpliHtifs  ilo  not  coiituiii  colloid,  ami  it  has,  therefore,  lie«'n  sugjrcf,.,! 
that  ohstruction  of  the  lymphutics  Ls  a  main  cause.  (Jiven  vas<iiliir 
oltstr  ftion,  it  is  not  difficult  to  see  how  atrophy  of  the  stnnna  will  lake 
place,  «'spetially  as  the  condition  is  not  improvetl  by  pressurs  of  (lie 
colloid  niateriaf.  The  walls  of  the  vesicles  niay  rupture  ami  large  cs^n 
filletl  with  colloid  result. 

Fm.  182 


Collriid  >>trtiinii  nf  the  thyr«»id  Klutxl.     The  ttcini  are  (creatly  diluted  and  tilled  with  .mM  ii^i 
I,eil/  ohj.  No.  7.  without  twulur.     (From  the  collection  of  Or.  A.  O.  Nii-lmll'  ' 

Ttimors. — More  fre(|ueiitly,  however,  colloid  goitre  originates  in  adeno- 
matous growth.  In  this  case,  mxlular  swellings  in  the  thyroid  ;ii<'  nut 
with  that  on  section  appear  to  l)e  composed  of  dilated  vesicles  (iniiaiii- 
iiig  a  firm,  gnniniy  substance. 

Microscopically,  one  sees  vesicles  of  all  sizes,  from  the  small  :i(  imb  of 
the  normal  gland  to  large  cystic  cavities  linwl  with  flattened  cpiilit  liiiiii. 
For  the  most  part  the  connective  tissue  l)etween  the  vesicles  i-;  i  :i?ity. 
Owing  to  the  pressure  of  the  accunmlated  colloid,  the  vesicular  w;ilK  iimi 
the  fibrous  stroma  are  atrophic,  and  there  is  a  tendency  for  ilif  .  a\iti<'s 
to  coalesce,  so  that  a  multiliKnilar  or  even  a  uniloculttr  cyst  is  tin  n  Milt. 
In  the  larger  cvsts,  the  colloid  is  converted  into  a  slippery,  alliiuiiKiiis 
fluid.  In  another  form  of  colloid  struma,  there  is  a  imiforni  i  !i!.ir).'e- 
mcnt  of  the  thyroid,  which  on  examination  presents  ahundr.i  ■ 
formation,  cystic  degeneration,  and  fibroid  induration  (//'/  ' 
adenoma  of  Wolfler).  In  still  a  third  variety,  lioth  lol)es  of  i'. 
are  enlarged  and  on  the  surface  soft,  n)unded  elevations  car 


claml 
.r  felt. 


SARCOMA 


em 


Oh  sH-tion,  it  is  a  (•*>\\ml  fp)itre,  within  thf  nivitirs  of  which  there  an- 
larp'  impillury  out^nrnths  {papiUary  cyataileiinma). 

Ill  how  fur  tliese  tlitfereiit  tyfH's  are  ilue  to  the  proliferation  of  emlin 
oiiic  "rests"  must  l)e  re>{anle<i  iw  iiiule('i<le<l,  hut  there  Is  i«ie  form,  at  all 
tveiits,  the  .so-falle«l  faUl  ■dasonu,  in  which  Wolfler's  view  is  |m>lial)ly 
(■omHt.  Tilts  jjrowth  is  met  with  at  any  time  from  hirth  to  the  a>;e  of 
puU'rty,  ami  its  tx-ciirrence  "n  yoiin^  children  ar>;in's  for  its  origin  in 
<iiiliryoni«'  cell-iiicliisioas.  It  forms  multiple  cireumscrilied  notlules  that 
lire  often  extremely  vast  alar. 

Kio.  IM 


I  (il:il  udeniitna  iif  llw  tliyriiicl.     WiiK'krl  ohj.  No.  :t,  without  oculur.     (From    the 
I'ollri'tinn  of  Dr.  A.  C.  Nicholls.) 


A  rare  form  of  tumor  that  should  l)e  mentioned  is  tlu>  cylindrical- 
celled  adenoma  which  is  found  l>oth  in  the  normal  and  in  the  struinous 
lliMoid. 

Amoii):;  the  l)enign  tumors  may  also  lie  mentioned  the  fibroma,  an 
exiiiiiple  of  which  has  l)een  recordetl  hy  Wolfler,  and  osteoid  chondroma. 
Will  ilur  chondroma  and  osteoma  (x-cur  is  perhaps  douhtful.  It  would 
lie  1  letter  to  restrict  the  term  adenoiaa  to  those  cases  wliere  there  is 
II  Mil  ire  or  less  definite  overprowth  of  the  glandular  elements,  which  is 
iiniliihir  and  sharply  define*!  from  the  rest  of  the  thyroid  substance. 

Sarcoma. — Sar  <  ;;  a  is  the  most  common  of  the  mcsohlastic  tumors, 
anil  i^  more  liable  to  l)e  f.;„iid  in  cases  where  j»oitrous  eiilarj;ement  of 
thf  jhiiid  has  preexisted.  If  mav  Iw  rmniii-^elhd,  xphitUr-rt'lled,  giniif- 
ci'll,  !.  alreolar,  or  aiigiomatoiM.  Rarely,  in  such  tumors  striated  mii.scle 
filiii-  have  l)een  found  (W*IHer).  San'omiis  form  nodular  tumors  that 
oil  I  jiy  inttre  or  le.ss  of  the  organ,  but  rarely  the  whole. 


THE  THYROID  OLAND 


I 


Ml 

ill 


M 


Oil  .station,  tlit>  coiMLstenrv  varim  atid  thr  surface  U  fliniNrfh  niwl 
.soitifwhat  inlentecti^  by  fibruut  bamiit.  'V\w  color  ia  while  or  Kniy,  or, 
Ag&'m,  aihnixcd  with  red,  according  to  the  amount  of  blooil  presfnt. 
Tlie  tuniur  fftovis  rapidly  bihI  may  {lenctrate  the  trachea  or  jugular  vfin, 
MO  that  widespread  inctu-staM-s  are  quite  coinnuiii. 

Oanrfnomi. — Piiaary  cardBOBU  atuully  takes  the  form  of  earvinnma 
timplrx  or  carcinoma  meduUan  ami  prodwes  tumors  varying  in  >ize 
from  that  of  a  hen's  egg  to  that  of  a  child's  head.  Hillroth,  howrvrr, 
has  describetl  cases  where  the  thyroid  was  not  enlarged.  rurciiMnim 
develops,  aa  a  rule,  in  glands  previously  enlarged  atHi  forms  fitlicr 
grayish-white  nodules  surrounded  by  connective  tissue,  or  a  uniform, 
more  or  less  diffuse,  infiltration  with  only  slightly  altered  pareiKJiviim 
between  the  areas  of  new-growth.  'I'he  nodular  form  is  reganlc<|  hy 
Wdlfler  as  developing  in  a  follicular-fibrous  goife,  and  tlie  diiriisi- 
variety  from  the  interacinar  embryonal  cells.  Cifltndrical-rflltd  rarci- 
uoma  is  described  as  well  as  papUlary  cyitic  carcinoma.  In  ti-rlain 
cancers  the  stroma  may  undergo  myxomatous  degeneration  (carvi mwia 
myjromat(xlrii). 

S(fiiamou*-cellid  epithelioma*  have  lieen  met  with,  due  to  die  irMJiisjon 
of  epidermal  cells  during  fcetal  life,  but  the  vast  majority  are  e.\aiM|>l(*.s 
of  swondary  growths. 

A  few  instances  of  mixed  sarcomatous  and  carcinomatous  growths  Imve 
been  descril)e«l.    They  are  more  common  in  the  thyroid  than  elsowhcrf.' 

An  extremely  rare  and  interesting  tumor  is  a  mixed  form  of  vorcinoma 
and  perithclittl  angitmarcoma,  of  which  an  example  has  lieen  reported  liy 
Woolley.^    Only  four  of  them  are  on  reconl,  one  of  them  in  a  dog  ( \V<II.>'). 

Inasmuch  as  many  carcinomas  contain  colloid  material,  the  .stH(»ncliin 
growths  frojuently  pnxluce  the  same  substance.  Any  tumor  coiitainiiip 
cuHoid,  particularly  if  found  in  lume,  should  arouse  the  su>f  ion  of 
a  primary  growth  in  the  thyroid.  According  to  Kolisko,  pcillicliai 
ungi')sarcomas  of  the  thyroid  may  give  rise  to  pulsating  secondary  ^Towtlis. 
(Jn)wths  in  the  gland  produce  serious  effects  not  only  from  extension,  lnjt 
also  from  pressure.  The  trachea  may  l)e  compressed  and  tlic  cariila^.'t's 
ero<le«l,  or  paralysis  may  easue  from  involvement  of  the  recurrent  laryn- 
geal nerve.  Invasion  of  the  great  vessels  of  the  neck  may  lead  to  ^t.isLs. 
thromlxxsis,  enilmli.sra,  hemorrhage,  and  secondary  growth. 

A  point  of  some  importance  in  regard  to  tumors  Ls  that  they  an  apt 
to  l»e  considerably  altered  in  appearance  by  secondary  clian;;e>.  Tlie 
connective  tissue  is  frequently  increased  either  diffusely,  or  about  tlie 
nodules  and  cysts.  It  may  also  show  hyaline  or  mucoid  dejiem  iiiion. 
Cystic  metaniorphasis  is  not  uncommon,  due  to  the  overdisteii-i'  m  and 
rupture  of  adjacent  follicles  or  from  colliquative  necrosis. 

A  special  form  of  cyst  is  the  hbmoirhagie  cyit,  formed  by  riij'  '  re  of 


'  Leo  Locb,  Mixe<i    iiiniors  of  the  Thyroitl  Gland,  Amc-r.  Jour.  Mt .i. 
1003:243. 
'  American  Me<licitie,  4:  No.  9:  1902:  331. 
'.four,  of  Path,  anil  Bact.,  Juno,  1901. 


.  l.'.i: 


THE  THYMUS 


<H>7 


vesseU  and  the  diwharKe  of  I.IikxI  into  the  rBvitif.t.  UiikitunHky'  wus 
probtthly  the  first  to  jwint  out  that  heinorrhu>{e»  (xviirrwl  for  tlu-  most 
part  only  in  nropla-stk-  growths  of  thf  thymid.  Thw  ol>»enuti.ni  Ims 
Ufn  continned  here  hy  AnhilwW.'  'I'here  iire  two  foriiw  of  henior- 
rhajfic  cy."»ta:  one  in  which  hemorrhage  takes  place  intt»  an  onlinarv 
(..lloifl  retention-<yst,  ami  ar«)lher  where  exieiwive  extravasation  ImuIi 
into  the  vesicUfs  ai'ul  into  ;he  intentitial  coniRH'tive  tissue  occurs.  'I'he 
lutler  form  has  been  more      »e<ially  studiiil  l»y  Hnidley.' 

(  akification  of  the  sinMna  .  <mI  even  of  the  vesit  ular  contents  has  been 
..ksenwl.  Amyloid  and  fatty  changes,  as  well  as  inflammation,  may 
also  take  place. 

TBI  THTMUS. 

'Hie  thymus  is  one  of  the  ductless  glands,  and  its  function  is  as  yet 
l.y  no  means  tlion)Ughly  understootl.  Watney*  has  suggested  that  it 
partici|Miti>s  in  the  'orniation  of  the  retl  and  white  cells.  It  is  possihle, 
«)«),  that  th'  .  '.  elalwrates  an  internal  secretion.  Svehla'  has  shown 
timt  when  'oses  of  a  watery  extract  of  the  'hymus  are  injectwl 

into  dogs,  .  with  dyspna>a  takes  place.    This  is  suggestive  in  cou- 

ncil ion  witii  the  subject  of  "thymic  asthma."    Small  amounts  of  an 
i(Hline-containing  substance  have  l)een  found  by  liaumann. 

'I'lie  thvmus  lies  in  the  upper  part  of  the  anterior  mediastinum,  ex- 
ten.liiig  from  the  pericardium  almost  to  the  thyroid,  and  is  composed  of 
Itto  long,  Hat  IoIm-s,  more  or  less  intimately  united  along  their  median 
asiM-cts.  The  organ  is  enc-losed  in  a  connective-tissue  capsule  tiuit  sends 
in  imlHH-ulie  dividing  it  into  l(»l>es  and  again  into  lobules. 

Microsccjpically,  the  lobules  are  composal  of  acini  that  liear  a  close 
rcM  inblance  to  thcxse  of  the  lymphatic  glands.  In  the  peripheral  zone, 
tlif  connective  tissue  is  richer  and  the  lymphoid  cells  more  numerous, 
so  that  the  lobules  ma  v  l>e  divided  into  a  cortical  and  a  medullary  |)orticm. 
\  sliikin;;  fc^ature  of  the  picture  is  the  so-called  Hassall's  c-orp-.scles  which 
lit'  in  the  middle  of  the  follicles  and  are  composed  of  homogeneous 
aii.l,  toward  the  periphery,  concentrically  arranged  epithelial  elements. 
'rii(»e  sometimes  cakify. 

'llic  thymus  is  originally  an  epithelial  structure  derived  from  the  hypo- 
l)la>i  of  tiu"  third  gill  clefts.  (Gradually,  however,  the  epithelial  elements 
un.h  rj;o  atrophy,  the  sole  representative  of  their  existence  l)eing  the 
Ha  sill's  bodies*  which  are  said  to  lie  due  to  the  coalescence  of  the  epi- 
tli.  lial  remnants,  and  the  structure  is  substituted  by  vascular  connective 
ti-  1.  from  which  the  lymphoid  elements  are  derived. 

I !.(   thymus  weighs'about  twenty-four  grams  at  birth,  and  slightly 

'  Zur  Anat.  des  Kropfes,  Wien,  1849. 
^Moulruttl  M«i.  Jour.,  2.t:  lSii7:7S0. 
'  Jour.  Exp.  MchI.,  1:  1896:401. 

*  Phil.  Trans,  of  the  Hoval  Soc.,  .1:  18S2. 

•  Wien.  niwl.  Blatter,  1890. 


60,S 


THE  THYMUS 


increases  in  size  until  the  end  of  the  second  year.  It  then  remiiiiis 
stationary  until  the  a^  of  puberty,  and  after  that  underg<K's  gnulii.il 
involution.  At  the  end  of  the  twentieth  year  it  is  almost  compKtilv 
substituted  by  fat.  According  to  VValdeyer,'  remains  of  the  lyni|)h()i(i 
structure  ami  of  the  Hassall's  iKxlies  are  to  be  recognized  throughout  life. 
Involution  is,  therefore,  not  always  constant,  and  the  gland  in  a  more 
or  less  complete  form  may  persist  into  old  age. 


OOKQKHITAL  AH0MALIE8. 

Complete  aba«ne«  of  the  thymus  has  been  observed  in  the  case  of 
monsters,  and,  rarely,  in  otherwise  normal  children.  Aeeeisory  glands 
are  not  uncommon  and  are  usually  found  just  above  the  main  tliyiniis 
and  near  the  thyroid.  Irregularity  in  the  shape  and  lobnlation  arc  not 
rare.    Enormous  enlargement  is  sometimes  met  with. 


OntOULATOKT  DDTUBBANOES. 

These  occur  in  tleath  from  asphyxia  and  in  the  hemorrhagic  diiitlicsis. 


OrrLAMMATIONS. 

Primary  inflammation  is  rare,  if  indeed  it  occur  at  all.  Generally,  the 
affection  is  due  to  extension  from  the  neighboring  organs. 

Suppurative  inflammation  is  found  more  particularly  in  septiceiiiiii. 
(^arc  siiuiild  l)e  taken  not  to  regartl  the  yellowish  i-ellular  juice  of  the 
normal  gland  as  pus,  which  it  much  resembles.  Multiple  abscesses  are 
met  with  and,  also,  diffuse  purulent  infiltration. 

Tuberculosis. — Tul)erculasis  is  somewhat  rare,  and  is  foiiml  in 
miliary  form  and  caseous  masses. 

Syphilis. — .Syphilis  takes  the  form  of  gummas  or  a  diffuse,  lilimid 
indunition. 

RETROORESSIVK  MST1MORPH08E8. 

Focal  necroses  have  l)een  descril)ed  by  Jacobi'  in  connection  with 
diphtheria. 

Degeneration  Cysts. — Degeneration  cysts  containing  puiilnrTii 
matter,  which  has  leil  to  their  l)eing  mistaken  for  abscesses  (Diiliois), 
have  l)een  descril)e<l  by  Chiari.'  They  are  due  to  the  ingrowim;  "f  the 
thymus  tissue  into  the  Hassall's  corpuscles,  and  are  said  to  Ik-  <1ui'  "  ler- 
istie  of  congenital  syphilis. 

'  liiickliiiiliiiiK  <ler  Thvmiw,  Centrnlbl.  f.  d.  mod.  Wiss.,  1S!I0. 

2  TrniiK.  Akwk-.  of  Amer.  Phys.,  :{:  ISSS:  2fl7. 

'  IcIxT  ('ystonliildiing  In  <lrr  Thymus,  Zeit.  f.  Heilk.,  4:  WM. 


TUMORS 


PROOBE88IVE  METAMORPHOSES. 

HVDerpla8ia.-The  thymus  may  participate  in  the  general  lymphatic 
e„R.^.niat  occurs  in  leukemia,  pseudoleukemm.  and  the  "status 

'•  TfWasia  mav  occur  after  birth  and  has  been  noted  in  connection 

wi  h  Spsv  (OhWcher').  exophthalmic  Roitre  (Hektoen')  m  aero- 

™kP  mvxcedema    and  Addison's  disease.      It  is  most  commonly 

SliJS^a'^n^ral  lymphoid  hy^n>l^^- and  is  of^mte^^^^^^^^ 

the  inferioJ  laryngeal  nerves,  or  to  pressure  on  the  vag.  ami  trachea. 
t"I^i  it  may  be  toxic.  There  have  only  beer  -^"^or  tv.-o 
it^r  in  wS  compression  of  the  trachea  has  been  discovered  pos 
;^ter  so  that  mechanical  pressure  does  not  appear  to  be  an  .mporlBnt 
tT  ™  much  should  be  said,  however,  that  U  .s  not  impassible. 
•  „  unlikeh-  that  the  organ  may  be  subject  to  sudden  hyje-nuc 
enlargement,  a  condition  that  at  times  might  pass  off  before  the  case 

*"K;iL£"Ssformati«.,    of  the  thymus    has   been  described  by 

''Tior8.-The  thymas  is  the  favorite  site  of  or\&notm^^l^\ 
.n,  ™s  Of  the  l>enign  tumors  may  be  mentioned  .ngiom*.  of  which 
''^  ^llmnle  has  l.een  descrilied  by  Osier,  and  dermoid  eyrts.  The  latter 
;:iirrtSSnt  epithelial'"^  and  contain  yellow.h-white. 
fall V  and  granular  material,  together  with  hair.  i,„„h. 

The  m^t  frequent  tum.,r  is  Micom  in  its  various  forms.*  Lympho- 
sar  ol  nmv  l,^  rec-ognized  by  its  smooth  homc,geneous  appearance. 
,3.^1^0  some  extent  to  the  normal  outlines  of  the  gland,  m  contra- 
.SiSto  the  more  irn^gular  ami  nodular  arrangement  of  sarc-oma 
oiii'lnating  in  the  lymphatic  glands.  ..,.,,      . 

Carcinoma  mav  lie  developed  from  the  epithelial  structures. 

^'mnors  of  the  thymus  are  important,  smce  they  m.s  grow  rapidly 
a„l        roach  upon  Vital  structui;;;  like  the  heart,  lungs,  an.l  great 


VtN,fls. 


■  Bull.  Ohio  HoHp.  for  EpileptiCH,  ISHS  and  1809. 

'  Intemat.  Me<l.  Magaz.,  1896. 

•Centralbl.  f.  all)?.  Path.  n.  path..  .\tmt.,  10-  1890: 1. 

«  Schm-i.ler,  libroHarcoina,  Inuug.  Diss.,  Crpifswal.l.  IS.t-J. 


J 


CHAPTER    XXXIII. 

THE  SUPRARENAL  GLAND,  PITUITARY,  PINEAL  AND  CAROTID 
BODIES,  AND  COCCYGEAL  GLAND. 

THE  SUPRASENALS. 

The  suprarenak,  or  adrenals,  are  a  pair  of  organs  situated  at  tlie 
upper  end  of  the  kidneys,  with  which  they  lie  in  close  apposition. 
They  originate  in  the  same  embryological  elements  as  the  kidneys 

In  shape  the  suprarenal  gland  is  generally  compared  to  a  cocke<i  hat, 
and  consists  of  a  cortex  and  medulla,  encUwed  in  a  fibrous  capsule,  wliich 
sends  prolongations  into  the  interior  of  the  structure.  The  cortex  is 
composed  of  three  zones.  The  outer,  or  zona  glomerulosa,  consists 
of  numerous  .spherical  or  oval  masses  of  cells,  of  cylindrical  or  polyhedral 
shape,  containing  a  spherical  or  oval  nucleus.  The  middle  zone,  /ona 
fasciculata,  is  composed  of  vertical  columns  of  polygonal  epithelial  cells, 
having  a  spherical  nucleus.  The  protoplasm  is  clear  and  pale,  and 
the  cell-bodi  ;  are  usually  loaded  with  fat.  Between  the  colunuis  are 
fibrous  sep*a  containing  blood  capillaries.  Tl'e  innermost  layer,  the  zona 
reticularis,  is  formed  of  irregular  mas.ses  of  |x)lyhedral  cells,  the  various 
clusters  of  which  ana.stomose  one  with  the  other.  The  cells  are  .soinew  liat 
larger  than  those  of  the  zona  fasciculata,  and  are  often  slightly  pigmented. 
The  medulla  consists  in  cylindrical  clusters  o(  tran.sparent  cells,  wliicii 
are  polyhedral,  columnar,  or  branching.  The  i-ell-groups  here  also 
anastomose  with  each  other.  The  medulla  is  often  deeply  pignunted 
and  is  particularly  rich  in  bloodvessels,  non-medullated  nerve-tiliers, 
chromaffin  cells,  and  ganglia.  In  the  centre  is  a  large  vein,  surnmnded 
by  a  comparatively  large  amount  of  unstripeil  muscle. 

The  physiological  importance  of  the  suprarenal  glands  is  sointwliat 
obscure.  It  is  generally  acceptetl,  however,  that  ttiey  l)elong  to  tlii'  <  ale- 
gory  of  ductless  glands  and  elal»orate  an  internal  .secretion  of  git;il  im- 
portance to  the  economy.  The  great  vascularity  of  the  organs  and  the 
close  relationship  of  the  capillaries  to  the  groups  of  cells  siippoii  this 
view.  The  mascle  bundles  surrounding  the  central  vein  su^'i;'  ^t  a 
mechanism  for  contnilling  the  amount  of  blood  in  the  organ.  'I'lii-'  is 
possibly  regulatetl  by  the  sympathetic  .system,  the  SImts  and  gan-lia  of 
which  are  particularly  numerous  in  the  medulla.  Whatever  tiie  (iii'ilfte 
action  of  the  internal  secretion  may  be,  we  have  experimental  pi  >  > 
extracts  and  alkaloids  derived  from  the  mc<hilla  have  the  pnwe;  ■ 
tracting  blootlvessels  and  increasing  blood  pressure,  while  in  cast  - 
the  suprarenals  are  extensively  disorganize<l,  as  from  tul)erculou^ 
or  tumors,  cardiova-scular  phent)niena  and  asthenia  are  marked  Ir 


.!'  tliat 


'iiires. 


Fj 


ADDISON'S  DISEASE 


101 


'1  his  is  well  seen  in  Addiion's  diiwie.  In  th«  affection,  in  the  nriajonty 
of  cases,  caseous  tuben^ulasis  of  the  glands  «  found,  although  other 
"L  lesions,  such  as  tumors,  may  be  present  Add.son  s  d«fa««  ^o^ 
tot  however,  usually  result  unless  the  medullary  portion  is  largely 
Sro^r  Exceptional  cases  are  on  record  where  the  suprarenals  we« 
found  to  be  normal,  the  only  lesions  being  m  the  semilunar  ganglia  and 
thesolar  plexus  (see  also  p.  (>81).  ,     ,.,  i    _ 

Clinically,  the  disease  is  characterized  by  great  bodily  weakness, 
.ardiovascular  asthenia,  vomiting,  and  a  peculiar  P'^.T."*?'*""  "^X 
skin  and  mucous  membranes.  The  pigmentation,  which  is  brownish 
.xcurs  first  as  an  obscure  mottling,  but  soon  becomes  uniform.  It 
its  chiefly  the  skin  of  the  face.  neck,  hands,  flexures  of  the  joints,  and 
aiiv  parts  subjected  lo  irritation.  .        ,     •  *  .:„„ 

\Vhat  conn^tion  there  is  lietween  the  suprarenal  and  pigmentation 
of  the  skin  is  still  largely  unknown.  That  there  is  some  relation  is  imli- 
t!e.t  by  the  ?act  tha^in  negroes  the  glands  are  deeply  pigmented  (see 
also  p.  681). 

CONOKNITAL  ANOMALIES. 

Complete  defect  and  hypopUsU  are  rar^     T*  ^re  seems  to  l^  some 
relationship  In-tween  the  development  of  the  suprarenals  and  that  o 
the  brain,  for  in  hvdrocephalus  and  anencephaly.  hypoplasia,  partial 
i-.lasia,  and  fibrasis  of  the  former  organs  have  l)een  found. 

Aeceuory  BuprKewai  form  the  mast  common  anomaly.  Ihev  maj 
iH.  found  in  widelv  distant  parts,  in  the  capsule  of  the  suprarenal,  at 
tlie  hiliis  of  the  kidnev,  on  the  renal  and  spermatic  veins,  in  the  iver, 
„n  the  ovarv.and  Immd  ligament.  The  accessories  may  be  singe  or 
„n.ltiple,and  are  mor^  common  in  children.  Of  .special  interes  are 
those  fouml  in  the  capsule  of  the  ki.lney,  between  the  capsule  an<l  the 
...rtex,  or  within  the  kidney  substance,  since,  according  to  GrawiU  anU 
otLcrs,  these  misplacetl  "rests"  may  give  rise  to  tumors  (see  p.  /bX). 

OntOTJLATORT  DIBTUKBAHOM. 

Hyperemia.— Puiive  congestion  is  common,  und  is  met  with  under 

the  same  conditions  as  elsewhere.  ,  .,       i     j     :.i.„- 

Hemorrhaffes.— Hemorrhages  into  the  sulwtanc-e  of  the  gland,  either 
,„i„ute  or  larger  (hem»tom»)  art-  met  with  from  traumati-sm  at  birth. 
in  passive  congestion,  fatty  degeneration  of  the  vessels  'nflammat.on^ 
1,  ukemia.  and  the  hemorrhagic  diathesis.  Chiari  ha.s'  de.scnl>etl  a  case 
i„  which  the  hematoma  was  as  large  as  a  m"!"  «  h^^;!  .»"}  ^^'f* 
.'  kilos.     In  some  ca.se.s  calrijicailon  results  and  phleholiths  have  been 

ii!i,t'rveil. 

'  Wcigert,  Vireh.  .\rchiv,  UMl:  188.5:  17«:  u.  10.1;  1880:  204. 
»  Wieii.  intHl.  I'resHi-,  21 :  1880. 


•m 


702 


THE  SUPRAREXALS 


Woolley'  has  reconle<l  u  case  of  heinorrlmj;k-  intaretion  of  the  ri^'lit 
suprarenal  in  the  newborn,  due  to  thrombosii  of  the  central  vein. 


nmiMBCATIONS. 

Hemorrhagic  Inflammation. — Under  the  term  hemorrhagic  infliiin- 
mation,  Virchow  has  descril>ed  a  condition  in  which  the  supmreniil  is 
swollen,  thickenetl,  and  infiltrateil  with  blood.  Microscopically,  fatty 
degeneration  is  marked. 

Small  collections  of  inflammatory  round  cells  are  sometimes  met  with 
in  the  interstitial  substance  in  cases  of  infection,  pyemia  and  the  like. 
They  are  probably  due  to  emlwlic  infection. 

Fki.  1N4 


Karly  cu^pmus  tuberculcisiM  cif  the  !-i:|iriireiial  kI:iiii1.     I/eiti  <il>j.  Ni>.  7.  witluiiil  mill  ii 
(Krmn  t'.     ciillei'tion  uf  Dr.  A.  G.  Nictiolls.) 

Suppurative  Inflammation. — Suppurative  inflammation,  eitlur  l<Hal- 
ized  or  diffuse,  is  met  with  in  gcnend  septicemia.  Abscesses  cil  inn- 
sidcrable  size  may  result,  and  sometimes  burst  into  the  cnliiii  <ir 
du(Mlcniim.  The  suprarenal  may  be  secondarily  involved  in  iiill:iMi!iia- 
tory  pnKcsses  originating  in  the  kitlney,  and  (in  the  case  of  tin  li-lit 
supriircnal)  in  the  liver. 

Tuberculosis,  'i'lihcifulosis  of  the  suprarcnals  is  not  iii!< 
ill  cases  of  ailvaiicetl  <lisease  of  the  lungs  and  other  organs. 
miliary  graniilomata  may  often  lie  .swn  in  the  interstitial  sn 

'  J<)ur.  of  .M«hI.  Ilfscarcli,  Nrw  Scru-s,  2;  No.  2:  !iHl2:  2.JI. 


^:lill) 

inali 


TUMORfi 


703 


Larcer  caseous  ntxlules  may  lie  foun.l  occupyuiK  the  centre  of  the 
Uliiml,  and,  through  liquefaction  and  nei.wis,  may  convert  it  into  a 
kind  of  cyst.  Tuberculosis  of  these  organs  is  the  usual  lesion  found  in 
cases  of  Addison's  disease.  .        ,     ,  , 

Syphilis.— SN-philis  is  rare.  It  usually  takes  the  form  of  gumma. 
CoaRulation  nwrases  resembling  anemic  infarcts  have  l)een  met  with 
in  congenital  lues.' 

KETBOORADE  METAMORPHOSES. 

Atrophy.— Simple  atrophy  is  met  with  in  old  age  and  general  manis- 
ni.is.  and.  occ-asionally,  in  Addison's  disease.  The  chief  feature  is  the 
great  diminution  in  the  amount  of  the  fat  which  is  normally  present  in 

ill!  adult  suprarenals.  i        •.  .    i 

The  gland  is  often  found  to  be  softened  in  the  centre  and  cavitatecl. 
Tills  is  probably  a  postmortem  change,  although,  possibly,  in  some 
'  '.sc-s  this  mav  lie  assisted  by  careless  removal. 

Cloudy  Swelling.— rioudy  swelling  is  met  with  here  under  the 
same  conditions  as  elsewhere.  •       i      -.i 

Fatty  Degeneration.— A  true  fatty  degeneration,  asscKiatecl  with 
atrophy  and  disappearance  of  the  nuclei,  has  lieen  descril)ecl  in  connection 
Nvitl,  inarasimis,  anemia,  and  affections  of  the  heart,  lungs,  and  vessels. 
Amyloid  Disease.- Amyloid  disease  is  fairly  common  in  all  cases 
„f  widespread  amvloid  transformation.  It  affects,  chiefly,  the  walls  of 
the  capillaries  IwtWeen  the  coliimns  of  the  zona  fasciculata. 

Coagulation  Necrosis.— Coagulation  necrosis,  either  fcxal  or 
(litfuse  is  a  rather  common  condition,  met  with  in  puerperal  echunpsia, 
, hn.nic  tulH-nulosis,  and  a  great  variety  of  infections  and  intoxications. 
'I'lic  cells  of  the  zona  fasciculata  are  the  ones  usually  picked  out.  1  liey 
arc  opacjue,  turbid,  have  lost  their  clear  vesicular  appearance,  and  the 
niK-lci  stain  badly  or  not  at  all. 


PROGRESSIVE  METAMORPHOSES. 

Tumors.  Virchow'  has  described,  under  the  term  struma  Upomatosa 
suprarenaliB,  a  diffuse,  or,  cx-c-asionally,  a  ncnlular  overgrowth  of  tiie 
(.Hiidd  substance.  The  nodules  are  single  or  multiple,  scmietimes 
l.ilMt.ral,  and  may  reach  the  size  of  a  walnut.  They  are  veilowish  in 
(..lor  and  are  situated  in  the  cortex,  less  frecpiently  m  the  medulla.  •>»«•">- 
vcnpicallv,  the  growths  are  composed  of  long,  sometimes  branched, 
ii!,.-cs  of  cells,  similar  to  thcxse  of  the  zona  fasciculata,  containing  fat, 
an  I  often  pigment.  In  many  cases  the  connec-tive  tissue  is  increased. 
(      i.   degeneration  and  calcification  sometimes  cKTur. 

'  iM.kulH.,  Coiitralhl.  f.  allR.  Path,  und  path.  .\imt.,  14:  .N..s.  Hi  ami  17:  IWW. 
•  i  'ir  krankbafte  (jcschwiilsto,  2. 


704 


THE  SUPRARENAL8 


A  second  form  of  new-growth  has  also  been  descril»ed  hy  Virchow,  as 
a  gUoma,  which  takes  the  form  of  a  nodular  mass  in  the  medulla.  Tlie 
cells  composing  it  are  pale,  irregular  or  stellate,  faintly  granular,  with 
relatively  large  nuclei,  and  have  been  regarded  as  homologoas  witli 
those  of  the  normal  medulla.  The  tumor  may  be  as  large  as  a  ni.s|v 
berry.  A  ganglionic  nenroma  and  a  ganglioflbromjoiu  have  also  Imth 
described.  Upoma  is  said  to  occur.  Angioma  and  UTtmons  lymph- 
angioma' are  rare. 

Among  the  malignant  tumors  that  have  l)een  descnbed  are  urconus 
of  various  types,  round-celled  sarcoma,  myxosarcoma,  angiosarcoma, 
melanosarcoma,  lymphosarcoma,  and  carcinoma,  so-calle<l. 

Malignant  tumors  may  arise  from  the  cortex  or  the  medulla. 

Thase  originating  in  the  cortex  are  composed  of  cells  varying  more  or 
less  widely  from  those  of  the  normal  cortex,  but,  as  a  rule,  it  is  pas,sible 
to  make  out  the  transition.  The  cells  are  moderately  large,  polyliedral 
or  flattened,  containing  a  relatively  large,  oval,  or  irregular  nucleus  with 
a  deeply  staining chromatin-net.  The  interstitial  stroma  is  not  intenellii- 
lar,  but  surrounds  masses  or  columns  of  the  cells.  Multinucleated  cells 
are  numerous.  Such  tumors  from  their  histological  appearance  inislit. 
therefore,  be  called  careinomas.  In  view  of  the  recent  careful  studies 
of  Minot,'  Aichel,'  and  others,  however,  we  have  to  believe  that  the 
suprarenals  are  derived  in  their  entirety  from  the  Wolffian  Ixxly  and 
are,  c()nse<|uently,  mesoblastic,  or,  more  precisely,  to  use  Minot's  term, 
mesothelial.  Malignant  tumors  of  such  derivation  cannot  prop'rly, 
then,  l»e  termed  careinomas,  if  we  attach  to  this  name  its  usual  significa- 
tion. As  a  matter  of  fact,  these  tumors,  microscopically,  present  in  some 
cases  a  carcinomatous  appearance,  and  in  others  are  more  like  tiie  sar- 
comas. As  illustrating  this  point,  Woolley*  has  described  a  tmnor  of 
the  suprarenal,  resembling  a  carcinoma,  the  metastases  of  whith  in  the 
linig.  brain,  and  lymph-glands  were  indistinguishable  from  sarcoma. 
The  secondary  growths  in  the  lung  were  of  transitional  appearance, 
varying  fn)m  a  tumor  composed  of  polyhedral  cells  in  the  yonnpr 
portions  to  a  spindle-celled  form  in  the  older.  In  the  brain,  the  imta- 
stases  were  chiefly  composetl  of  round  cells.  Possibly  it  would  In- 
less  confusing  if,  with  Woolley.  we  speak  of  tumors  arising  from  the 
parenchyinu  of  the  adrenals  as  misothellomas,  irre.spective  of  tiiiii-  his- 
tological appearance.  .  . 

Tumors  composed  of  polygonal  cells,  with  oval  nuclei,  and  tontiumii^' 
gminilar  pigment,  have  \wen  de.scribe«l  by  Morris,  among  others.  I  litv 
are  strictiv  comparable  to  the  normal  inetlullary  structure.     Miili-niiiit 

new-growths  of  the  medulla,  however,  often  resemble  ordinary  i nl- 

celle<l  sarcoma. 


'  Ohrrn.iorfrr,  licit,  z.  allg.  Prttli.  u.  z.  path.  .\mif  ,  29:  l!tO!:.'i!0. 
'Tlio  Kml)ryi)l(>Kical  Basis  of  riith<ilo(f\-,  Science,  New  Series.  i:<:  l!KiI 
'  Veruleicliemlo  Kntwickl.  u.  b.  w.  der  Nebtni.  .\rch   f.  mikros.  Anat.,  ti''- 
•  .\  Primnry  ( "arcinomatoid  Tumor  (Mesothelioma)  of  the  .Vdrenals,  wi' 
atons  Metastases,  Trans.  Assoc.  Amer.  Phys.,  17: 1902:  ti27. 


;si. 
1 1 1'om- 


THE  HYPOPHYSIS  OR  PITUITARY  BODY  705 

Secondary  carcinoma,  ta-coma,  and  endothelioma  are  met  with  in  the 

'"The'^raURnant  tumors  originating  in  the  suprarenal  »«  Pa;^"J;|f'y 
liable  to  invade  the  veins,  and  metastases  are  usually  rapidly  produced. 
It  has  l^n  noted  that  they  are  liable  to  be  associated  at  the  same  time 
with  similar  tumors  of  the  thyroid  or  genitalia. 

It  should  be  remarked  in  concluding  the  discussion  of  tumors  of  the 
suprarenal  that  the  nomenclature  is  at  present  «^o'^"«'7;.  ^*'''  '! 
pe?haps  due  to  the  fact  that  the  exact  nature  of  many  of  these  ne«- 
CTOWths  U  open  to  debate.  It  is  the  fashion  nowadays  however,  to 
Lak  simply  of  all  tumors  arising  from  the  parenchyma  «*  t^e  suprarena 
oTof  supminal "rests"  as  hypemephromU  C«!«''-»'^^'ff ,^>.:  .^^V 
of  the  g^wths  called  by  the  earlier  writers  'ma  ignant  tumor  aUeola 
sarcoma,"  "carcinoma."  would  property  be  cla.s.sified  under  this  head 
(see  p.  768). 

THE  HYPOPHYSIS  OE  PirOTTARY  BODY. 

The  pituitary  body  is  a  peculiar  gland-like  structure  about  the  size  of 
.,  pea  sUua  ed  at  the  base  oUhe  brain,  to  which  it  is  attached  by  a  slender 
talk,      "weighs  usually  from  3  to  6  decigrams  and  fits  snugly  into  an 
exTavation  in  the  floor  of  the  skull,  known  as  the  sella  turcica.     It  is 
Generally  described  as  consisting  of  an  anterior  and  a  posterior  portion 
to.  ether  with  a  stem  or  infundibulum.    The  antenor,  or  glandular 
STs  crmposp  .  of  a  connective-tissue  stroma,  rich  m  cap.l  anes   in 
hie ,  are  e£beo.ed  rounded  or  elongated  masses  of  epithelial  ^Us  or 
acini,  rather  closely  packed  together.    The  cells  composing   ^ese  a«m 
"re  polvhedral.  round  or  oval,  and  are  of  two  main  varieties  chromo- 
.  ilkand  chromophobic.    In  the  chromophiUc  cells   the  cvtoplasmrs 
Lundant  an.l  contains  granules  that  stain  -l^'' "^^^^f  ^^^^t.  ^JI^ 
or  else  assume  a  purplish  tinge  with  hematoxylin.    Klotz,  working  at  the 
Uoval  Victoria  Hospital,  has  noted  the  fairly  constant  presence  of  clear 
lioulclear  cells  tL  have  an  affinity  for  acid  .lyes    The  eh^mophobic 
cells  or  "chief"  cells,  are  more  numerous,  smaller,  and  ha\e  a  ciear 
..v,„i>lasm.     According  to  Berkeley.'  the  nene  elenients  a^e  der.v«l 
tiun;  the  carotid  sympathetic  plexus.     At  the  periphery  of  the    obe^ 
an.l  especially  in  the  boundary  zone  between  the  t«x,  lobes,  the  ac  . u  are 
otVn  dilated  line<l  with  cubical  cells,  and  filled  with  ^vhat  appear   to  be 
,  ,  ,.lloid  substance,  which  is  also  to  be  seen  in  the  neighboring  Ijmph 

>li;iirs  and  vessels.  .         ,    .     i  u.-^io  ;a 

The  smaller  posterior,  or  infundibular,  portion  of  the  hjpophvsis  is 
con„H.se,l  of  vaicular  connecuve  tissue  in  which  are  numerous  spind  e- 
si,  .ped  or  stellate  cells,  often  pigmented.  The  structure  is  V^^'^f^ 
th.l  of  neuroglia.  Berkeley  has  reported  the  presence  of  ga"g''f  «"^ 
•vti.  ,v.o  ncn-e-fibrils,  hut  Kolliker  denies  the  existence  of  ner%e  elements 
ill  tliis  portion. 


<  Johns  Hopkins  Hosp.  Rep.,  4:  I'^O.'i:  2S.i. 


4.5 


70»1 


THE  PITUITARY  BODY 


In  the  iMHindurv  zone  l)etween  tlie  two  lol)e.s  the  ve.s.<»i  U  are  purtiiiiliirly 
ninnerons,  and,  in  man,  there  is  a  hiiolieil  cavity  '.ined  with  (iliiiicd 
t-ylindrical  e|>ithelinin. 

The  enibrvologicul  development  of  the  pituitary  is  curious  and  i^'- 
^testive.  In  the  ainphioxuit  and  ammcK-etes  there  is  a  duct  whicli  pa^^cs 
from  tlie  huccal  to  the  neural  cavity.  This  is  lin(*d  with  ciliated  epithe- 
lium, and  in  its  wail  are  glandular  structures.  N'er\'e-*'ells  are  ^roii|Hil 
al>out  the  end  which  connnunicates  with  the  ventricular  cavity.  .Vnd- 
riezen'  repanls  this  duct  as  a  nutrient  channel,  throu>;h  which  waitr, 
pipnent  granules,  and  other  substances  are  conveyeil  to  the  (rninii 
neurtd  canal.  With  (Jaskell,'  we  must  con.si«ler  it  to  lie  the  anterior  ex- 
tremity of  the  primitive  gut  or  neurenteron. 


Flo,  IM 


Kpiphuti*. 


/■.'<■((»/.  rm. 
MfKxlinit. 
'  h'nihulenii. 
Vrr.  rrtiiliiiittii'ii 

•  liuccul  ft'Oilitintii' 


:    — Chiiriin  di*nui}iit. 


Buccfil  cavity.       Pharynx, 

(liiiiinof  epiphyni^  (piiipal  rIhihI)  ulul  liytH)|ihy!*i!«  (cituitary  Klantt).  Tho  tilup  pan  r>.in- 
.••piiiKl^  (u  rlie  intpniiediiitp  hruiii  cir  tlialanienretihal.  The  red  part  i.^  a  purtion  nf  ttit*  luii  ral 
ei-tuilenii.  The  hypophyftin  i)»  formed  by  the  ciialewenc'e  of  two  evaginatioii!-  (after  Mihul<'i'\  ii -. 
at  inotlitied  hy  rhnn>y  ifi  Pctirier';*  Trait(5  d'anatumie  Hiiniaine.) 

In  man,  the  pituitary  has  a  twofold  origin.  The  anterior,  ;;l:iiiiliil:ir 
|M)rfion  rmginates  in  a  tliverticuluin  from  the  primitive  oral  ciivity.  in 
time,  the  proximal  portion  of  the  resulting  tul)e  InH-omes  constricttcl  mihI 
impermeable;  traces  of  it  are  frecjuently  to  l)e  detectetl.  Lan/crt  >i;iic> 
that  he  has  recognized  the  canalis  craniopharyngeus  in  10  per  < i  iit.  ol 
children  examined.  Suchannek  also  founti  in  a  chilil  a  proloii^'iitinii  of 
the  dura  mater,  surroimding  a  column  of  epithelial  cells,  whicli  eMiinleil 
fmm  flic  pituitary  thn)Ugh  the  sphenoid  Iwne  to  a  cul-tle-siu  in  tlie 
posterior  ]>ortion  of  the  pharyngeal  vault.  The  Laschka's  tonsil  marks 
the  -lite  of  the  term  i  nation  of  the  duct.     Occasionally  cysts  an-  ft';' •!  ;it 


Urit.  Med.  .lour.,  1:  ISIM. 
'  Till!  Origin  of  VerteliruteH,  l.ongiiian«,  Cireen  &  Co.,  lOflS:  321 


THE  FUXCTIOX  OF  THE  PITUITARY  BODY  707 

this  point,  due  to  closure  of  the  so-t-alled  pouch  of  Hathke,  from  which 
the  duct  Kprinfts. 

'I'he  posterior  IoIk"  is  fonne«l  hy  an  evagination  fn)m  the  floor  of  the 
primitive  midbrain,  the  cavity  of  which  i<«  in  communication  with  the 
central  neural  canal.  'I'lie  proximal  portion  here  also  liecomes  con- 
stricted and  forms  the  infundii)ulum,  the  lumen  lieinj;  in  time  j(enerallv, 
though  not  invariably,  c"  iiterated.  In  the  higher  vertebrates  the  two 
diverticula  just  descrilKxl  come  in  contact  and  unite,  but  do  not  com- 
niiuiicate.  The  mcMle  of  development  is  well  seen  in  the  accompanving 
diagram  (Fig.  lS,i). 

The  persistence  of  the  pituitary  in  some  form  or  f)ther  timmghout  a 
wide  range  of  animal  life  and  its  rather  complicate*!  structure  in  the 
higher  forms  suggest  that  it  plays  an   important  part  in  the  economy. 

Fl<i.  180 


Dincruii  I.,  illustrate  tlif  nititual  relatiim-hip  i.f  certain  nf   the  ilu<-tle»»  Klaiiil«.  and 
their  cimnet'tiun  wii'.  Uidily  development. 

The  nature  of  its  function,  while  still  obscure,  is  gra<lually  l)ecoming 
cleiirer.  Evidence  is  acciunulating  which  goes  to  prove  that,  like  the 
thyroid  and  the  suprarenals,  it  belongs  to  the  group  of  ductless  glands, 
iiml  elalwrates  an  internal  .secretion  of  im{M>rtance  in  metalmlism. 
Tliere  is,  for  instance,  a  .somewhat  clo.se  resemblance  to  the  thyroid  gland, 
wliith  is  generally  admitted  to  elalwrate  an  internal  secretion,  in  its 
vascularity  and  the  presence  of  acini  and  lymphatic  vessels  containing 
I  t.llt.id.  .Schnitzler  and  Ewahl'  have  also  demonstratetl  the  existence  of 
i'«line  in  minute  amounts  in  the  pituitary.  There  is,  further,  a  compen- 
-iiory  hypertrophy  of  the  organ  after  thyroidectomv  in  the  lower  animals 
( l{i)f,'()witch,'  Hofmeister'),  and  in  cases  of  atrophy'of  the  thyroid  (Boyce 
ami  Beadles*).  Then,  agiiin,  those  curious  anomalies  of'growth  ami 
'Irvvl.tpiiictit,  known  a.s  ai Ti>u»egaly  and  gigantism,  in  a  large  majoritv 
"f  the  cases  are  a.s.sociate<l  with  lesions  in  the  hy|K»phy.sis,  such  as  cvsts. 


'  W  ii'ri.  klin.  Woch.,  lS9(i. 

'  1  urt.>chrittc  der  Mctliziri,   1892. 


'  ZicKlcr's  Hcitriigp,  4:  1S,S<):  4.53. 
'Jour,  of  Path.,  1:  1893:  223,  359. 


708 


THE  PITUITARY  BODY 


hvpertrophv,  or  tumors.  In  acromegaly,  too,  the  thvroiil  has  ocasidii- 
ally  been  found  enlarge*!,  cystic  or  atrrohic,  and  the  diaea^'e  nay  U- 
complicated  with  myxiwlema  or  exophtnalmic  goitre.  There  a|«pears 
also  to  l>e  some  relatioiuship  be.*een  the  pituitary  an«l  the  genital  systi-in. 
One  of  m  (Xicholls)  some  years  ago  performed  an  autopsy  on  a  woman, 
about  thirty  years  of  age,  with  a  tumor  of  the  pituitary,  in  whom  there 
was  a  pronounced  infantile  c-ondition  of  the  sexual  apparatus,  and  a 
similar  state  of  things  has  been  note<l  in  the  male  (Pechkranz').  Geniial 
inadequacy,  genital  hj-poplasia,  and  malformation  have  also  been  fre- 
quently ol)ser\-e<l  in  acromegaly  and  gigantism  (Gamier  ct  Santenoise,' 
Thonw,' Babinski*). 

Thus,  as  the  earlier  anatomists  were  feign  to  make  a  fanciful  com- 
parison between  the  three  vital  centres— heart,  lungs,  and  brain— and  a 
tripod,  which  they  called  the  "  tripod  of  life,"  so  we  may  see  a  threefold 
relationship  between  the  ductless  glands— pituitarj-,  thyroid,  and  sexual 
glands— and  somatic  ilevelopment.  Although,  if  we  have  to  admit  the 
right  of  the  suprarenals  to  Ik-  classed  with  the  other  organs  contn>lhii); 
this  particular  form  of  metabolism,  as  seems  possible,  our  tripod  is  in 
danger  of  becoming  a  four-leggwl  stool. 

Other  phases  of  this  sidiji-ct  have  been  discussed  in  the  introduction 
to  this  section  (p.  67.')). 

OONOBHITAL  AHOMALIU. 

Partial  or  complete  pariiitene*  of  the  ductus  craniopharyngeus,  iiml 
eyits  in  its  course  have  already  been  referred  to.  Abunc*  of  the  pitiiiciiy 
bodv  is  verv  rare. 

«  • 

OXBOULATORT  DISTUKBAN0C8. 

Hjrperemia.— Ilyjiereniui  is  found  in  general  •    -'brid  congestinn  ami 

in  iiiHammatorv  and  circulatory  disorders  at  th  ase  of  the  brum. 

Hemorrhage.— Hemorrhage' into  the  |)oster  iobe  has  lieen  oIim  i\<<l 
(FlppingerJ.    It  is  often  agonal. 


INTLAMMATIONS. 


vlisei 


iISC  '  if 


iiiii~  a 


Inflammation  of  the  hypophysis  is  generally  secondary  t 
meninges  or  of  the  bones  at  the  base  of  the  skull.    Stengel''  in.iu 
case  in  which  the  anterior  lobe  was  inflamed,  apparently  from  int<e;Mn 
wh     .  reached  it  from  the  parotid  through  the  retropharyngeal  lyiii|.li;i!ns. 

>  Zuf  Casiii-itik  der  Hypophy«i«-Tiim<>rfn  Neurol.  Centralb!..  N<>-  -i:  1S'.".»:  -'•'■''■ 

» Arch,  de  neurol.,  March,  1808. 

•Text-book  of  Gen.  Path.,  1:  189(i:  19S,  English  eilition. 

«  Neurol.  .Soc.  of  Paris.,  7:  June,  lOOO. 

»  Text-book  of  Pathology,  ItMX):  790,  W.  B.  Saunders  &  Co.,  Philaaelpha 


TUMORS 


709 


Tllb«reill<»if .— Coiieniui  tubercles  have  been  de!icrii)ed  aa  occurring 
in  the  pituitary  by  Boyce  and  Beadles.' 

SypoiUfl.— According  to  LAncereaux,  the  pituitary  is  enlarged  and 
indurated  in  congenital  syphilis.    Gummas  have  also  been  met  with.' 

Paruitei.— A  few  cases  of  Echinococcut  cytU  have  been  obsened 
(Sommering,  Lancereaux). 


BBTXOOEIMin  MBTiJiOKPHOin. 

Atrophy  may  occur.  In  cretinism  ami  niyxcMlema,  the  sella  turcica  has 
l)een  found  to  be  enlarged,  quite  out  of  proportion  to  the  gland  resting 
in  it.  'Hiis  has  been  explained  as  due  to  an  mvolution  of  the  hvpophysis 
subsequent  to  a  previous  enlargement. 

I^rge  Mlloid  deposits  are  sometimes  found  within  dilated  follicles  and 
in  the  lymphatics.  \Miether  this  is  to  be  interpreted  as  due  to  over- 
activity of  the  gland  or  as  a  degenerative  manifestation  b  doubtful. 

Fatty  degeneration  of  the  cells  and  hyaline  changes  in  the  vessels  have 
lieen  described  in  old  people.  Amyloid  disease  of  the  bloodvessels  has 
been  observed  in  advanced  general  amyloidosis,  (kkarooai  deposits 
occasionally  may  be  found. 


PP  :<}RI88IVK  MITAMORPHMn. 

Vicarious  hyportrophy,  often  of  coasiderahle  amount,  has  l)een  noted 
iti  ex|>eriraentttl  thyroiilectomy,  fibroitl  goitre,  cretinism,  and  myxoedema. 

Tiiinor8.-4ltmma  or  goitre  of  the  pituitary  luniy  Is  a  condition  not 
always  readfly  distinguishable  from  adenoma.*  In  'it  the  organ  is  con- 
siderably enlarged,  owing  to  the  cystic  dilatation  of  the  acini  with  un 
excess  of  colloid  material,  together  with  proliferative  and  vascular  changes 
ill  the  stroma.  The  enlarged  pituitary  may  reach  the  size  even  of  a  hen's 
<>:H  and  produce  marked  pressure  disturbances  in  the  brain  and  floor 
of  the  skull. 

Cysts,  lined  with  ciliated  epithelium  an<l  containing  homogeneous  or 
^'laimlar  material,  have  i)een  descrilxHl  by  Weichselbauni.' 

<'onsidering  the  complicated  development  of  the  hvpophvsis,  we 
^hi  mid  expect  to  find  that  teratoid  new-formations  were  rather  common, 
l>ut  this  is  not  the  case.  Dermoid  cyiti  have  lieen  descril)ed  bv  Beck* 
ami  Weipert."  Hale  AMiite  has  reported  a  neoromyoma  composed  of 
Mriatcil  niu-scle  and  medullated  nerve-fibers.  Cvstic  tumors,  presum- 
alil.\  derived  from  the  infundibular  canal,  have  Ijeen  noteil  bv  Uaver, 
li'ikitunsky,  and  Langer. 

'Jour,  of  Path,  and  Bact..  1;  1893;  223  uii.i  3.">9. 

I  Iloktoen,  Trans.  Chicago  Path.  S«>c.,  2:  1897:  129. 

'■  Neuhildungen  der  Hypophysis,  Virch.  .\rchi^ ,  75:  1879:  iU. 

*  Tcrafoin.   Zeit.  f.  Hcllk.,  4 :  1883. 

'Teratom.  Virch.  Archiv,  7.5:  187.1. 


710 


THE  PITLITAHY  HODY 


Of  tht  Mtii|)ler  lieiujtu  Uimon  may  \ie  iiieiilionwl  Upom*  (^Weithsil- 
batiiii),  iiDgiOiM  ttml  ebuidnBU  (I^iK-trniux ). 

The  ti  st  im}H)rtant  j<n»wth.s.  however,  are  the  caniMaa  uimI  iw- 
evnuk.  Tl  .••.<■  i  .  ni  iliffuse  or  nmhilHr  mask's, «lestn»vinjc  the  MrtMliiri' of 
tlie gland,  UII.I  oifen  lemling  to  infiltration  of  the  Wrain,  optir  Inicis,  hikI 
base  of  !■  '•  I.  'i'liey  may  exten<l  to  the  tm.s<»|»lmrynx  and  tiliii. 
The  pi  n.;arv  It  ini:  mainly '  epililiwtic,  the  new-jjrowth.s  ori^imiiiii),' 
in  the  y  <  i  '1  -n- 1  are  |m)|'>erly  to  l)e  termetl  can-inomus.  Sarconuis 
pn)UM^  a  <  >•  fi'  n  the  sheath  of  the  ve*K-ls,  the  emhillu-lial  liiiiiii;^  i.f 
the  hi.H  t  aiul  Iv  ;iph-<haniiel.s,  ntMl  from  the  pia.  W«-  Imve  rtMl  with 
one  ca.>-  ■>)  «-  v'tl  Mm»,'  ami  amrther  of  pariUMlitl  »ngioiare*na. 

Ki...  IMT 


l  \'^    -•*.  V 


r^\i  **:  t;  V 


v*s;.- 


I'rriilirlial  ttiixii-arnmia  of  th»  iiiiuitary  b<«l'.       Winckrf  "bj.  No.  'i    wiih.uit  ...iiU 
(Kr..ni  III'-  i-.illfiiic,n  of  I'r    A    t;.  Nirli<>II>.| 

Secondary  tiunors  may  involve  the  hypophysis.      Colhoil  oim,,, 
and  milaiiomrroma  Imve  Ixf n  met  with. 

In  addition  to  the  j.'eneral  symptoms  of  hrain-fiimor.  yrowtli^  i- 
pituitarv  rather  early  involve  the  optic  tracts  and  otlur  <  raimil  mi 
in  the  nei>;h!M>rho<«l,  s!i  that  Mindness  aiid  various  Irx  il  iwirnlw 
met  with.     I'ronoimciHl  systemic  anemia  is  a  curious  symptom  "H  ^i 
ally  fomid.     The  explanation  of  this  is  not  ea.sy.     It  should  ik 
that  pituitary  tmnors  may  exi.st  without  the  sym|)toms  of  mnm  ■  ; 
iHH't.-iiiiu^   iii.tnifest.      iii  such   ca.scs  we  tiitt.sf   a.■s.^uliH'  «■■•-"  '•■ 
growth   has   progressml  .so  rapidly  that  death  has  (K-curnii  ii.t'i. 

'  S'c  .lames  SU-warl,  I'lie  .'Sympti>in«i"ii>({y  of   ruiiior-  IiiMilviiii!  ilii.ll-  i    ■  ' 
fertbri,  I'hilii.  M<mI.  Jour..  3:  18U9:  Il«.''. 


Ilw 
,irc 

(Ol- 
il.'o 


TIIK  rmOTlD  CLASH 


711 


.llspttse  cwiH  HWK-ar.  ilmt  ('oin(it>ii.sation  Im.s  tukrii  i)lm«'.  or  tliiit  (>m> 
iiUiiH  p.rtion  o^  iIh>  kIuimI  <>r  jH-rhaps  the  tumor  itH«-ir  has  li«rii  iiilt^iimtf 
ii>  siipplv  the  nwe^sarv  H(HT«*ti(tn. 


TBI  FDIIAL  OLAKD. 

Thi'  pitwal  >;I>ikI.  or  epiphysis,  is  fonneii  h\  u  <iiverti«ii|„iii  fn.in  the 
r<H)f  of  tJie  iHwterior  poiiioii  of  the  anterior  <-eirl.nil  vesi<  1.-.  /t  is  j;»ii,t- 
ally  U'liev*-.!  to  Iwve  im  function,  hut  Is  the  atn)phie<l  remnant  of  a  ( .  ntral 
fve,  which  is  s«inicwhat  lietter  markwf  in  certain  of  the  lower  uninmls. 

lli>toli>>ricallv.  it  loiwists  of  n  comiM-tive-tissue  sti  ,ina,  in  which  are 
iiiiiucrous  aive«>h',  interse«-te<l  Ia  fine  traheculie  and  fiHol  with  roiin.icl 
rclls,  often  iMiMses-iiiK  delicate  pn^esses.  The  follicles  also  confaii, 
...Msiderahie  "hrain  nam!  "  The  .irjpm  is  hijtlilv  vas<ular  and  <  ..ntains 
ii  plexus  of  sympathetic  ner^e-tiliers. 

The  ••piphvsis  is  eaafMtai  in  inHamnwtorv  o.n.  lit  ions. 

flamoniug*  into  its  sulistance  may  <«  ur  with  the  t.-nimtiou  of  u 
In:  iiiloina. 

Hyaline  de^'eneration  of  the  \   ssels  is  <lr  seril>ed. 

liic  talcart  MIS  matter  ina\  In-  notai  I'  increasjnl  (pummomt)  and 
IV -  ^  may  l>e  pr»'.sent. 

RyparpluiA  ami  tnmon  occur. 

S  rcoiaw'  is  the  mo,st  important  form.   Dtnaoid  cyst*  also  aif  descHU-d 


TBI  OAROnO  OLAND. 

^ln^  i>  a  small  InMly.  alMnit  I  to  .\  mm.  in  diain.  ■.  Ivinjr  in  the 
iMfiir.  iition  (,f  th,-  common  carotid  arter  slightlv  to  th.  ".sterior  side 
;'t  iIk  int.TiMd  carotid  ar'  ry  just  as  it  leaves  (I,  main  irunk.  At  first. 
II  «ii,  tli,)u;;lit  to  l)e  of  epithelial  oripn,  derivt  i.  like  the  i 
th  iiiii^  ^jlands  from  the  hranchial  clefts.  Thi  is  now  k 
>ii">rrc«t.  Ft  is  formerl  from  the  primitive  \as<  ular  nlii<i, 
•I  <['itlielioid  typ  which  l«-»()nie  he,i|>ed  up  at  i  li-  M>ini 
HTf  .oiifinuous  w.  I  th..M  -f  the  ves~<-|-wall.  T'  resulfiiif; 
'  "ln-»(l  in  adventitia.  .S<M)n,  eapttkry  v. 
( •iiniiiun  carotid,  eiiier  the  mass,  and  as- ;me  » 
iilii  Wiitii  eomplete,  the  j;land  is  t mk'1  >se<l 
-'■iia-  in  tmlieculic,  dividin-  it  int..  lol,ul. 
irtii,.  SI,"  ri>ini».s«l  of  a  tuft  of  capiji     1. 


I  lid  and 

II  to  he 
ini  cells 

i  at  first 
iii'dule  is 
:>Mn    the 


'  s,    deri'  t-d 
^n  not  unlike  a  _ioiner- 
a  fiiinnLs  cap^nlt-  which 
le  unit  of  struciurt'  is  the 

.  -r 'hat  unite  to  form  a  vein. 

Nv.ral  of  tl«..se  ccll-lmlls  are  in.lu.i.si  i,  ,.  |„l,ule.  Tlie  >;lomci,,le- 
lik.'  Miti-  are  surruniKltsl  l,y  c-  ii„i,|  ,.||..  arranged  in  cord,  or 
tnil,.-u, ,.,  which  have  an  oval  ..R-k-ns  urd  uiM-leoln-c  and  a  =:riui!i!ar 
|'i-'nj.ii,„n.  |i,.sides  thi-,.  the  strwtun^  contains  -anglion  cells  and 
'Wiiutluitc  filH-rs  deriveil  fmm  t  w  ,mi<-al  jprngli*"'-     There  aiv  ai.  . 


i  'irmr.  S|„tiillo-<-.  1K.,|  Sarcoma.  Tr:ii'-«.  I 


of  ijonAan,  1S.S.">, 


712 


UfL. 

1 

mm 

" 

THE  CAROTID  GLAND 

Fio.  188 


Turner  of  the  crolid  iland;  6>.  ve«*l.:  Bl.  hemorrhage  into  a  clumn  of  cell.;  at  d  il.e  cell,  ot 
,he  growth  are  takinii  on  a  more  connective-ti«.ue  tyi«;  at  c.  hyahne  degenerai.u... 


Kio.  189 


I'orlioii  of  the  same  tumor  more  hillhly  ma«nified  >o  .how  r>erithrli..mttl..u«  ^>"  ' 
of  the  n  •nor  cell-  in  relationi.hi|.  to  the  vascuUr  endotheUum.     n  an. 


THE  COCCYGEAL  GLASD 


713 


to  be  seen  certain  cells  possessing  the  same  affinity  for  chromic  acid 
(chromaffin  celb)  that  similar  cells  do  which  are  found  in  the  adrenals 
and  coccygeal  gland.  The  function  of  the  carotid  body  is  quite  un- 
known, but  it  is  undoubtetlly  connected  with  the  sympathetic  nervous 
system. 

Very  little  is  written  aljoiit  the  disorders  of  this  curious  little  structure. 
Probably  some  of  them  escape  obser\'ation  on  account  of  its  small  size 
and  from  the  fact  that  it  is  but  rarely  examined.  Some  eight  cases  of 
tumors  have  been  described,  all  of  them  removed  by  operative  procedure. 

Histologically,  they  are  perithelionuks  and  are  highly  vascular.  They 
are  composed  of  capillaries,  about  which  are  layers  of  epithelioid  cells. 
The  lobular  arrangement  of  the  gland  is  retained.  So  far,  no  case 
has  been  recorded  in  which  there  was  recurrence  or  the  formation  of 
metastases.' 

THE  OOGCTOEAL  GLAND. 

The  coccygeal  gland,  discovered  by  Luschka^  in  1860,  is  a  smajl 
body  about  the  size  of  a  pea,  situated  near  the  tip  of  the  coccy.x  just 
above  the  coccygeal  attachment  of  the  sphincter  ani,  in  the  small  tendin- 

Fiu.  190 


Si'i'iiun  of  ■  peritlieliiima  of  Luschka's  or  the  coccygeal  glaiiU.     (\  on  Hleb-Kosiaiika.) 

mis  interval  formed  by  the  union  of  the  levator  muscles  of  the  anus. 
Ill  structure,  it  somewhat  resembles  the  carotid  Ixxly,  and  is  composed 
'•'  iuiinerous  loops  of  blootivcsscls,  anastomosing  freely  with  each  other, 

■  lor  literature  see  H.  Gideon  Wells,  Ref .  Handbk.  Sled.  Sci.,  8 :  1904 :  413. 
-  Die  Stteisdruse  d.  Menscben.,  Vireh.  Archiv,  IS:  ISW. 


714 


THE  COCCYGEAL  GLAXD 


derived  from  the  middle  sacral  artery.  These  are  encloseil  in  one  or 
more  layers  of  granular  polyhedral  cells,  sharply  differentiating  if  fnnn 
the  dense,  fibrillar  connective  tissue  rouml  aixnit.  The  whole  structure 
is  surrounde*!  by  a  connective-tissue  capsule,  which  sends  in  tnibeculu' 
dividing  the  interior  into  a  numWr  of  lobules.  Sympathetic  nerve 
and  mascle  fibers  have  also  been  «lemoastrated. 

Its  function  is  quite  olwcure.  But  little,  also,  is  knrvn  about  its 
patholog,v.  Luschka  thought  that  in  it  he  had  found  tVie  starting  point 
of  the  various  tumors  of  the  sacral  region.  Subse<|uent  study  has  shown, 
however,  that  the  majority  of  these  are  to  be  classed  as  spina*  bifida', 
and  new-growths  derived  from  misplaced  "rests,"  or  teratomas,  and  liave 
no  connection  whatever  with  the  coccygeal  gland.  From  its  structnre, 
one  would  infer  a  priori  that  tumors  originating  in  this  organ  wonld 
assume  the  type  of  an  angitxsan-oma  rather  than  that  of  the  forms  just 
mentioned.  Klelw  has  described  a  eyitosueoma,  Fausto-Buzzi'  an  »ngio- 
ureoma,  and  Schmidt'  a  teratoma,  apparently  arising  in  this  little  buiy. 


'  Virch.  Archiv,  109:  1887,  9. 


>  Ibid.,  112:  ISSS:  :<72. 


SECTION  VI. 
THE  URINARY  SYSTEM. 


CHAPTER    XXXIV. 

THE  RENAL  FUNCTIONS  AND  THEIR  DISTIRBANCES. 

As  a  basis  for  understanding  the  pathology  of  any  organ,  it  is  essential 
tlmt  we  have  a  grasp  of  its  physiology.  Unfortunately  we  are  far  from 
I >eing  assured  aliout  some  of  the  most  basal  matters  regarding  the  normal 
functions  of  the  kidneys,  and,  as  a  result,  there  are  many  moot  points 
in  (-(jnnection  with  the  morbid  disturliances  in  thase  organs  ami  their 
significance.  Thus,  we  know,  from  a  study  of  the  liver,  that  some  glands 
possessing  excretory  ducts  may  perform  a  double  function— may  discharge 
ill)  internal  as  well  as  an  external  secretion,  Iwth  being  essential  parts 
of  their  activity;  they  may  so  metaliolize  the  material  lirought  to  them 
l>y  the  bloo«l  that  some  of  the  products  are  eliminated,  others  elalwratefl 
for  the  use  of  the  economy.  How  far  is  this  the  case  with  the  kidnevs? 
It  is  difficult  to  say. 

I'pon  general  grounds  it  may  be  laid  down  that  external  excretion  is 
tlic  iill-importan  '  mction  of  these  organs.  Embryologically,  the  kidney 
of  the  higher  aiiimal  is  the  homologue  of  the  segmental  ducts  of  the 
worms  and  other  lowlier  forms.  And  these  segmental  organs  are  tiil)es 
of  ilirei-t  communication  l)etween  the  Ixxly  cavity  ami  the  exterior, 
riiere  is  no  question  reganling  their  fuiiction;  'they  are  primarilv 
ex(  retory,  to  discharge  the  e.xcess  body-fluid,  tior  are  thev  of  sufficient 
leii>;ih  to  exercise  exteasive  al)sorption  from  the  fluid  pa.ssing  throtigh 
tlicin.  I.ater,  we  find  a  stage  in  which  the  kidney  p<xsses.ses  tul)es 
having  Iwth  a  funnel-shaped  orifice  into  the  Ixxly  cavitv  ami  gloni- 
eriili.  Higher  up  again  m  the  .scale  the  funnels  wholl'v  disap|>ear. 
llic  Klom-ruli  taking  their  place.  In  other  wonis,  with  the  "development 
of  the  lil(xxi-va.scular  .sy.stem,  the  di.srharge  of  fluid  is  from  the  bhxxl, 
.;"il  not  froin  the  body  cavity.  But  simultaneously  with  the  development 
of  t;li)ineri:li,  the  relative  length  of  the  urinarv"  tubules  undergoes  an 
»\tni  .r.linary  increase.  What  is  the  meaning  of  this?  The  cells  lining 
ni..c  ,  ibules  assume  further  the  character  we  have  learned  to  assfx-iate 


W!! 


I. 


-'cretory  cells;  they  do  nor  form,  at  lea.^t  .so  far  as  regards  tlieir 
•  oiikmI  portions,  a  mere  inert  lining-epithelium.  How  do  thev  act? 
I»"  tluy  di-scharge  material  taken  from  the  abimdant  surroumling'capil- 


ri6 


THE  RESAL  FUSCTIONS  ASD  THEIR  DISTIRBANCES 


lanes  into  the  lumen;  or,  on  the  c-ontrarv,  do  they  re.sorb  material 
useful  for  the  economy  which  has  l)een  flushed  out  of  the  blood  tliroiigh 
the  glomeruli;  or,  thirdly,  do  they  atx-omplish  Iwth  of  those  ohj»-<ts? 
Here,  on  jt^neral  principles,  we  are  foR-ctl  to  conclude  that  their  iiiaii( 
function  is  excretory,  with  discharge  into  the  lumen  of  the  tubules— and 
that  l»ecause,  when  "irritated  or  inhamed,  we  ol)ser^•e  that  it  is  the  portion 
of  the  cell  toward  the  lumen  that  undergoes  well-marked  breaking-down 
processes,  with  dissociation  and  discharge  of  its  sul)stance  into  die 
lumen,  the  discharge  often  taking  the  form  of  delicate  fluid  vesicles. 
So  also  it  may,  we  think,  be  laid  down  as  a  broad  principle  that  wliere 
a  glandular  surface  has  an  absorptive  function,  there  as  lai^e  and  not 
as  small  an  area  as  possible  is  provided.  The  stomach,  we  know, 
has  little  alworptive,  but  active  discharging  powers,  and  in  it  we  have 
abundant  long  tubules,  but  no  villi;  ab.s«)rption  of  foodstuffs  is  at  its 
height  ii  the  small  intestine,  and  there  we  find  abundant  villous  processes, 
affording  the  largest  possible  amount  of  surface.  The  structure  of  tiie 
renal  tubules  is  the  very  reverse,  the  largest  surface  is  exi)ose<l  lo  the 
surrounding  Ivmph,  the  smallest  to  the  contained  urine.  The  arraii<;e- 
ment  indiciUes  that  absorption  from  that  lymph  and  discharge  into  the 
lumen  is  the  main  function. 

It  was  considerations  of  this  sort  that  led  Bowman,  in  1S42,  to  pro- 
pound his  theory  that  the  glomerulus  "furnishes  water  to  aid  in  liie 
separation  of  the  urinous  products  from  the  epithelium  of  the  tnln'. " 
Nor,  must  it  be  confessed,  have  we,  in  the  last  sixty  years,  advancetl 
surely  verv  much  farther.  Only  two  years  later  Ludwig  enunciated  tlie 
"mechanical  theory,"  to  the  effect  that  under  blood  pressure  a  .lilute 
fluid  is  filtered  iti  abundance  through  the  glomeruli,  and  that  ilie 
function  of  the  tubular  epithelium  is  to  concentrate  this  until  it  a(.|Uires 
the  normal  character  of  the  urine.  But,  as  pointed  out  by  Ileidenimiti 
and  his  pupils,  there  are  many  objections  to  this  theory.  \Vf  shall 
not  enter  into  the  long-continuetl  contest,  or  describe  how,  uj)  i<>  the 
present  day,  the  battle  has  surged  to  and  fro.  For  onrseh.s  we 
cannot  accept  the  Ludwig  hypothesis,  if  only  because,  as  llii.l.nliain 
pointed  out,  so  small  is  the  amount  of  urea  in  the  blood  that  if  tins  »tre 
removed  by  mere  filtration,  then  no  less  than  about  70  kilos  of  tliiul 
would  have  dailv  to  be  filtered  and  resorl)ed  by  the  tubules  to  .xplani 
the  amount  of  urea  present  in  the  day's  urine.  This  is  asking  alioL'-ilur 
too  much.  Further,  we  have  the  fact,  curiously  neglected  t>>  tli-  ad- 
herents of  the  filtration  hypothesis,  of  die  existence  of  hvdron.i.hinsis. 
and  of  its  physiological  cause,  the  fact  that  tiie  pressure  iin.i.r  uln.h 
the  urine  is  dischargeil  into  the  pelvis  is  capable  of  l)eing  greater  tlnm  tlie 
bl(KMl  pressure;  there  is  no  escape  from  the  conclusion  that  i.ntiiaiilv 
this  indicates  an  active  excretory  prcness.  All  the  same,  we  \::,\v  to 
admit  that  it  is  <lifficult  to  bring  fo^^vard  absolute  evidence  in  l.i\Mr  of 
the  secretory  hypothesis.  Heidenhain  and  others  have  att.mi c  I  i" 
prove  the  matter  bv  demonstrating  the  passage  into  and  through  '"  <.ll> 
of  the  convolute*!  tubules  of  indigo-c-armine  an<l  other  Mil-'  'Krs 
which  are  rivogniza|)le  under  the  microscope,  ami  in  this  an  .  "ihtr 


'"^■i' 


OBSEHVATIOXS  OF  HEIDEXHAIS  ASD  OTHERS 


m 


ways,  there  has  been  aeriinnilHted  a  fair  amount  of  evidence  that  the 
ilifferent  regions  of  the  renal  tubules  subserw  different  functions.  But 
admittedly,  it  is  difficult  to  obtain  preparations  by  these  means  that  are 
alisoiutely  convincinj;  and  not  capable  of  two  interpretations;  nay,  with 
ordinary  carmine,  the  bulk  of  evidence  lies  in  the  other  direction. 

Dreser's  observations  and  the  conclusions  he  has  drawn  from  them 
present  the  same  ambiguitv.  We  know  that  the  bloo<l  and  lymph  are 
alkaline  in  reaction,  the  ..«rmal  urine  in  general  acid.  Dreser  em- 
ployetl  acid  fuchsin  as  an  indicator.  This  in  acid  solutions  is  of  brilliant 
red  color;  almast  c-olorless  in  weak  alkaline  solutions.  Injecting  the  dye 
into  the  dorsal  lymph-sac  of  a  frog,  the  urine  e.xcreted  in  the  course  of 
an  hour  or  two  is  of  a  brilliant  ret!  color.  And  now  the  glomerular 
repons  of  the  kidneys  on  section  were  found  to  be  almost  colorless,  i.  e., 
the  discharge  through  the  glomeruli  was  alkaline,  the  tubules  l)elow  were 
filleil  with  a  bright  red  fluid.  Here  it  will  he  seen  there  are  two  possi- 
bilities— either  that  the  cells  of  the  tubules  excrete  acid  iKxIies,  or  that 
they  absorb  those  bodies  which  give  to  the  lymph  its  alkaline  reaction. 
Were  the  latter  the  case,  the  cells  of  the  tubule.s  should  l)e  colorless.  This 
they  were,  as  a  matter  of  fact,  in  the  early  stages  of  such  experiments, 
liiit  on  repeating  the  injection,  they  assumetl  the  red  stain.  On  the  whole, 
this  staining  must  l>e  regarded  as  favoring  the  secretion  hypothesis, 
'i'here  is,  however,  indubitable  evidence  from  (Jurwitch's'  experiments, 
that  in  the  frog  the  convoluted  tubules  excrete  pigment  matter.  In  that 
animal  there  is  a  separate  bloixl  supply  for  the  glomeruli  and  the  tubules 
rtsijcctively.  If  the  tubular  blcMxl  supply  (through  the  renal  portid 
vein)  be  cut  off,  no  pigment  appears  in  the  urine,  although  the  pigment 
has  free  access  to  the  glomeruli.  The  glomeruli  and  the  cells  of  the 
convoluted  tubules  in  the  frog  have  the  same  general  architecture  as  those 
ill  man,  ami  this  to  a  striking  degree,  and  it  would  seem  that  if  excretion 
(Mciirs  through  the  epithelium  in  the  one  animal,  it  mast  l>e  the  same  in 
the  other.  Hosier,  by  forcing  pigment  into  the  tubules  from  the  ureter 
found  no  ai>sorption,  althougli  under  similar  conditions  sugar  and  ferro- 
(Viiiiide  solutions  were  absorl>ed  and  appeared  in  the  urine  of  the  other 
kidney.  What  is,  however,  most  in  favor  of  the  secretion  hypothesis  is 
a  consideration  of  the  metaiiolic  and  constructive  pnxesses  undergone 
ill  ilie  kidney.  One  of  these  lla!^  l>eeii  known  for  long.  Hippuric  aci 
i>  one  of  the  normal  coastituents  of  the  urine;  it  can  l)e  synthesized  an^ 
ex< ivtwl  by  the  passage  of  glycine  and  benzoic  acitl  through  the  vessels 
of  the  kidney.  The  conversion  is  not  found  to  take  place  in  other  organs ; 
it  i^  a  function  of  the  kidney  tissue;  it  is  inconceivai)le  that  it  occurs  in 
the  •,'loineruli;  we  must  conclude  that  it  is  bnmght  alniuf  by  the  epithelium 
of  ihe  tubules.  Uric  acid,  again,  is  a  most  insoluble  substance;  the  abun- 
daiiie  of  the  same  in  the  urine  of  birds  is  such  that  we  cannot  believe 
that  it  j)asses  out  of  the  glomeruli  in  that  form.  In  fact,  we  have  indica- 
t!i>i!<  tliat  it  Is  not  present  in  the  blootl  as  the  acid,  but  as  a  more  soluble 
si"h'ii-i  salt;  while  the  researches  of  the  late  Sir  William  Roberts  indicate 


'  Pfliigcr's  Arch,  f.  d.  fles.  I'hvsiol.,  !»1: 1902  :71. 


71.S       THE  RESAL  FIXCTIOXS  ASD  THEIR  DISTURB  A  XCES 

tlmt  even  in  the  renal  tubules  of  the  binl — and  of  man — it  is  first  <ii>- 
chargeil  as  a  fonipounil  salt,  the  "quadriurate,"  which  underlies  iliss<>- 
ciation  with  liliention  ami  deposition  of  the  urio  acid.  It  is  further  note- 
worthy that  uric  aiid  intHMliicetl  into  the  human  economy  appejirs  Inr^'cly 
in  the  urine  a.s  urea,  while,  contrariwise,  urea  fe<l  to  birds  reap|H'ars  as 
uric  acid.  When,  further,  a.s  pointed  out  by  Ciowland  Hopkins,  wt- 
obsene  that  the  renal  excretives  are,  as  a  cla.s.s,  more  complex  or  less 
stai)le  than  their  immetliate  precursors  in  the  iKMly.  it  is  difficult  not  to 
conclude  that  the  terminal  steps  of  nitrogenous  nietalM>lisni,  wliercliy 
urea,  uric  acid,  hippuric  acid,  creatinin  and  other  iKxlies  appear  in  tlic 
urine,  are  very  largely  ct)ntrolle<l  by  the  renal  epithelium. 

The  Vasctilar  Supply  of  the  Kidney.— The  distribution  of  the 
1>1(kmI  ill  the] kidney  i.s  not  a  little  remarkable,  and  possibly  throws 
some  light  upon  the  mechanics  of  urinary  excretion.  In  the  first  place 
the  arterial  supply  of  the  «)rtex  passes  almost  entirely  to  the  glomeruli. 
A  study  of  injected  specimeas  shows  that,  with  rare  and  inconsideralije 
exceptions,  the  interlobular  branches  of  the  wirtical  arteries  pass  to  the 
glonieridl,  <-onstituting  the  afferent  arterioles.  The  effereiit  vessels  frt)m 
the  glomeruli  break  up  into  an  intricate  meshwork  of  capillaries  aroinni 
the  convoluted  tubules.  On  the  other  hand,  in  the  medulla  the  blood 
supply  of  the  collecting  tubules  is  by  a  capillary  network  prtHcedinj; 
•lirectly  fnim  the  arteriie  rec-tie.  All  are  agree<l  that  the  main  bulk 
of  the  water  in  the  kidney  jMi.sses  out  of  the  delic-ate  walls  of  the  glomeru- 
lar tuft.  Cut  off  the  glomerular  blood  supply,  as  in  Nussbaiun's  well- 
known  experiment  upon  the  fr()g  (which  has  a  double  blcMxl  sniiply 
through  the  renal  arteries  supplying  the  glomeruli,  and  the  renal  portal 
vein  supplying  the  tubules),  and  the  .secretion  of  urine  immetliately  falls 
to  almost  nil.  It  follows,  therefore,  that  the  blood  c-irculating  in  the 
cortical  capillaries,  in  having  already  parsed  through  one  capillary  >ystein 
(that  of  the  glomeruli),  is  Iwth  more  concentrated  and  under  a  lower 
pressure  than  that  supplying  the  collecting  tubules  in  the  ineiiulla. 
\Yith  a  dilute  urine,  that  is,  in  the  convoluted  tubules,  atui  a  low  eMeniiil 
bliMKl  pressure,  we  c-an  imagine  a  resorption  or  reverse  filtration  of  the 
urinary  water  from  the  tubules.  These  coiLsi«lerations  would  xrin  to 
favor  i.udwig's  theory,  but  the  .same  line  of  thought  would  sii<:i;i>i  that 
if  this  the<iry  \w  accepteil,  when  the  urine  reaches  the  collectinj.'  iiilndes 
its  greater  i-oncentration,  and  the  higher  capillary  blcKKl  pressure  >hould 
favor  additional  discharge  of  water  from  the  bUxnl  into  the  iiilmlts. 

That  the  di.schargt'  of  urine  is  largely  determined  by  circiilatoiy  (  nudi- 
tions  must  l)e  clearly  accepted;  re<luce  the  general  blixxl  pressure  I >>  any 
means  to  40  mm.  Ilg.  or  Mow,  and  the  flow  of  urine  iraM-.;  in.  n ase 
the  amount  of  bhxxl  cin-ulating  through  the  organ,  as  by  lifiiitniiiL'  ihf 
arteries  ptissing  to  imjiortant  areius  of  the  Ixxly,  and  the  flow  i^  -naily 
increased.  Ludwig  laid  down  that  it  is  the  blo«xl  pressure  iliai  n:  •>  li.iii- 
ically  determines  the  flow.  Heidenhain,  on  the  other  liaifi.  |  iiired 
out  ihat  if  the  renal  vein  l)e  ligatetl,  the  kidney  liecomes  enorniMM  !>  <on- 
gestJtl,  the  bhxxl  pressure  within  it  is  greatly  increa.sed,  and  n-  .  ilieless 
there  is  a  complete  stoppage  of  urinary  flow.     It  is,  he  po>iii!    •  d.  the 


THE  SEHVt:  SUPPLY 


719 


ntie  of  blood  flmc  througli  nuher  than  the  lilcMid  pressure  in  the  glomeruli 
that  iletemiines  the  <Rs<lmrKe.  He  concluded  that  with  arrest  of  bloo<l 
fl(.w.  the  glomerular  epithelium  l)ecomes  asphyxiated,  swollen  and 
uiiahle  to  fuiK-tion.  Ludwig,  on  the  other  hand,"  expkine.1  the  results 
lis  due  to  the  intease  capillary  congestion  causing  compression  and  ol)- 
striHtK.n  of  the  urinary  tubules.  The  rapid  resumption  of  urinary 
.lischurge  m  the  inflamed  and  congeste<l  kidnev  which  follows  EdelM>hl3' 
(>|)cwtion  of  decortication  of  the  ki.lney,  or  excision  of  its  capsule 
favors  Ludwig's  explanation;  hut.  on  the  other  hand,  it  deser^■es  note 
that  the  tren«l  of  nxKlern  work,  as  repre.sente<l  hy  the  studies  of  F.  Muller 
and  Marchand  and  his  schwi.  is  to  ascrilie  the  oliguria  of  acute  nephritis 
more  anil  more  to  glomerular  lesions  rather  than  to  mechanical  disturh- 
aiices  of  the  circulation. 

From  the  alxne  data  it  will  be  seen  how  difficult  it  is  at  the  present 
time  to  reach  any  precise  conclusion  reganling  the  nature  of  the  urinary 
disc  liarge.  On  the  whole,  we  conclude  that  while  the  water  of  the  urine 
IS  III  the  mam  discharged  through  the  glomeruli,  along  with  sundry 
simple  soluble  .salts  an<l  other  sulxstanc-es  (peptone,  grape-sugar)  that  <li.s- 
cliarge  is  not  a  simple,  but  a  selective  filtration,  and  that  while  in  the 
imssage  down  the  tubules  there  may  l)e  a  resorption  of  certain  constitu- 
ents of  the  discharge,  this  resorption  is  of  secondary  importance  com- 
I)arwl  with  the  active  excretion  of  such  substances  as  urea,  uric  acid 
aii.l  other  "extractives."  Inxlies  of  the  nature  of  toxias.  coupled,  (t 
wo.il.l  seem,  with  active  analwlic  pro^es-ses  to  fonn  bodies  like  hippuric 

The  Nerve  Supply.  -The  nenes  passing  to  the  kidnev  form  a 
hm-  plexus  surrounding  the  renal  artery.  Varioits  experiments  have 
shown  that  the.se  nen-^  are  very  largely  vasomotor  in  function,  although 
{.rkelcy.  m  lis  admirable  studies  of  the  terminal  distributi.m  of  the  nene 
lilanients  within  the  organ,  by  means  of  (lolgi's  methcxi.  has  demonstrated 
th.-  existence  of  a  wide  network  of  filaments  throughout  the  cortex  and 
MH'.lullH  with  end  knobs  upon  the  Bowman's  capsules  and  other  termina- 
ti'.Ms  iH'iietrating  the  niembrana  propria  of  the  convoluted  tubules,  an 
arran^rement  which  suggests  strongly  that  these  nerve-filaments  are 
>.rr,..„ry  ,„  function.     It  is  the  v«.soinotor  effects  that  have  lieen  most 

St  I  III  It'll. 

S,rti<)ii  of  the  spinal  conl  in  the  cenical  region,  by  removing  the  in- 

t^ii.m-,.  of  the  mam  medullary  va.scmiotor  centres,  'leads  to  a  diffu.se 

•lii^i  at.on  of  the  arteries  of  the  trunk,  and  lowering  of  the  blotxl  pressure 

'''"'"•%•  f^r  under,  with  which  the  urinary  discharge  is  completely 

a  n.,,e,l.     I  he  renal  vessels,  along  with  the  others,  are  relaxtnl.  but  at 

!"■  snne  ime  the  bl.H,d  flow  is  .so  much  diminished  that  the  organ  lessens 

^y-v.     If.  after  such  .section  the  renal  ner%es  W  divi.lcl.  ami  now  the 

'I M..I  rm  en,l  of  the  cord  l>e  stimulate.1.  there  is  proimunc-ed  general 

-  ot  bUx  pressure  and  rc-sumption  of  the  urinaiy  flow.    Such  section 

"  '■  renal  nenes  lea.ls  to  vasomotor  paralysis  in  the  organ,  and  if 

.  'l"M  ,1  alone  is  a  so  followed  by  increased  flow  of  urine,  in  toaseciuence 

"'  'I'-  augmented  blood  flow  through  the  organ.    Stimulation  of  the 


720       THE  RENAL  FVSCTIONS  AXD  THEIR  DISTURBANCES 

renal  nenes,  on  the  contrary,  causes  contraction  of  the  organ  ami  its 
vessels,  and  diminished  urinary  flow.  The  o»Jser>ations  here  are  similar 
to  what  is  observetl  with  organs  and  vessels  in  general,  namely,  timt 
disturbance  of  the  tonic  vasoconstrictor  ner\es  may  be  demorislrutp.1 
with  fair  ease.  That  vasotlilators  also  exist  has  been  shown  by  Brad- 
ford;  appropriate  stimulation  of  the  anterior  roots  of  the  eleventh, 
twelfth  and  thirteenth  dorsal  nerves  leads  to  definite  expansion  and  con- 
gestion of  the  kidney  without  alteration  in  the  general  bloo<l  pressure. 
As  Starling'  points  out,  it  is  extremely  probable  that  such  vasodiliitor 
stimulation  ia  the  cause  of  the  extreme  hydruria  encountered  in  hystenn 
and  other  nervous  affections— and  we  may  add,  of  the  polyuria  of  emo- 
tional states.  Similariy  the  anuria  following  catheterization  is  liest 
ascribed  to  reflex  extreme  vasoconstrictor  effects. 

Recognizing,  thus,  the  profound  influence  that  the  nervoas  system 
has  upon  the  amount  of  the  urinary  discharge,  it  may  be  asked  what  h 
the  mechanism  wherebv  that  discharge  is  controlled.  The  only  satis- 
factory answer  at  the  present  time  is  that  the  amount  of  unne  exiivted 
is  primarily  dependent  upon  the  glomerular  blood  supply,  and  this. 
in  Its  turn,  depends  upon  the  tonus  of  the  interlobular  arteries.  It  is 
the  relative  contraction  or  tlilatation  of  these  arteries  that  determines 
the  amount  of  blood  entering  the  glomerular  system.  Histolo^'Kully 
a  striking  feature  of  the  arteries  in  question  is  the  good  development  of 
their  muscular  coat.  Berkeley  was  unable  to  find  any  nerNe-Hlaiiients 
passing  into  the  glomerular  loops;  or  otherwise,  we  have  no  evuleiiee 
of  independent  contraction  and  expansion  of  the  glomeruli;  tlies«.  are 

^It'E  to  repeat,  the  afferent  vessels  that  primarily  determine  the  l.l.xid 
supply,  and  so  the  extent  of  excretion  of  the  urinary  flui.l.  (jnly 
secondarily  the  constituents  of  the  blood  as  they  act  upon  the  cai.illarv 
walls  in  the  glomeruli  mav  influence  their  filtration  capacity.  As  with 
the  arterioles  in  general  (pp.  25  and  26),  we  have  to  recognize  that  con- 
traction and  expaiLsicm  of  these  arterioles  may  \w  brought  alM)ut  .ither 
by  central  ner^•ous  influence,  or  dire<'tly  by  the  action  of  suLsiancs 
diffusing  out  from  the  circulating  blexxl.        _         ^  .  _.       .^ 

The  Relationship  between  Circulatory  Disturbances  and  Chrome 
Interstitial  Nephritis.— Wliere  there  has  been  a  history  of  lo;'ir- 
continued  rise  of  general  blo<xl  pressure,  there  we  are  apt  to  li'i'l 
the  muscular  coat  of  the  cortical  arteries  hypertrophied— an  in.lKation 
of  continued  increased  functional  activity,  and,  whether  from  .Alnnie 
contraction  or  from  the  later  condition  of  " emlartoritis  ol.litdaiis 
certain  glomeruli  undergo  hyaline  degeneration  and  »)«ome  . ..im.l.tei> 
imperN-ious.  These  now  are  represented  as  soli.l.  sli  .  xeii,  tiaii  p.^rem 
bodies,  and  are  a  characteristic  feature  in  the  e-ontn  ..ed  areas  oi  tne 
gi.;  ular  contracted  kidney  of  chronic  interstitial  nepLitis.  J  i-'  sim- 
plest explanation  of  this  liyaliiie  degeneration  is  that  it  is  a  n..  ■  .lo  k- 
change  imluce<l  by  the  progressive  diminution  of  the  I.!"..!    'ijipi., 

•  Schiifcr's  Physiology,  1:1S98:(W«. 


CONCLUaiOSS 


721 


through  arteriolar  contraction  and  obliteration,  preceded  bv  a  swollen 
state  of  the  glomerular  epithelium.  It  is  to  be  noted  that  where  certain 
){lomeruli  show  this  degeneration,  others  in  their  neighborhood  exhibit 
the  condition  (of  compensatory)  hypertrophy,  and  may  be  of  twice  the 
normal  diameter,  with  strikingly  large  capillary  loops;  and  these  it  would 
seem  are  more  pervious  than  normal,  for  in  this  condition  of  chronic 
interstitial  nephritis,  instead  of  there  being  a  diminished  excretion  of 
urine,  there  is  apt  to  be,  on  the  contrary,  an  increased  passing  out  of 
thin,  watery  urine  of  low  specific  gravity,  containing  a  small  amount 
of  albumin,  or,  otherwise,  these  distended  glomeruli  permit  an  abun- 
dant discharge  of  fluid  through  their  thinned  walls,  and  with  this,  some 
••M-ape  of  albumin  from  the  blood  plasma.  Frietlrich  MUller  is  of 
opinion  that  this  increased  discharge  is,  in  part,  due  to  a  modification 
ill  function  of  the  epithelium  of  certain  tubules.  That  epithelium 
liecoines  flattened  and  endothelial  in  type.  This  indicates,  he  holds, 
that  now  it  permits  the  freer  passage  of  fluid.' 

Vucnlar  Disturbancai  and  their  BeUtionibip  to  Ohrosic  Inter- 
stitial Nephritis.— We  shall,  in  the  ensuing  chapter,  describe  the 
ilifferent  forms  of  the  contracted  kidney— the  postinftommatory,  follow- 
iiiK  Jipon  an  acute  nephritis,  the  atrophic  or  senile,  and  the  arterio- 
sclenjtic.  It  is  this  last,  and  the  form  allied  to  it,  that  we  here  refer  to, 
|H)iiiting  out  that  a  similar  sequence  of  changes  occur  in  the  cortex' 
when  there  is  intimal  overgrowth  with  obliteration  of  the  vascular  lumen, 
hikI  when,  without  .such  overgrowth,  hypertrophy  of  the  media  aiul  c-on- 
tnution  of  the  arterioles  lead  to  degeneration  of  certain  of  the  glomeruli. 
Ill  either  ease,  if  the  glomerular  supply  be  cut  off,  the  capillarv  network 
connetted  with  the  efferent  vein  of  the  affected  glomeruli  (1)  receive 
no  urine,  and  (2)  have  an  impoverished  surrounding  blood  supply.  As 
II  result,  they  undergo  atrophy,  and  shrink  until  they  are  representetl  by 
(ohiinns  of  small  cells  with  a  scarcely  visible  lumen,  and  as  they  .shrink 
tlicre  is  some  compensatory  overgrowth  of  the  surrounding  interstitial 
(oiinective  tissue.  Thus,  as  not  all  the  interlobular  arteries  and  their 
l)ni(Khes  are  similarly  affected,  we  find  areas  of  hyaline  glomeruli  and 
shriiiiken  tubules  with  interstitial  fibrosis  alternating  with  other  areas 
"f  'hstended  glomeruli  and  large  tubules  with  large  lumina.  This  is 
III'  («inmonest  type  of  so^alled  chrtmic  interstitial  nephritis,  a  con- 
iia.  twl  granular  kidney,  and,  we  would  emphasize,  in  this  the  primarv 
ItMci  would  seem  to  be  arterial. 

Conclusions.  -To  siun  up,  it  would  seem  that  the  (|iiantitv  of  urine 
'  iM  liiirjied  depends  directly  upon  the  quantitv  of  bloo«l  flowing  through 
t  If  ;:l<.meruli.  This  hlcKxl  flow  depends  iii  the  first  place  upon  the 
<litr,.rt.n<-e  between  the  pressure  in  the  renal  artery,  and  that  in  the  renal 
vtiM.  If  the  arterial  pressure  be  increased  w'ithout  increase  in  the 
v<iM.iis,  then  the  flow  is  greater,  and  the  urinary  excretion  increases; 
ii.  "II  ilie  contrary,  through  local  obstruction  or  cardiac  incompetence, 
111'  |)rtssure  in  the  renal  vein  be  raised  without  corresponding  rise  in  the 


4(i 


Verhandl.  d.  Deutuch.  pathol.  Gesellnch.,  .Meran,  9: 1905;  73. 


722       THE  RKSAL  Fl'SCTIOSS  A\D  TIIKIR  DISTVRBASCm 


arterial  prcMiire,  the  urinary  exrrrtion  i.i  (limini.shni.  At  the  .tame  time 
the  .size  of  the  arterial  t-haniieLH  in  the  kidney  ha.s  to  lie  taken  into  ati ■oiiiii ; 
not  only  is  there  inrrea-ied  excretion  when  the  general  arterial  preMiin-  ii 
raised,  hut  without  rise  of  this  ^>neral  pressure,  if  the  interlobular  nntl 
afferent  arteries  l>econie  dilated,  there  is  increased  blood  flow  uihI 
increased  excretion,  while,  contrariwise,  if  without  alteration  of  the 
)(eneral  blood  pressure  the  afferent  arterioles  underfp  contraction,  lli» 
((lonierular  circulation  is  diminished,  and  with  this  the  urinarv  excretion 
falls. 

Poljmria. — AcconlinR  to  these  funeral  principles,  polyuria  and  in- 
creasetl  excretion  of  urine  may  l>e  Imiuf^ht  alMUit  (1)  by  increase  in  the 
(general  arterial  pressure  without  renal  change,  or  (2)  dilatation  of  tli»- 
cortical  arterioles  without,  «»f  necessity,  any  rise  in  the  }(eneral  1>I(kh| 
pressure.  The  condition  of  diahetea  hmipidun  would  .seem  to  come  iirnlcr 
the  se<x)nd  catejjor}'.  Here  we  encounter  an  excessive  di-schnrj^i-  of  u 
thin,  watery  urine  free  from  sujpir.  There  is  a  ten«lency  towuni  incri'iiscd 
excretion  of  urea  (in  the  twenty-four  hours),  althou);h  this  is  attribiiit-il 
to  the  increa.se<l  c«>nsumplion  of  fiMNl  which,  as  in  dia1)etes  mclliii  s,  is 
often  |)resent.  \  marke<l  featurt*  of  this  disturlmnce  is  the  fn'(|iniit 
presence  of  inosite  in  the  urine.  Inosite,  <\Hii^'«'  '•''  *  '"cnzene  dcrivmive 
found  in  muscle,  liver,  and  other  or^^ns,  and,  it  may  lie  added,  Mtn 
nlsu  in  (lie  urine  of  other  |>utiioiof;ical  conilitions.'  The  condition  has 
often  ixH-n  notetl  as  uffectinj;  several  meml»ers  of  the  same  family.  In 
other  ca.ses  Imiin  lesions  have  lH*en  pn'.sent,  affecting  the  |)ons,  cerclK'lhiiri, 
or  medidlu.  This  suggests  that  »hslurlmnce  of  the  va.somotor  (rnlns  in 
the  medulla  may  play  a  mle.  K>p<'rimentally,  as  .shown  by  ('l.inile 
liernard,  a  similar  polyuria  may  Ite  brought  about  by  injury  to  the 
medulla,  and,  jis  already  noted,  transient  polyuria,  evidently  of  the  siiiu- 
onler,  is  seen  in  hysterical  and  emotional  states. 

With  this  increa.sed  discharge  there  is,  broadly  sjK'aking,  a  cornN|  Mind- 
ing decrease  in  the  total  .solids  of  the  urine;  the  solids,  that  is  ir  -ny, 
are  redutwl,  although  the  re<luction  of  the  different  constituents  i>  not 
parallel,  and  individual  cases  show  variation  in  its  extent.  Tin  total 
amoimt  of  scxlium  chloride,  for  example,  is  in<le|)ende!it  of  the  aiiiniint 
of  urine,  suggi-sting  that  the  escape  of  the  .salt  is  governe*!,  ami  is  not 
a  mere  act  of  flltration. 

These  considerations  lea<l  tc»  a  referen(v  to  the  action  of  tlinniics, 
and  the  rec()gnition  of  a  very  [M)ssil)lc  thinl  factor  in  the  pHnliK  iiin  of 
polyuria.  Of  .such  diuretics  there  are  two  groups:  those  in.!  uin); 
heightencil  blood  pres.sure  plus  inipn>ve<l  cin-ulation  thmiigli  Oi> 
ney,  of  which  digitalis  is  an  example;  and  tho.se  having  little  or  :i  ■ 
upon  the  general  IiIocmI  pressun-,  among  which  are  to  l)c  iiulnl' 
.soluble  crystaHoid  .sub.stances — dextrose,  urea.  .siKlimn  chloride,  ai' 
.saline  diureti<"s.  Regarding  the  former  there  is  this  to  Ite  iioi'  ' 
drugs  which  cause  heightened  iihxtd  pressure  ac<ompli.sh  ilii^  ' 
traction  of  the  arterioles,  and  thus  we  must  conclude  either  ■     i 


ki.l- 

ir.-ct 

t  ihf 

illlIT 

ihal 
tlie 


'  See  MeiUdre,  InoHurie,  I'uris,  lOtXV. 


OLItlUHIA  ASb  ASVHIA 


723 


.liiiivtic  Mieml)erM  oi  iliw  ^nxip  have  a  spwific  lack  of  action  upon  the 
niial  vessels,  or  that  the  rwe  in  blood  pressure  more  than  eom|»ensates 
till-  contraction  of  the  renal  vessels.  As  a  matter  of  fact,  the  drug  that 
ciiiises  the  most  extreme  arteriolar  contraction— adrenalin— materially 
rt^liires  the  How  of  urine,  and  digiulls  is  often  without  diurvtic  effect  uiwn 
iii.iividuals  in  sound  health.  As  reganis  the  hitter,  it  is  still  a  matter  of 
<l«l«te  as  to  whether  they  act  by  kxal  specific  dilatation  of  the  renal 
vessels  (for  the  kidneys  exhibit  distinct  enlarjjement),  or  directly  stiuiulute 
ilif  n-nul  cells,  their  «lischarKi'  through  these  beinj?  accompanied  by  an 
iiiiiiMin(  of  water  necessary  lo  retain  them  in  a  state  of  solution.  It  has 
I)!-*!!  urneii  that  all  these  salts  alwtract  water  from  the  ti(Mues,  render  the 
l.liM.I  more  Imlremic,  and  so  favor  increasetl  filtration;  the  fact  that 
tli.s«-  salts  initiate  excretion  when  added  to  the  blocxl  perfu.se<|  throu>;h 
llif  ivtirpated  kidney  supfxirts  the  other  evideni-e  we  i>«i.s.se.ss  that  these 
Miits  arc  lar>{ely  disciiarj^ed  thmugh  the  tubular  epithelium,  thaf  thev 
fX«T(  isc  a  dire«'t  secretory  influence. 

Oligori*  and  Anuria.  Alonj?  similar  lines  it  is  to  l>e  laiti  down  that 
nslii.iion  or  suppression  of  urinary  How  can  l»e  broujjht  al  out  { I )  i)v 
ilir.ct  (•ontraction  of  the  alfcrcnt  arterioles  (as  throufjh  tl  •  action  o*f 
mlrctmlin),  (2)  by  a  lowerinf?  of  the  arterial  pressure,  or  (.'»;  a  rise  in 
tlic  venous  pressure.  These  last  two  may  la-  combined  and  expressed 
l.v  sayiiij;  that  a  re«lu<tion  in  the  differencr  l)etween  arterial  and  venous 
|)rtssiire  leads  to  oliffuriu.  Kxamples  of  lowered  arterial  pressure  have 
alrcaily  l>een  ({iven;  of  raised  venous  pressure,  the  oliguria  accompanying 
(il>strn(tive  heart  ilisease  is  the  commonest  example.  A  fourth  cause 
iHcds  to  l)e  taken  into  consideration,  namely,  obstruction  to  the  out- 
How,  ;.r()vi.l»tl  that  this  affects  lH)th  kidnevs.  Such  obstruction  mav 
(xriir  ttithii.  the  renal  tubules  through  bl.H-kage  of  the  same  with  in- 
s|)iss:itcil  e\(rctii)!i,  as  ill  renal  hematuria  and  hemoglobinuria,  or 
iiluiij;  the  coursf  of  the  ureters  atid  (lassages  of  discharge. 

.\>  \vf  have  stated,  there  is  still  delmte  as  to  how  far  the  oliguria  of  acute 
nephritis  is  due  to  sw.  Iliiig  of  the  tubular  epithelium  and  obliteration 
of  Ihc  liiiiu'i)  of  the  tubules  as  a  result  of  congestion;  how  far  it  is  due  to 
(.'loiiiiriilar  disturbance.  At  the  Meran  meeting  of  the  German  Patho- 
l-.KKal  SiHiety,  Frietlrich  Muller'  laid  down  verv  preci.selv  that  the 
oli^'iiria  of  acute  nephritis  is  correlated  to  the  extent  of  glomerulonephritis 
foiiM.  present.  The  acute  swelling  of  the  glomendar  epithelium  fol- 
ovvcl  l,y  pmliferation  r.f  the  same,  arr.sts  the  function  of  these  organs, 
bolilem,-  fnnn  Marchand's  lalwratory,  has  made  an  extende«l  studv  of 
the  Kl"i"erular  changes  in  different  forms  of  nephritis,  and  concludes 
tliiii  i\No  tyiH-s  of  acute  nephritis  are  to  lie  .letermined:  (1)  in  which  the 
tMlm  i.r.pithelium  alone  is  involveil  (kidneys  of  cholera  ami  diphtheria. 
ot  Mil.hmate  poisoning,  and  many  kidnevs  of  pregnancy;  such  kidnevs,  ' 
"ttiMi;  lo  the  great  regenerative  power  of  the  tubular  'epithelium,  m'av 

'  \ '  riiiiiidl.  ,1.  Dcutsch.  Pathol.  C.pHollsch.,  (t:  Iflai:  (M. 

■I,l.,r  ,lio    entziin<llichen    Veranderungen   dcr   Glomeruli   der    monsclilichen 
Mw...   Leipzig,   Hirgel,   1907. 


724       THK  HESAL  FVSCTI0N8  ASD  THEIR  DISTURBANCIS 

undergo  rapW  and  complete  healiiist);  ""d  (2)  what  he  would  limi 
Hcute  nephritw  proper,  in  which  th*-  - '  »merul(  are  characteristically 
invoiveil.  Of  this  the  classical  example  ?.  he  Mcariatinal  kidney.  ll.re 
the  extent  of  the  tubular  change  appeai  >  to  depend  upon  the  !«ev«riiy 
of  the  jflomerular  change.  Of  chronic  \  .nns  of  the  disease,  hp  Ihvh 
down  that  chronic  parenchymatous  nephritis  (chronic  nephritis  with 
dropsy)  is  a  later  stage  of  unhealed  glonwnilonephritL:,  or  a  scpiic 
glomerulonephritis  of  insidious  origin.  So  also  the  "secr>ndar\-  (on. 
tracted  kidney"— the  contracted  khiney  following  upon  acute  neplmti> 
shows  ifgulariy  changw  in  the  gkHneruli,  exhibiting  transition  stamps 
to  those  seen  in  the  acute  disease. 

HydlMltphrOBif . — ObstructkNi  to  the  • 
mulstion  of  urine  in  the  oelvis  or  pelvis  ■  u.l 
atrophy  of  the  affected  kidney;  if  in       ■?'■ 
the  condition  of  hydronephrtJsis.     It 
pressure  of  60  ram.  Kg.  within  the  rer 


How    leading  to  the  !i<'<'ii- 

•ter  •,  if  complete,  U-uils  (o 

tnd  intermittent,  imiucefi 

generally  aocepieil  timl  a 

vis  causes  complete  iirivst  (if 


urinary  ex»Tetion,  and  if  continued,  so  compresses  the  renal  capillnripg 
that  now  the  epithelium  undergoes  atrophy.  If  continue<l,  the  ulni[>liy 
is  rapi<l.  If  some  escape  of  urine  be  possible,  with  intermittent  iiu  rtiiM-d 
pressure,  there  is  dilatation  of  the  pelvis  and  more  gradual  i-«inipr<Nsi(m 
and  atrophy  of  the  kidney  substance,  which  may  continue  until  the 
kidney  is  represented  by  a  multisacculated  cyst  of  great  size,  the  wiill-  of 
which,  but  a  millimeter  or  two  in  thickness,  still  contain  indications  of 
atniphied  tubules  and  glomeruli. 

QoalitetiTe  Ohaoffet  in  the  Urine. — ^lliere  may  be  pnniDuiKiMl 
variati»>fis  in  the  relative  amounts  of  the  normal  constituents  of  the  urine 
-  the  urea,  uric  acid,  phosphates,  chlorides,  and  other  suits,  and  (lie 
urinarv  extractives,  kreatinin,  etc.,  and  the  pigments  or  unKliroin- ,  as, 
again.'bodies  not  present  in  the  normal  urine,  or  present  in  alnuMf  inlini- 
tosiinal  quantities,  may  be  discharged  in  notable  amounts.  Anion;;  ilipse 
are  various  proteins,  more  particularly  serum  albumin,  serum  ^tlolmiin, 
hemoglobin,  albumoses  and  nucleoproteins,  dextrose,  lactose  and  lt\u- 
lose,  pentose  acetone,  diacetic  and  oxybutyric  acids,  homogentiMc  and 
uroleucic  aci«ls  (alkapton),  cystin,  indican,  phenol  and  other  iir..„miK- 
compounds,  bile  pigments,  foodstuffs  and  drugs  absoriKnl  frum  the 
alimentary  canal  and  discharged  without  modification  (egg-alLiinnn 
when  taken  in  excess,  methylene  blue,  etc.),  erythrocytes,  lenku.ytcs. 
etc.  In  our  first  volume  we  have  discussed  the  greater  numlnr  n;  ihcse 
and  their  significance.  Here  we  must  only  note  those  whose  yu  .nee 
in  the  urine  is  associate«l  with  gross  disturbance  in  the  renal  inc. '.  .niMu. 
t  -  Albuminuria.— Various  proteins  may  appear  in  the  iirr 
clmage<l  from  absorbed  food,  as  egg-albumin  after  an  excessiw 
raw  eggs,  mucins  in  inflammatory  or  degenerative  states  of  tlic  ' 
n,„.]e,^lbijmin  and  nucleinic  acids  from  flisintegratitni  of  t' 
parenchyma  (although  these  liodies  may  also  be  derived  fn)in  tli 
passages  and  bladder).  But  these  are  inconsiderable  in  atn 
fre<iuency  of  appearance,  as  compared  with  serum  album  n 
serum  globulins.     It  is  with  these  latter  bodies  that  we  ai- 


iiii- 
Itt  of 
Ili'V.s, 
;.;,al 
;iiary 

iiiid 
I  the 
.ially 


PLATE   VII 


M..r.,.,„  of  an  afreccl  „lomerulu,.    The  «.om«ru,ar  loop,  are  ph.n,,..  w,,,, 
Bii  mcTeased   number  or  nuclei 

.eui!!:;,'l;v;''!«"„;.!;':;;7;'''rr"^''i''  ''■'i'^'  ''""•" """'  «'"''i^™.i.,„  ,.„,i „. „ 


QUALITATIVE  CHANGES  IN  THE  URINE 


725 


concerned  when  we  speak  of  albuminuria.  They  are  the  dominant 
proteins  of  the  blood  plasma,  hence  their  presence  in  the  urine  in  the 
main  indicates  an  abnormal  escape  of  these  colloidal  constituents  of 
the  fluid  of  the  blood. 

This,  in  the  first  place,  may  be  laid  down  with  precision;  unlike  the 
oniinary  capillaries,  the  glomerular  loops  do  not  normally  permit  the 
escape  of  the  proteins  of  the  plasma.  Take,  on  the  one  hand,  a  per- 
fectly healthy  kidney  imme<l lately  after  death;  cut  off  small  pieces  of  the 
cortex,  and  plunge  into  boiling  water  or  a  solution  of  corrosive  sublimate, 
unci  make  sections;  the  capsule  chambers  of  the  Malpighian  bodies  are 
found  perfectly  free  from  any  coagulum.  Take,  on  the  other  hand, 
the  kidney  of  an  animal  in  which  by  one  or  other  means  albuminuria 
has  l)een  induced;  repeat  the  process,  and  now  in  many  of  the  capsule 
chambers  larger  or  smaller  menisci  of  coagulated  albumin  are  to  b<> 
seen.  It  is  clear  from  this,  in  the  fir^t  place,  that  albumin  does  not 
normally  filter  through  the  glomeruli  to  be  subsequently  resorbe<l  in 
its  passage  down  the  tubes;  and  in  the  second,  that,  when  albuminuria 
develops,  the  main  discharge  is  through  the  delicate  walls  of  the  glomer- 
ular tuft.  In  the  frog,  and  even  in  much  higher  animals,  the  presence 
of  long  cilia  in  the  neck  or  first  part  of  the  renal  tubule  iiinders  regurgita- 
tion of  urine  fn)m  the  tubule  into  the  rapsule  chimber;  this  albumin, 
tiierefore,  cannot  have  lieen  excreted  in  the  first  pluce  into  the  convoluto-i 
tiii)ules. 

Is  this  the  only  source  of  the  albumin?  Probably  not.  It  is  inher- 
ently probable,  that  is,  that  in  acute  nephritis,  with  the  active  disintegra- 
tion of  the  tubular  epithelium  there  occurring,  the  products  of  the  broken- 
down  cells  swell  the  amount  of  albuminous  bodies  present  in  the  urine. 
So,  also,  when  the  tubular  epitheliimi  becomes  so  disorganized  that  it  is 
cast  oiT  and  the  naked  basement  membrane  alone  left,  albumin-containing 
lymph  may  exude  into  the  damaged  tubr'es;  and  thus  in  acute  nephritis 
with  diminished  urine,  and  that  so  full  of  albumin  that  in  heating  it 
clots  into  a  solid  mass,  it  may  well  be  that  the  tubules  as  distinct  from 
tiic  ^'lomeruli,  have  contributed  a  considerable  proportion  of  the  proteins. 
Mut  in  the  milder  and  more  chronic  cases,  we  are  safe  to  conclude  that 
tlic  hulk  of  the  albumins  have  been  discharged  through  the  glomeruli, 
litre  it  is  of  interest  to  recall  that  cell-disintegration  is  not  necessarily 
:i-Mi(  ia'ed  with  the  presence  of  albumin  in  the  urine;  casts,  the  coagulated 
|>ri"hicts  of  cell-disintegration,  may  be  present  in  urme  that  gives  no 
rem  lion  for  albumin.  Most  often  the  albumin  consists  of  serum 
ulliiiiiiin  alone,  l>ut  the  proportion  may  vary  within  wide  limits,  and 
MjiL'uire'  and  others  have  recorded  cases  in  which  the  globulins  alone 
tt.Mv  |)resent,  or  with  traces  of  serum  albumin  so  small  tltat  they  could 
iii.r  1,1  estimated.  And  this  notwithstanding  that,  according  to  Salvioli, 
•portion  of  albumin  to  globulin  in  the  bltxKl  plasma  (roughly ."}  :  2) 
inrkably  constant,  and  that  from  their  constitution,  the  globulins 
I  Ih"  the  more  diffusible.     Here,  we  have  some  of  the  strongest 


thf  'riiii 


Lancet,   Lon.lon.   1:  1S8(J:  10ti2  and   1100. 


72i>       THE  KKSAL  FVS'CTIOSS  AXD  THEIR  DISTURBANCES 

evidence  that  the  glomeruli  are  not  simple  filters,  hut  exert  a  seletlivc 
or  controlling  influence  upon  the  fluid  passing  through  their  walls. 
What  then  are  the  conditions  favoring  albuminuria  ?  'I'liis  (juestion  is 
jH-rhajw  lH*st  answereil  by  detailing  the  conditions  under  which  allm- 
niinuria  is  encountered. 

1.  Phyiiological  Albamiitniia. — Albumin  is  apt  to  appear  in  the  urine 
after  cold  Itaths,  and  violent  exertion,  the  latter  more  particularly  if 
partaken  of  in  the  morning,  soon  after  change  from  the  supine  to  the 
erect  position.  In  these  i-onditions  it  is  supposed  that  glomerular  ((m- 
gestion,  with  dilatation  of  the  capillary  l(M»ps,  favors  the  exudation. 

2.  Oyelieal  Albnmiiuixik.— This  is  noie<l  more  es|)ecially  in  lM>yliiNHl 
and  adole-scence,  although  cases  are  on  recojtl  in  which  it  has  continiitd 
into  adult  life.  The  subjects  may  appear  to  lie  in  excellent  health,  Ixil 
usually  they  eompkiin  of  tiring  easily.  The  charai-teristic  featun-  is 
that  albumin  is  alxsent  from  the  urine  passed  on  rising,  but  after  iliis 
makes  its  appearance,  rising  rapidly  in  amount  until  the  forenoon,  dis- 
appearing in  the  afternoon.  In  some  of  these  cases  paraglobulin  idime 
is  present.  Here,  again,  the  change  in  the  circulation  ai-compaiiyint: 
the  change  from  the  resting  to  the  erect,  active  state  would  appear  to  Ite 
a  primary  factor,  although  with  it  there  must  l)e  assume<l  a  peciiiiar 
sensitiveness  or  idiosyncra.sy  of  the  glomerular  .epithelium.  The  condi- 
tion may  follow  scarlet  fever,  in  which  we  know  that  the  glomeruli  ;irc 
IKfuliarly  liable  to  Ik*  affe<'ted,  and  has  l)een  note<l  after  other  fexcrs. 
There  is  no  clear  evidence  that  this  form  pa.sses  on  to  chronic  nepliiiiis, 
although  Dukes,  one  of  the  first  to  call  attention  to  its  frequency  aiMon<; 
sclnH)llK)ys,  has  placed  on  reconl  ca,ses  in  which,  after  disapjK-ariiiKe. 
it  has  shown  itself  again  yt-ars  later  under  various  stresses. 

.'{.  Albuminuiia  from  OircnUtory  DistnrbuiMS. — Anything  which  ni;ii<Ti- 
allv  slows  the  rate  of  bl<M)d  flow  through  the  kidneys  favors  tlie  >u|>rr- 
vention  of  albuminuria,  and  this  presunmbly  by  partial  asphy.xiji.  ami. 
therefore,  imperfect  function  of  the  glomeruli  with  »)r  without  tlilaiaiion 
of  the  capillary  UK)ps.  Thus,  on  the  one  hand,  c<;'>raction  of  tlic  nnal 
arteries,  as  in  leatl  colic,  or,  more  commonly,  on  the  other,  various  oli- 
stnictions  (as  from  heart  ilisease  or  hnal  obstruction  of  the  renal  \tin> 
is  a<-(  <>nipani«Hl  by  a  definite  grade  of  albuminuria.  In  tin-  fonnt  r  i  a>f 
then'  is  lowentl  pressure  in  the  glomenili  and  renal  capillaries,  in  the 
latter,  heightene<l  pressure.  In  both  forms  the  amount  of  urine  «  \. n  tol 
is  n'(luce«l.  In  lK>th  cases  also  it  is  possil)le  that  the  niahniiiiihii  of 
the  tulndes  leads  to  some  tlisinfegnition  of  the  parenchyma,  an. I  io  a 
contributory  all)uniinuria  from  this  cause. 

4.  Toxic  Albuminuiia.  There  are  various  drugs  which  a|ii":ii  t<> 
act  nioH'  ])articularly  on  the  tuttules-  to  Ik-  ••xcrctcd  thnnigh  thox- 1 iii.iilcs 
and,  indwil,  to  influence  sjKiifically  particular  n*gions  of  tin  -iiiii'. 
I'erhaps  the  most  marked  examples  have  Iktu  afTonUnl  from  Ij  lidis 
lalM»nitory,   Leva<liti'  and    Hehns-  having  shown  that  vinylan    i  and 

'  Arch,  inti'rimt.  dc  I'haniiariHlynaiiiir  ft  'I'licnip..  S:  I'.KIl :  I-' 
Ml>id.,  |i.  I!MI. 


JL 


ClIYLVRIA 


727 


m^\ 


tftrahydro<|iiinoleTne  caase  a  iiwrosis  strictly  localized  to  the  papillae 
ami  colle<'tiiig  tubules.  More  often,  as  by  sublimate  and  cantharidin, 
the  convoluted  tubules  are  involved.  Some  of  these  in  their  action 
iiiiluce  a  well-marke«l  albuminuria.  Here,  we  include  chrome  ami  various 
otiier  metallic  salts,  cantharidin,  varioas  balsams,  several  iiacterial 
toxins,  ami  the  so  far  unknown  toxic  suKstance  of  the  eclamptic  state. 
.\s  already  noted,  Lohlein  and  others  doubt  whether  the  degenerative 
clianges  set  up  by  these  agents  should  l)e  classe<l  as  true  nephritis. 
With  some  of  these  there  is  evidence  of  atromjianying  glomerular  dis- 
liirimnce,  but  in  general  the  parenchymal  disturbance  is  so  severe  that 
we  may  attribute  the  albuminuria  mainly  to  this  caase. 

.').  Infectious  Attminiiniria. — As  laid  down  on  page  724,  the  typical  acute 
nephritis  of  infectious  disease,  notably  of  scarlatina  and  strept(X'occal 
conditions,  is  characterize*!  by  pronounce<l  irritation  and  disturbance  of 
tlie  glomeruli,  and  here  in  general  we  find  the  most  abundant  discharge 
of  iiiliimiin.  'ITie  disturlmnce  in  some  cases  is  so  acute  that  there  is 
iin  escape  of  blood  corpuscles  through  the  glomeruli  (acute  hemorrhagic 
ncpliritis).'  With  these  changes  there  develop  also  notable  disturbances 
of  the  parenchyma,  with  cloudy  swelling,  fatty  tlegeneration,  necrasis 
and  (les(|uamation.  More  rarely,  as  in  scarlatina,  there  may  l)e  asswi- 
atcil  an  acute  interstitial  nephritis,  with  accnimulations  of  plasma  cells 
between  the  tubules. 

Hemoglobinuria. — Besi<les  the  hematuria  alwve  mentioned,  there 
may  !«•  escape  of  dissolve<l  hemoglobin  into  the  urine.  Experimentally, 
this  may  l)e  brought  about  in  a  variety  of  ways,  by  introducing  substances 
into  tile  circulation  which  caase  hemolysis  (large  quantities  of  water, 
jtlyctrin,  pyn)gallic  acid,  toluylenediamin,  etc.).  In  disease,  hemoglo- 
l)iniiria  also  follows  acute  hemolysis  (after  snake  bite,  pota.ssium  chlorate 
poisoning,  and  in  pamxysmal  hemoglobinuria).  We  have  discussed 
ihtM-  conditions  in  our  first  volume  (p.  SS()),  and  only  n'fer  to  them 
lure  to  note  that,  as  shown  by  one  of  us,*  it  is  pixssible  to  deinon- 
sirate  the  dis<harge  of  hemoglobin  through  the  glomeruli  when  the 
lilood  pressun'  is  so  low  that  amiria  has  set  in,  as  also  to  obtain  a  urine 
containing  three  times  the  amount  of  hemoglobin  present  in  the  l)loo<l 
plasmii.  In  other  wonls,  the  pri'sence  of  hemoglobin  in  the  urine  is  due 
to  ac  tive  excretion,  and  not  mere  filtration. 

Chyluria.— Rarely,  we  encounter  cases  in  which  the  urine  is  diluted 
"itii  lymph.  Such  chyluria  may  |)ersist  with  exacerbations  over  long 
ytiiis.  Wlien  due  to  rt'iial  disturbance,  the  cause  is  now  generally  rc- 
tTiitilnl  as  a  lymphangiectalic  condition  affe<-ting  the  papilla-,  with  rup- 
iiiiv  of  one  or  more  of  the  dilafe<l  vessels. 


\-  ''iirnil  well  ixmiiKmI  out,  thi-  riiiLsiilc  chaml)rr  of  ilir  Kloiiit-riili  may  Im-  roiii- 
|i:iv.i|  Willi  a  serous  mic  like  tlii'  |M'ricuritiiliii  or  pleural  ra\  itv.  It  may  Ih"  affected 
li\  ti.i  siiiie  Keries  of  acute  iiitlamiiiatiiry  cliati(ji's.  anil  with  coiitiinieil  subacute 
"ill  iiHiiiatiou  may  show  pnililerative  rliaii)!<>s  in  its  epitlielium  auil  the  ilevelopmeiit 
"!     Ml.  (Ilia  anil  locali/.eil  ailliesiuns. 

■>l  iiiii.  Jour,  of  IMiVNJol..  (i:  ISSii;  ,JS2. 


CHAPTER    XXXV. 

THE  KIDNEYS  AND  URETERS. 

THE  KIDNIT8. 
OOMOSNITAL  AND  AOQUIBID  ANOMALIU. 

Thj^k  consist  lai^elv  in  defeotive  ilevelopment  and  ahnonnulities 
in  size,  "liaiM-,  {Kxsitiun,  and  aiiatutuical  structure. 

Aplasia. — One  or  other  of  the  organs  may  be  absent  (aplasia)  in 
j)e«p|p  otherwi.se  perfectly  formed.  'ITiis  occurretl  three  times  in  one 
tliousund  autopsies  of  our  series.  According  to  Ballowitz,  in  57  jier  <-eiit. 
of  cases  it  Ls  the  left  kidney  which  is  defective.  The  condition  is  usually 
of  no  great  oiKisequence,  a.s  the  remaining  kidney  undergoes  compensatory 
liypeq)la.sia.  The  occurrence  of  the  ctmdition  should  be  remenjlH-nHl  in 
connection  with  surgical  operatioas,  however,  for  ca.ses  have  l)een  known 
where  the  only  kidney  was  removed  for  disease,  with,  of  course,  disastrous 
results.  As  a  rule,  the  corresponding  ureter  is  absent,  although  (Hcasion- 
ally  a  rudiment  of  it  may  lie  found  connected  with  the  l)ladder.  Where 
only  one  kidney  is  present  it  is  often  long  and  narrow,  suggesting;  the 
su(>erposition  of  one  kidney  upon  the  other,  and  may,  moreover,  !«■ 
pn)vide<l  with  a  double  jn-lvis  and  two  ureters. 

Both  kidneys  may  In?  abient  in  certain  monsters,  a  condition  wliicli  is, 
of  course,  inconsistent  with  life. 

Hypoplasia. — Congenital  hypoplasia  of  one  kidney  Ls  rather  coiniimii. 
The  organ  is  small,  surrounded  by  much  perirenal  fat,  the  secretin}; 
structure  is  .scanty,  and  there  may  l)e  considerable  fibrosis.  The  ves-ils 
supplying  it  are  also  small.    More  rarely,  both  kidneys  are  thus  atlVi  t.ij. 

Horseshoe  Kidney. — An  interesting  anomaly,  which  is  rathi  i  iii- 
fre<|uent,  iKrurring  according  to  our  statistics  in  0.4  j)er  cent,  ol'  nil 
autopsies,  is  the  so-called  "horseshoe"  kidney.  In  this  condition  ili 
kidneys  are  imjierfectly  separated  one  from  the  other.  They  lie  rU<<  i" 
the  vertebral  column,  and  are  united  most  conunonly  at  their  l^'  >r 
einl  l>y  kidney  substance,  or,  more  rarely,  by  a  fibrous  baiiil.  It.i'  1^. 
the  union  takes  place  at  the  upper  or  middle  portion.  Tiie  iioi-i  h- 
kidney  is  usually  situatetl  somewhat  lower  than  normal,  aii<l  iii  ■  •' 
fomid  upon  the  promontory  of  the  sacrum.  In  the  latter  sitiui!:  it 
may  prove  an  iin|M'(liment  to  labor.  One  of  the  component  ori;.r  '^ 
somewhat   higher  than  the  other.      The  ureters  giMiendly  pa>-  ■       i" 

the  front  and  the  ve.s.s«'ls  are  abnormal  in  their  origin.     Thee -n 

is  of  no  great  moment  and  is  asually  discoveretl  a<tridentally,  li.:         i- 
sionally  serious  symptoms  have  resulte«l,  such  as  thromlnxsis  of  tlu  i- 


DOUBLE  PELVIS  AND  UHETER 


729 


l.viii}5  veiiis  and  pressure  upon  the  ureters  giving  rise  to  hydronephrosis  or 
jnelonephritis.  Such  kidneys  would  seem  to  be  more  liable  to  disease 
than  normal  ones.  We  have  met  with  one  case  in  which  one-half  of  the 
organ  was  tuberculous,  and  another  in  which  ii  contained  a  large  coral 
cuiculus. 


Fio.  191 


Fio.  183 


ll..r„.,h„e  kidney.     (Frnm  the  Pmthnl,«i,.al  Mu*u,u  „f         C.miplete    double   ureter      ( Kmm 
McGill  Univeraity.)  ,he  l'athol.«ical  Muneuni  ..f  Mctiill 

Uuivenity.) 

KkIiicvs  are  not  uiiconunonly  found  which  are  elongited,  rounded, 
spleen-like,  or  hogbaeked  in  shape.  The  hoglMickwl  ki.lnev  is  pnAwblv 
IK"  <lu<"  to  alcoholiMn,  as  used  to  l)e  thought,  but.  rather.  Is  congenital. 
I'-i  It  IS  found  often  in  children  and  in  others  who  have  never  toiiche.! 
■il'"l")l.  In  the  spWii-  or  cake-like  ki«lnev  the  wlvis  is  frenuentlv 
■^iiii^iifil  posteriorly.  "  ' 

Double  Pelvis"  and  Ureter-  Another  fairlv  common  unomalv  is 
t"i  "lie  "ir  lK.th  kuliievs  to  be  provided  with  a  double  pelvis  and  ure'ter. 
I ' '  ureters  iisujdly  unite  somewhere  about  their  lower  thini  and  continue 


730 


Tllf:  KIDNEYS 


as  a  single  channel,  or  may  fuse  at  the  jM»rnt  of  junction  with  tlie  hiaiiilcr. 
or,  again,  more  rarely,  may  empty  hy  separate  oritiees  into  the  l>la«l(l«  r 
When  more  or  less  sepanite,  one  ureter  itivnrial>ly  crosses  the  other 
Such  kitlneys  art-  often  ahnornuilly  lonjj,  tis  if  siiowing  a  tendency  to 
reduplication  in  series. 

The  ureter  of  a  normal  kidney  may,  instead  of  emptying  into  the  blail- 
«ler,  discharge  into  the  collicuhis  seminalis,  a  seminal  vesi<'le,  the  uretlini. 
vagina,  or  uterus. 

ToBtal  LobnUtion. — A  very  common  anomaly  is  fa>tal  loitulation. 
Here,  on  the  surface  of  the  organ  are  numerous  shallow  furrows  n'prt-- 
senting  the  original  tlivisions  of  the  various  renculi.  Rarely,  the  ki<ii«-v 
is  composed  of  a  numlter  of  small  separate  organs. 


Klu.  19.1 


Cunicenital  cystic  kitliiey.     Zeiw  ohj.  I>l>.  without  ocular. 
Hospital  collection.) 


(From  the  Itoyal  Vict- 


Dislocation  of  the  Kidney.— I )i.sl(Nat ion  of  a  kidney  is  fnirl} 
qucnt  also.     It  may  he  congenital  or  actpiired.     In  the  congenitiil 
the  ve.s.sels  present  an  ahnormal  origin,   while  the  ureter  is  n 
.shortened.     In  the  ac(|uired  form,  the  vessels  are  normal  in  orifrii 
di.'-trihution,  though  lM>fh  the  vessels  and  ureter  are  lengliu'imi 
tortuous.     The  suprarenals  usually  occupy  their  normal  position. 
ahiiornially  situate<l  kidney  may  lie  on  the  vertehnd  <i)hin)ii,  citii 
its  own  or  the  opposite  side,  «)n  the  .sacnd  promontory,  in  tlic  \h\' 
iK'iieath  the  anterior  alKloininal  wall.     The  organ  may  l)e  tixtd 
ahnormal  situaticm  hy  fihroas  adhesions. 

Congenital  dishn-ation,  a<ronling  to  Kiipfer,  is  due  to  a  dcliii. 
the  movement  of  the  cinhrvonic  nuliineiits  of  the  kidiievs,  wliit  i 


In- 
foriii 
unllv 

Mild 

.[Ml! 

■     Mil 

'>,  or 
.  it.s 

.  i'l 

IP  to 


PASSIVE  HYPEREMIA 


731 


ii  certain  period,  aw  formed  just  in  front  of  the  point  of  bifurcation 
of  the  aorta. 

'I'iie  ttc(|uired  form  .seems  to  l»e  due  to  deficiency  in  the  amount  of  tlie 
perirenal  fat,  such  as  occurs  in  prolonged  wasting  disease;  pressure,  as 
from  tight-lacing;  traumatism;  heavy  lifting;  or  to  a  relaxed  abdominal 
Willi,  resulting  in  diminished  intra-alidominal  pressure.  In  most  cases 
i(  is  part  of  a  general  gastro-enteroptmis  or  splanchnoptosis.  Occasion- 
ally, the  dislocation  is  brought  about  by  the  weight  of  a  renal  tumor. 

OystS. —  Cysts  of  the  kidney  are  not  uncommon.  The  oi^as  are 
jjrcdtly  enlarge*!,  warty,  and  on  section  present  great  numl)ers  of  sacs 
••oiitaining  thin  fluid.  The  condition  is  supposed  to  be  due  to  retention 
owing  t(»  imperfect  fusion  of  the  collecting  tubules  with  the  secretory 
portion.' 

OntOULATORT  DUTITRBAHOU. 


Oligemia. — Generalized  oligemia  of  the  kiilney  is  found  in  cases  of 
j.'fnenU  systemic  oligemia,  either  essential  or  secondary.  In  the  early 
Ntajjes,  the  organ  on  section  is  unifonnly  pale,  of  a  grayish-yellow  color 
and  fairly  tninslucent.  In  the  advanced  condition,  as  is  well  seen  in 
pernicious  anemia,  the  ki<lney  is  pale,  yellow,  and  turbid-KK)king, 
owing  to  the  resulting  fatty  degeneration. 

Local  anemia  is  met  with  in  the  white  infarct. 

Hyperemia.— Active  Hyperemia. — Active  hyperemia  is  met  with 
in  acute  inflammations,  a  forcibly  acting  left  heart,  varioas  intoxications, 
and  in  death  from  cerebral  tumors,  meningitis,  and  the  like. 

Pasaire  Hyperemia. — Passive  hvperemia  is  usually  due  to  some  o\t- 
slniction  in  the  general  circulation,  such  as  valvular  heart  disease,  or 
M>nu"  pulmonary  disturbance.  A  unilateral  lesion  is  rarer,  and  results 
from  some  ol)Structi«n  in  the  inferior  vena  cava  or  renal  vein,  as  from 
tliromlM>sis  or  the  pressure  of  enlarged  glands  or  tumor-masses  upon 
1 1  If  vessel. 

Tlic  kidney  is  eidarged,  its  consistency  firmer  than  normal,  and  the 
capMile  peels  oil  with  great  ea.se.  The  stellate  veins  are  injected  and 
liic  surface  has  a  dark  purple  red,  or  cyanotic  appearance.  On  section, 
llif  organ  is  very  firm,  drips  blcxxl,  and  has  a  uniformly  dark  red  apptiir- 
aiKf.  In  the  milder  grades,  the  ."-'raight  vessels  can  l)e  made  out  as 
rcil,  converging  lines  and  the  glomeruli  as  minute  reddi.sh  points  in  the 
cortical  porti<m. 

Microscopically,  the  ves.sels  are  all  enlarge<l  and  congested,  the  How- 
iiiaiis  capsules  contain  albumin,  with  p<AS,sibly  a  few  retl  blood-cells, 
and  the  tubules  contain  a  few  hyaline  casts.  Certain  of  the  epithelial 
I  ills,  notably  tho.se  of  the  descending  loops,  contain  pigment  granules 
'Iciivcd  from  altered  blood.     In  long-standing  cases  the  capillary  and 

\ii  i'\collcnt  arcoiitit  of  thi-  various  nnnmnlios  of  tlu  'iilneys  will  lie  fomiil  in 
il  i'!tiT,t.,|,,„'»  JIarvrv  I.crHiri',i,  lil(K>-7:  222,  l.ippincotl. 


732 


THE  KIDNEYS 

Ite.  104 


Anpiiiii-  infarct  i.f  cnrli-x  .if  kiiliii-v  t<i  >li<,w  I'oaiiulalinii  necnmin,  with  Hurniundinil  li.iip 
t>f  <-'iii|ti*'«tiiiii.     a,  nrtpry-      n»rth.) 


Km    1»5 


Whin-  iiifurrt  nf  th»  kidney  underKniiiK  nrciuiiution.     Leiti  obj.  No.  3.  wiihcun 
'Jhf  iinnilic  area  is  to  the  riglit.     (Krom  the  collection  of  l>r.  A.  (i.  Niili..!! 


THE  ARTERlOSCLk'ROTlC  COSTRACTED  KIDSEY 


733 


vciioiu  walls  appear  thickene«l,  there  is  increase  in  the  interstitial  con- 
nective tissue,  ami  ix-casioiutlly  a  round-celle<l  interstitial  infiltration — a 
condition  known  as  "cynnot'w  induration."  In  some  instances  the 
secreting  epithelium  is  found  to  lie  fatty. 

HemoiAage.— (See  pp.  743  and  74(>.) 

Infarction. — Infarction  of  the  kidney  is  due  to  a  sudden  stoppage 
jif  the  circulation  in  a  ()ortiun  of  the  organ,  through  embolism  of  one  of 
the  bram-hes  of  the  renal  artery.  It  is  usually  anemic  in  nature.  In  the 
course  of  a  few  hours  the  part  which  is  deprived  of  its  blood-supply, 
i)econies  pale,  grayish-white,  and  more  or  less  opaque  and  granular. 
The  area  is  usually  roughly  we<lge-shape<l,  with  the  apex  toward  the 
Ixumdary  zone.  The  margin  is  well-deKntxi  by  a  zone  of  hyperemia  or 
hemorrhage. 

Microscopically,  the  affecte<I  area  presents  all  the  appearances  of 
coagulation  necrosis.  The  cells  are  swollen,  granular,  opa(|ue,  and  take 
a  diffuse  muddy  stain.  The  nuclei  are  pale  or  invisible.  Round  the 
margin  the  vessels  are  congested,  there  may  be  hemorrhage,  and  an 
nccuinulation  of  leukocytes  due  to  a  reactive  inflammation.  The 
iiifarcted  areas  vary  in  size  from  that  of  a  bean  to  a  third  or  even 
the  whole  of  the  organ.  The  necrosed  portion  may  reach  quite  to  the 
capsule  or  there  may  be  a  small  zone  of  healthy  or  rektively  healthy 
kidney  tissue  between,  depending  on  the  amount  of  anastomosis  with 
the  vessels  of  the  capsule.  In  course  of  time  the  affected  cells  undergo 
fatty  and  hydropic  degeneration  and  are  eventually  absorbed  and  de- 
stroyed, their  places  being  taken  by  proliferating  connective  tissue  from 
margin.  Ultimately,  only  a  scar  is  left.  The  scar-tissue  is  grayish- 
wiiite  or  reddish  in  color,  sometimes  pigmented.  WTiere  there  have 
l>pen  numerous  infarcts,  the  kidney  is  contracted,  scarred,  with  a  mark- 
edly irregular  surface  (embolic  granular  ki/tiiri/). 

The  Arteriosclerotic  Contracted  Kidney.— The  arteriosclerotic 
cimtracted  kidney  is  a  form  of  granular  'idney  originating  in  a  narrowing 
and  eventual  ol)Struction  of  the  afferent  vessels  of  the  organ.  The  condi- 
tion may  lie  restricted  to  the  renal  artery  and  its  branches,  or  may  be 
l>art  of  a  general  arteriosclerotic  process.  The  changes  are  of  the 
nature  of  a  chronic  proliferation  of  the  iiitima  or  media.  This  leads  to 
collapM'  of  the  glomerular  capillaries  and  atrophy  of  the  tufts.    The 

■:' •'•■"'i,  through  hyaline  changes  in  the  capillaries,  become  converted 

int..  rounded  masses,  at  first  relatively  poor  in  nuclei  but  ultimatelv 
^ml(•tll^eless  or  filmiid.  The  Howman's  capsules  may  be  thickene*!, 
ili-.iij,'li  usually  not  to  any  great  extent.  As  a  result  of  the  degi-neratioii 
of  tlie  glomeruli  the  efferent  tubules  become  collapse*!  and  atrophied. 
The  prwess.  as  a  whole,  ten-Is  to  affect  certain  vascular  districts  corre- 
>i"m(ling  to  the  interlobular  arteries.  .\s  the  various  structures  atrophy, 
ill'  ir  place  is  taken  by  coimective  tisstie,  which  gradually  shrinks,  leaditig 
t"  the  fonnation  of  a  scar.  Thus,  the  surface  of  the  kidney  Itecomes 
iM,n-  or  less  warty  or  granular,  ami  the  ciipsule  is  somewhat  adherent. 
I  !<'  atropine  process  is  more  marked  in  sonit  regioiLs  than  in  others,  uith 
I'"    result  that  localized  rather  sharply-defined  depressed  areas  are  to 


734 


TIIK  KIDSKYS 


lie  'M-en  on  the  surfare.     'Vhv  interloliiilar  vejweU  Uh-jhiu-  uUo  ttirliioiis 
or  spiral  throii^rli  .sirikiii>!  in  of  the  corli-x. 

'liu-  arteriiisflenrtio  kidnev  is  luiuilly  hri^ht  re<l  or  (^rayi.th-ni I  in 
color,  or.  (wiiij{  to  fatty  dejji'iieration,  may  ln>  .strenketl  w'ith  y<>||ow. 
It  is  iliiiiinLshed  in  size,  the  rspsuk'  i:*  adherent,  ami  the  cortex  w  narrowol 
iind  diatorte<i.  ITie  organ  cuts  more  firmly  than  asual  uih!  the  Klonicntii 
stand  ont  as  whitish  (lots.    'Hie  smaller  arterioles,  through  thickenin;; 


Kit.  IM 


All  aripriiiM'Irniiir  kidney.     Thr  prrparalicm  ■howi  writ  the  irraculsi  ciiarM-  Krainiliiii'iii-  <  u 
the  e.xteriur  vl  the  urxar..     (Fmni  the  PatholoKieal  Muaeum  of  MHiill  IHivrr-ity  ' 


of  their  walls,  are  easily  reeognized.  'J'he  renal  artery  itself  ofli-n  sIk.a^ 
murk<>d  s<'lerotif  chanj^s.  A  striking  feature  is  the  mark(><l  narrow  in,' 
of  (•«>rtex  and  medulla.  The  jielvis  is  relatively  larfje  ami  filltii  ui'li 
fatty  tissue. 

The  condition,  thou^rh  etiolo^'ically  different,  is  not  easily  (iitftrtiiri.in  ,1 
from  the  inflammatory  contracttnl  kidney.  In  the  latter  ty|M',  Iiducv.  i. 
the  prtK-ess  is  more  apt  to  l)e  diffasetl  anil  even  in  its  cliiinn  icr.  ' 
the  sipis  of  arterial  sclerosis  throughout  the  Inxly  are  not  so  ninrkt  ) 

Smile  Atrophy.-"-Allie<l  to  the  arteriosclerotic  kidney  is  senile  atn| -. 
This  h  also  a  form  of  granular  kidney,  liut  the  dimiiuition  in  >i/f  >■'■     • 
organ  is  usually  not  extreme.     The  capsule  is  thickened  and  soni'  ' 
adherent,  the  granuljitlon  fine.     The  contlition  is  often  coiiiincl  in      ' 
few  of  the  glomeruli,  so  that  the  s<-arr'!ig  is  slight  anti  the  nuirrn  ■ 
changes  a«'  not  ohtnisive.     The  condition  is,  i:>  large  nica-iiirr  ' 

events,  due  to  impoverished  blotxl  supply    -life  arteriixsclem  i  ■• 


SKPIIHITIS 


735 


1 . milium  in  rklerly  p(>ii|>lc,  hut  variiMn  n'tniKiv.s.Hivf  pnKt^iiiw  no  iloiiht 
|)luv  u  part. 

IVFLAMMATIOVI. 

Vephritis.— ThU  .s«-<ti<>ii  \m\\^  us  to  the  coiisiiU'nition  of  out-  of  the 
most  coiiiplii-uteil  aiu!  oli.>M-iin-  prohleiiM  in  tlie  wht»le  reiilin  «»f  |iulhoh>^v. 
The  truth  of  this  stuteinent  will  Imm-oihc  evident  iis  we  proceed.  The  <-hief 
(lifficuhy  (-oiwists  in  this,  that  it  Is  s<iinetimes  impossihie  to  determine  the 
ftiolo^fieal  faotoD*  at  w«)rk  in  certain  cas«'s  and  to  trace  the  course  of 
flic  Miorhitl  prix-eNses  thereby  set  up,  while  it  is  often  extremely  difficult 
In  hrinjj  the  clinical  maiiifestation.H  into  close  correspoiidt-nce  with 
the  Hiiatomical  conditions. 

'i'he  kidneys  are  the  chief  eliminative  orpins  of  the  ImxIv.  T'heir 
structure  is  glandular  mix!  their  function  is  to  ex<Tete  the  vurii'ms  waste 
products  of  nietalMilism  that  reach  them  throu)(h  the  l>l<M)d  stream. 
.Vhiiorinal  sulwtances  intHxluc-eil  into  the  Innly  from  without,  or  resulting 
fn.nidisturi)e<lorper\erte»linetaliolisin  within  the  system,  may.and  often 
do,  lead  to  irritation  of  tlies*-  im|N>rtant  organs  and  even  to  striu  iiiml 
dmiip'.  The  result  in  any  pven  case  will  de|N-nd  on  the  amount  ol  the 
<lilcteri(.us  substances  present  as  well  as  their  (juality.  In  fact,  suIh 
stiiiui's  normally  produced,  if  present  in  t«)o  fftvai  «n'iantity,  may  lut 
siiniliirly  to  those  that  are  essentially  toxic  in  their  nature.  ('onver.s«'lv, 
furHlioiial  inade<pia<-y  of  the  kidneys  is  not  without  its  effe<t  upon  tlie 
loiniKwition  of  the  blood.  T'he  quantity  of  water  elimiiiate<l  mav  deviate 
roiisidfnil)ly  from  the  normal  an<l  waste  products  niav  Ik- 'ri'tjiined 
instead  of  excreted.  The  <piality  of  the  bliMiil  is  thus  (lepreciafj-d.  and. 
Iwinj:  lailen  with  toxic  substaines,  it  in  turn  exerts  an  irritatinj;  and 
•  i.drioratinfj  effect  u|>on  the  kidneys.  In  tliis  way  a  vicious  circle  is 
set  up,  as  a  result  of  whic-h  the  condition  of  the  jmtieiit  pies  rapidlv 
frotii  had  to  worse. 

Wf  can,  {)erhaps,  lietter  apprc-ciate  the  patho;;env  of  kidnev  affections 
if  we  consider  for  a  moment  the  relationship  which  the  orjrans  "in  c|u«-stion 
iHar  l<)  other  parts  of  the  bcnly.  In  addition  to  the  kidiievs,  the  orjrans 
( oiiicrned  in  the  elimination  of  toxic  substances  are  tlie  intestines,  liver, 
liifiiis,  and  skin.  Any  disturbanc-e  of  these  orpins  which  inhibits  their 
fiUK  lion  of  necessity  throws  more  work  upon  the  kidnc-ys,  and  nir  irrm. 
'1  Ik  fMiictions  of  these  various  striic-tures  an-,  then,  fc'i  a  certain  c-xtent, 
coiiipleniental.  As  an  example  of  this  we  mav  cite  the  well-known  fact 
nf  the  excretion  of  urea  by  the  skin  when  flu-  function  of  the  kidnevs 
^  'Icl'ective.  Nephritis  also  has  lieeii  known  to  follow  upon  pistro- 
<  m.  ritis  (Kbstein,'  I)u|)eu').  Apain,  sudden  chilling  of  the  surface  of 
111'  ImkIv  may  lie  followed  by  nephritis. 

i'litM-  results  may  Ih-  broujjht  about  in  two  wavs:  namelv,  thronxh 
till  .  in  iilafory  and  through  the  nervous  systems. "  Thus,  toxins  elal>- 
"1  iii.i  by  abnormal  metabcdism  in  distant  parts  of  the  ImhIv  mav  be 


iH'itscli.  med.  Woch.,  .58:  IW»7;  1. 


'Jour,  lie  .Med.,  July  10,  l.S'J7. 


Micaocorv  iboiution  tbt  omit 

(ANSI  ond  ISO  TEST  CHART  No    2) 


1.0 


I.I 


lb 

la 


12^ 

1 40 


11-25   11.4 


1.8 
1.6 


j4 


/APPLIED  IIVMGE     \ 

1653   EqsI    Ma-n    SI'Mt 

Rocfieiter.   N««   Vorh         '+609       uSA 

(716)    *e2  -  O.WO  -  Phon. 

(716)    ^88  -  5989  -  fo. 


73<) 


THE  KIDNEYS 


fiirriwl  to  the  kidneys  by  the  bloodvessels,  aiul  untoward  nervous  im- 
pressions may  result  in  other  profound  disturbance.  'J'he  latter  eifec-t  is, 
perliaps,  also,  at  bottom  circulatory  in  that  the  caliljer  of  the  renal 
vessels  may  lie  modified  reflexly,  though  it  is  not  impossible  that  tlic 
changes  in  point  are  neurotrophic  in  character.  At  any  rate,  we  can, 
with  .safety,  conclude  that  the  bloodvessels  play  the  controlling  part  in 
the  production  of  most  forms  of  nephritis  by  detennining  the  (juality 
and  the  cpiantity  of  the  blood  brought  to  the  kidneys.  Sudden  in- 
repeated  congestion  of  the  kidneys  will  impair  their  vitality  and  pre- 
dispose them  to  infection  and  other  forms  of  irritation.  Any  condition, 
whether  of  general  or  local  character,  that  lessens  the  amount  of  bliMMJ 
going  to  the  organs  will  lead  to  their  deterioration.  Toxic  substances 
circulating  in  the  blood  pass  through  the  capillary  walls  into  tlie 
tubules,  bringing  about  in  their  transit  degenerative  changes  in  (lie 
lining  endothelium  and  in  the  .secreting  cells.  \\'hen  the  condition  is 
sufficiently  prolonged,  reactive  and  reparative  phenomena  make  tiicir 
appearance,  and  we  then  get  evidences  of  inflammation.  Degeneration 
and  inflammation  are,  therefore,  the  keynotes  to  the  proper  understand- 
ing of  the  many  differing  conditions  grouj)e<l  imder  the  generii-  term 
nephritis.  Degeneration  is  manifested  in  the  retrogressive  chaMi;es, 
cloudy  swelling,  vucuolation,  and  necrosis  met  with  in  the  endotiieliai 
and  secreting  cells;  inflammation  is  indicated  b_,  the  serous  and  cellular 
infiltration,  the  congestion,  and  the  hyperpla.sia  of  tissue.  The  distint- 
tioiis  between  the  degenerative  and  the  inflammatory  manifestations 
are  often  neither  clinically  nor  anatomically  to  l)e  sharply  drawn.  Tlie 
same  causes  which  bring  alK>ut  a  pure  degenenition  are  often  com- 
petent to  excite  inflammation.  Co!  versely,  certain  peculiar  chan^'es  in 
the  urine,  to  In*  referretl  to  more  at  length  shortly,  may  result  pi|uallv 
from  degenerative  or  inflammatory  prcx-esses.  As  a  matter  of  t'iict, 
degeneration  and  inflammation  are  nearly  always  coinbinetl,  eiilur 
in  the  relationship  of  cause  and  effect,  or  as  a  fortuitous  association  of 
conditions. 

The  Urine. — Valuable  information  as  to  the  coniuiion  of  tlie  kiijiirv-* 
may  l)e  gathereil  from  an  examination  of  the  urine.  The  most  strikin;,' 
changes  consist  in  a  more  or  less  marked  deviation  from  the  iiorni:il  in 
point  «)f  ((uantity,  specific  gravity,  and  reaction;  the  appcaramr  of 
albumin;  and  the  presence  of  foreign  material,  such  .as  casts,  red  lil'iml 
cells,  leuktK'vtes,  epithelium,  cell-«letritus,  bkxxl-pignient,  fat-dnipi'iN 
shreds  of  tissue,  urinary  salts,  and  bacteria,  'i'his  phase  of  the  >iil.ii(  t 
is  more  suitably  relegated  to  works  on  clinical  diagnosis,  and  we  i-h'moi 
do  more  here  than  draw  attention  to  the  main  outlines. 

Acute  Parenchymatous  Nephritis.— In  acute  partMichymntons  nepi'itis 
the  amount  of  .irine  e.xcreteil  in  the  twenty-four  hours  is  greatly  red  i  >  i|, 
namely,  to  3C  j  c.cm.  or  even,  in  the  earlier  stages  of  the  attack,  to  H  >o 
Complete  suppression  is  occasionally  met  with.  Tiie  urine  is  :!■ 
high  sptH-ific  gravity  (1024  to  10.30),  turViid,  and  of  high  color.  !' 
he  smoky,  or  even  bright  red  in  appearance  from  the  admixture  c'  '  ""I- 
The  percentage  of  tirea  may  be  increased  but  the  total  output  n'       a, 


111. 

of 

:iv 


THE  URINE 


737 


■ra, 


as  of  other  nitrogenous  substances,  is  diminished.  The  uric  acid  may 
l)e  normal  in  amount,  and  the  purin  bases  are  generally  in  excess.  The 
urine  contains  albumin,  varying  in  amount  from  0.3  to  1  per  cent,  (b^ 
weight,  5  to  10  grams  daily).  The  sediment,  which  is  usually  abundant 
consists  of  red  blood-cells,  leukocytes,  renal  and  bladder  epithelium] 
crystals  of  uric  acid  and  oxalates,  hyaline,  granular,  epithelial,  leukocytic' 
and  blootl  casts.  Hemoglobin  may  be  present  in  the  urine  in  cases  in 
which  severe  blood  destruction  has  taken  place  (hemoglobinemia).  Blood 
and  blood  pigment  may  be  present  in  considerable  amounts  in  the  forms 
known  as  acute  hemorrhagic  nephritis.  It  has  been  shown  recently 
that  the  freezing  point  of  the  urine  in  cases  of  nephritis  differs  from  that 
of  normal  urine.  The  process  for  the  determination  of  this  fact  is  calletl 
crvoscopy.  The  freezing  point  of  normal  urine  has  been  demonstrated 
t..  Ih-  from  1.3°  to  2.3°  C.  l)elow  that  of  distilled  water,  while  that  of  the 
iirnie  m  nephritis  is  only  1°  C.  or  less  below  that  of  distilled  wrter.  This 
IS  due  to  the  molecular  concentration  of  the  urine,  which  is  less  in  neph- 
ritis than  in  health.  *^ 

The  urine  in  acute  einlx)lic  suppurative  nephritis  is  practicallv  that 
of  acute  hemorrhagic  non-suppurative  parenchymatous  nephritis  ' 

Chrooic  Difliue  Mephritis.-ln  the  chronic  diffuse  nephritis  (without 
mduration),  or  large  white  kidney,  the  urine  is  also  diminished  in  amount 
varying  lietween  300  and  700  c.cm.  The  urine  is  acid,  turbid  and  of 
mcreaseil  specific  gravity  (1018  to  102.5).  It  is  often  highly  colored,  and 
may  contain  a  notable  amount  of  blood.  It  always  contains  consider- 
al>le  albumin,  from  15  to  30  grams  in  the  twenty-four  hours.  The 
tirca  and  other  solids  are  below  the  normal  quantity.  The  sediment  may 
consist  in  any  of  the  elements  mentioned  under  the  acute  form 

Chronic  Intentitial  Nephritis.-  In  the  chronic  interstitial  form  (chronic 
,  wi'r  "TPJi!""  '"*''.  '"^"f»*'»")'  <he  urine  is  increased  in  amount,  from 
IMH)  to  4000  cc-m.  daily.  It  is  acid,  pale  in  color,  and  of  low  specific 
jrrav.ty  (10()2  to  1015).  Albumin  is  trifling  in  amount  and  mnv  even 
U-  al)sent  for  prolonged  periods.  Casts  art"  few  and  usually  livaline  in 
'  liaracter.  Occasionally  a  few  erythrocytes  may  be  found.  '  The  solids 
"t  the  urine  are  generally  diminished. 

Pyelonephritis.— In  tlie  cases  of  pyelitis  and  pyelonephritis  resultini: 
tn.n,  stone,  granular  and  cellular  debris,  iirinarv  .salts,  epithelium,  and 
ims  cells  are  often  present  in  considerable  amounts.     Massive  hemor- 
rhap-  may  also  occur  into  the  urine.     Where  ulceration  takes  place 
>Niv<ls  of  tissue  may  be  passed  into  the  urine. 

Tlie  systemic  poisoning  resulting  from  the  absorption  of  the  urinary 
Willis  and  other  products  of  metabolism  is  known  as  uremia. 

I'i'nany  cases  of  nephritis,  especially  those  complicating  the  various 

"I. .  lous  fevers,  bacteria,  usually  those  specific-  for  the  primary  disease, 

•■I"  t.v  suitable  methods  be  found  in  the  urine.     The  bacteriology  of 

<•  ."-NIC  nephritis  has  not  as  yet  been  worked  out.     In   tubercujosis 

• '  'iK'  kidney,  the  specific  bacilli,  often  in  considerable  iniinl)ers,  can  l)e 

'■  i'<_'^u!)ject  of  the  eks,sificatioii  of  certain  affec-tioiis  of  the  kidnevs 


738 


THE  KIDNEYS 


I     . 


is  one  fmught  with  imk-h  difficulty.  This  is,  in  hirjre  piirt,  (iiic  to 
the  (lifficMilty  in  determining  the  correlation  In'tween  the  etiolojjy.  iIm- 
morbid  aiwtomy,  and  the  clinical  manifestations  in  many  cases  of 
nephritis.  On  the  one  hand,  the  same  etiological  factor  may  hring  uIhuU 
a  diversity  of  anatomical  changes,  and,  on  the  other,  one  and  the  sainc 
clinical  picture  may  result  from  a  variety  of  morhid  causes.  Afjaiii, 
the  severity  of  the  outward  manifestations  of  the  disease  does  not  alwavs 
iK-ar  a  <lirect  relatioiLship  to  the  apparent  extent  of  the  lesions,  'riiiic 
and  again,  we  find  at  autopsy  advanced  renal  disease  in  ca.ses  where  from 
the  clinical  features  we  would  not  have  e-xpected  it,  and,  conversely,  we 
may  have  well-marked  clinical  evidence  of  disease  with  kidneys  that  nrc 
practically  normal  to  gross  examination.  As  a  consecjuence,  we  do  not 
find  perfect  unanimity  among  writers  as  to  what  constitutes  nepliriiis 
and  what  does  not. 

There  are  three  ways  of  classifying  kidney  affect?  ^ns:  (1)  act-ordiiij:  to 
etiology;  (2)  according  to  the  hx-ation  of  the  lesions;  and  (:{)  accordinj: 
to  the  nature  of  the  inflammatory  pnx-ess. 

The  etiological  methtxl  would  l)e  eminently  scientific,  hut  ;;:es(iiis 
the  practical  difficulties  that  have  just  l)een  mentioned.  On  this  l>ii>is 
we  might  differentiate  congestive,  toxic,  and  infective  disturbaiues. 

The  second,  or  topographical  method,  is  theon-tically  possible  ami  is 
not  devoid  of  merit.  V  .•  may,  recognizing  that  the  epithelium,  ilic 
glomeruli,  the  interstitial  stroma,  and  the  l)lo(Mlvess;'ls  may  be  jiflVci.d, 
•lividc  nephritis  into  parenchymatous,  glomerular,  interstitial,  ;iiiil 
arteriosclerotic  forms.  The  first  three  of  these  forms  may  i-gaiii  be 
divided  into  acute  and  chronic;  the  last  is.  of  course,  always  (liionic. 
The  chief  objection  to  this  classification  lies  in  tiie  fact  that  it  is  impo^-ihle 
to  draw  a  hard  and  fast  line  between  parenchymatous  and  intci-iitiiil 
inflannnations.  'J'o  indicate  all  tlie  possible  permutations  and  ( nm- 
binations  would  necessitate  a  cmnbrous  terminology. 

According  to  the  thin)  metho<l,  we  may  recognize  with  DcliitirM. 
in  the  first  instance,  three  types  of  kidney  atfe<'tions  congestion,  di-ni- 
cration,  and  inflanunation.  Inflanunaticm  may,  again,  Ih"  divided  into 
acute  exudative  nephritis;  acute  productive  nephritis;  chronic  ii(|ili!itis 
with  exudation;  chronic  nephritis  without  exudation;  and  sii|>|>iiraiive 
nephritis.  The  considerations  just  detailed  are  sutticiciit  to  indie  mi<  i!ic 
difficult  nature  of  the  problem  In'fore  us. 

That  drojKsy  and  idbumimiria  are,  in  certain  cases,  related  to  aii.riluMs 
of  the  kidneys  has  been  recogniztHl  for  centuries.  Aetius  (.'{(i?  \  i>.i. 
Avicenna  (ItSO  to  KWti),  and  van  llcltiiont  (b")""  to  1(i44)  all  lul!  iluit 
certain  cases  of  dropsy  w»'re  due  to  disease  of  the  kidneys.  Coiiin  I'ls 
in  1770,  discovered  that  the  urine  of  dro|)sical  patients  could  !"•  <  fil- 
iated by  boiling. 

\Nc  owt-  our  iiKHlern  conceptions  of  kidney  inflammations,  li"  '  ^  i'. 
to  Richard  Mright,  of  (iuy's  Hospital,  who  published,  in  lS-'7,  i  ii~t 
tlioroui;!!  and  scientific  studies  of  this  type  of  disease.  Hriglil  ■''■  '•• 
stratcd  the  de|«'nd»'nce  of  albuminuria  and  dropsy  on  discii--'-  il»' 
kidniy.s.  accurately  described  the  morlml  changes  in  tin    !.       ,>s 


BRiaiirS  DISEASE 


739 


an.l  slHmtMl  Hie  relationship  of  tlie  clinical  symptoms  to  the  anatomical 
lesions.  lie  further,  .lescril)e<l  many  of  the  associated  conditions  and 
s...|iu>lie,  such  as  uremia  and  the  canliovascular  phenomena,  blindness 
aimplexy.  and  inflammation  of  the  serous  membianes.  So  uccurate  and' 
Ihoroufth  was  his  work  that  most  of  it  has  stwxl  the  test  of  suhseciuent 
nu|.nry.  As  a  result,  the  term  Bright's  disease  has  l)een  adopted  the 
world  over  as  the  designation  amonj;  clinicians  for  the  non-suppurative 
inHaniinations  of  the  kidney  asu«-|y  a.ssociated  with  albuminuria  and 
dropsy. 

Further  advances  were  made  by  llokitanskv,  who  described  in  1S4' 
the  amyloid  kidney.  Johnson  (1S.52)  drew  attention  to  the  vascular 
.  l.aMf;e.s  .n  the  kidney,  work  which  was  taken  up  and  amplified  in  1872 
l.v  (.nil  and  Sutton  in  their  study  of  what  they  called  "arteriocapillary 
liiirosis,  in  which  they  emphasized  the  relationship  of  certain  chances 
III  (he  bhxxlvessels  to  cirrhosis  and  atrophy  of  the  kidney. 

\  matter  of  some  importance  is  to  decide  how  much  we  should 
mcliide  umler  the  term  Bright's  disea.se.  Some  authorities,  such  as 
l.ev.len.  repr.  Bright's  di.sease  as  embracing  all  forms  of  k id nev  dis- 
ease ass.Kiated  with  albuminuria  and  hydrops,  and  would,  therefore, 
lueliide  in  this  category  cases  of  degeneration  of  the  kidnev  epithelium, 
pyeioMcphntis,  and  the  amyloid  kidnev.  Others,  again."  with  Klebs 
would  scpanite  tlie  non-inflammutory  degenerative  manifestations  from' 
true  Hnght  s  disease.  At  the  present  time,  it  seems  to  be  fairly  generallv 
a^'ned  to  .lirtereiitiate  the  .-in-ulatory  and  .legenerative  .lisorders  of 
tie  ki.iiievv  .rom  the  primarily  inflammatory  affectioas,  or  triif  Bright's 
UKea  ..  Vi,  ,  legard  to  the  forms  of  nephritis  proper.  Sir  Thomas 
.rainjrer  Stewart,  in  1,S71,  recognize,!  three  types-the  inflammatory. 
"■  amyloid,  and  the  infracting  forms.  Un.ler  the  first  he  describ^l 
thre."  stages,  tlmt  of  inflammatory  exudation,  that  of  fattv  degeneration 
an.  that  of  iiuliiration,  a  classification  practically  coinciding  with  that 
-  iJartels,  who  <lassihed  these  affections  into  acute  parenchymatous, 
(liroiiie  parenchymatous,  and  interstitial  nephritis 

I.I  the  classification  that  we  have  suggested  here  we  have  sided  with 
tli|j^e  who  would  .litterentiate  lietween  congestive,  degenerative  and 
'"•I^Mninatory  affections  of  the  kidney.  The  further  .livi.s^on  of  nephritis 
"■"|'.>-  into  uou-suppuranvc,  suppurative,  and  ,pecific  forms  of  inflam- 
"iaiioi,  IS  so  convenient  an.l  accurate  that  it  is  hardly  likely  to  arouse 
>enu,is  antagonism.  More  difference  of  opinion  may,  peHiaps.  ari.se 
'I'.- various  siibvarieties  of  no  ,  suppurative  nephritYs.  but  the  forms 

'"' '  '"''■^'  '"•«;  «»  types  well  known  to  the  pathological  histologist, 

;""l-"  any  rate,  do  not  conflict  with  clinical  experience.     Thcv  are 
'"'■V'--.  to  be  reganled  merely  as  types,  without  it  being  underMood' 
•"■I  tl ,  y  are  separated  one  trom  the  other  by  hard  and  fast  lines. 

Hcler  tlu-  afJwtions  of  the  kidney,  ordinarily  associated  with  either 
'"•■"Miiuina  or  anasarca,  or  both,  we  recognize,  therefore,  the  following: 


740 


TIIK  KIDNEYS 


A.  Oongeition 


n  ^ 


iilWBP^     : 


li.  DeK«nar«tioiu 


I'luwive  hyperemia. 
f  a.  I'arencliyiiiatouH  de);eia'ral  ion. 
I  h,  KnilHilic    eranular   kidney,  nr 

infarcte<r  kidney. 
J  r.  Senile  and  atrophic. 
1  (/.  -Vrteriosclerotic  kidney. 

(c.  Cyanotic  induration. 
/.  .\m>  loid  fatty  kidne.\  . 
I  </.  -Vmyloid  contracted  kidiicv. 


'  y-^n-suppurative 


(1. 

Acute  parenchymatojH  iirphri- 
tis. 
1.  IlemorrhaRic  nephritis. 

2.  (ilumerulitis. 

■  Acute 

3.  Desquamative      piipillary 
nephritis. 

(.. 

Acute  interstitial  nephriti>. 

r. 

The  kidnev  of  pn"({nano\ . 

</. 

.\cute  JitTuse  nephritic. 

n. 

Chronic  diffuse  nephritis. 
1.  IlemurrhnRic  nephriii* 

Chronic 

2.  Cdomerulitia. 

C.  Inflammation  -I 


■Suppurative 


S|iecific 


b.  Chronic  interstitial  no|>hrili> 

I  r.  Primary   (genuine)   coiiir.icliii 
I,  kidney. 

I  <;.  Kmholic  abscesses. 

I  h.  Pyelonephritis. 

•1  r.  I'yonephnisis. 

I  d.  Traumatic  nephriti.s. 

I  e.  Nephri'is  tier  rjcUiisiniiini. 

fn.  Tuberculosis. 

I  ft.  Syi:',ilis. 

\  r.  Cilanders. 

d.  .Actinomycosis. 

e.  Leprosy. 


With  regiird  to  the  etiolojjy  of  acute  nephriti.s  it  may  In-  rfiiiMikcd 
here  tliat  the  in  st  iinpurtant  single  causal  element  is  infection  Wv 
xiMU  n-cojtnize  four  main  cla.s.ses  of  this  affection: 

1.  Those  (hie  to  various  intoxications,  such  as  from  alcoiiol,  liail, 
cantlinriiies,  phosphorus,  chlorate  of  potash,  ami  .salicylic  acitl. 

2.  Those  complicating  the  acute  infections,  .such  as  scarlatiiiii.  -inall- 
pox.  |)neunionia,  acute  endocarditis,  erysipelas,  diphtheria,  typhni'l  t'tver, 
.septicemia,  acute  rheumati.sm,  cholera,  acute  tonsillitis,  vaccinia.  M'ptic 
woiinils,  epidemic  cerebrospinal  meningitis,  and  certain  gastro-init  ~iinal 
disorders. 

:5.  Tliose  associated  with  chronic  disea.ses  and  cachexias,  as  il  ,  'n  tes, 
citrciiioma,  pidmonary  tul)erculosis,  and  .syphilis. 

4.  The  .so-called  "idiopathic"  ca.ses. 

It  has  l)een  ahimdantly  deinonstrate<l  by  exjierimental  .>iii 
a  great  variety  of  toxins,  both  mineral  and  bacterial,  are  com 
set  up  degenerative  changes,  cjf  the  nature  of  cloudy  swell! 
degeneration,  and  even  necrosis,  in  the  .secreting  epithelium  of  tli 
For  example,  as  Wa!ider\elde'  has  shown,  toxins  like  those  o! 


that 

lit  to 

1,  :iy 

IllfV. 

,l,rj. 


'  .\ct.  (i    pois.  sur  les  cell.  cpith61.  d.  canalicules  contournecs,  Urus 


NKPHRITIS 


741 


cliolera  nostras,  tubereuhwis,  diphtheria,  pneumonia,  influenza,  an<l 
(<rtain  ihemicai  substances,  such  as  chromi<;  atid,  lead,  phosphorus, 
mercuric  chloride,  when  injected  into  laboratory  animals,  exert  a  hdrmful 
influence  upon  the  glandular  structure  of  the  kidnev,  bringinp  alnjut 
clianjjes  identical  in  appearance  with  those  met  with  in  the  human 
siil)ject.  IIow  far  these  are  inflammatory  is  open  to  debate.  I'aren- 
clivniatous  degeneration  is  doubtless  the  first  stage  of  inflammation  in 
iiiii'iy  cases  (»f  nephritis,  but,  from  the  pathologist's  point  of  view  at  least, 
can  (xciir  independently  of  inflammation,  and,  moreovei ,  nee<l  not  ii-ces- 
siirily  give  rise  to  it.  When  inflammation  does  supervene  in  sucli  cases 
it  is  (|uite  fair  to  assume,  in  the  absence  of  positive  information,  ihat 
it  is  as  likely  due  to  secon'iary  infection  as  to  the  influence  of  the  circu- 
lating toxin.  Consefjuently,  for  the  sake  of  clearness.  ..tiile  it  is  well  to 
;.nscrve  in  our  minds  the  distinction  hi-tween  " degeneration"  and 
•inflammation,"  practically,  as  we  have  before  remarke  it  is  not 
always  possible  to  distinguish  between  them. 

V>  c  are,  however,  on  more  certain  ground  when  we  come  to  discuss 
the  forms  of  nephritis  occurring  in  the  course  of  infective  processes. 
Here  a  niicrobic  origin  can  be  traced  in  nearly  every  case.  The  bm  teria 
foiiiid  in  the  urine  of  such  cases  are  asually  those  specific  of  the  primary 
disease.  Thus,  streptococci  and  staphylococci  have  l)een  found  iii 
the  urine  in  cases  of  acute  endcK-arditis'(Weichselbaum,  Mannaln-rg); 
tlie  i'yphoid  bacillus,  in  cases  of  nephritis  arising  during  the  course  of 
ivpiioid  fever  (Blumer);  the  PneumococciLs,  in  cases  of  pneumonia 
( Massalong,  Klebs,  Michelle).  In  a  .study  of  this  subject  made  bv  one 
of  us  (A.  G.  X.')  some  years  ago,  in  32  cases  of  acute  nephritis  of  various 
forms,  bacteria,  usually  the  specific  germs  of  the  primarv  disea.se  were 
l)resent  in  28. 

It  IS  difficult,  therefore,  to  avoid  the  conclusion  that  most  cases  o'  acute 
nephritis  in  man  are  due  to  infection  with  microorganisms.  The  specific 
<liaii>;es  are  |)r(xluce«l,  it  may  l)e  presumed,  in  the  course  of  an  attempt 
on  tlie  part  of  the  kidneys  to  eliminate  the  offending  agents. 

Tile  acute  forms  of  nephritis  arising  in  the  course  of  chronic  diseases 
are  larj.'ely  of  the  nature  of  terminal  infections. 

The  relationship  of  infection  to  chronic  nephritis  is,  iinforfunatelv 
miK  h  more  ()i)scure.  Xo  doubt  certain  cases  of  acute  nephritis  pass 
iiM|..icef)til.Iy  over  into  the  chronic  type,  and  it  is  passil)le,  ami  indeed 
likely,  iliat  m  these  instances  the  infective  agents  are  still  at  work.  As 
a  proi.f  „f  this,  it  may  \w  pointed  out  that  cirrhosis  of  the  kidnevs  has 
l>eeM  known  to  result  from  infective  diseases,  such  as  piieumoiiia  and 
mtliieiizii.  It  is  true  that  one  important  class  of  chronic  kidnev  disease 
\>  'hie  to  arteriosclerosis,  ami  another  (primarv  contracted  kidnev)  to 
liu'  niH.ience  of  alcohol,  lead,  and  gout.  (This  latter  form,  however. 
"i:i)  I-  at  bottom  but  a  variety  of  the  arteriosclerotic  tvpe.)  Vet 
ni  rluKis  nf  the  kidneys  has  l»eeii  met  with  in  children,  in  whoin  the  influ- 

'■  Ni.  hoUs,  \  Contribution  to  the  .Study  of  Hrighfs  Disease,  Montreal  .Med  Sum 
Js:  \^'M;  liil.  ■• 


742 


KIDNEYS 


eiKf  of  arltTiosclerosis  aiul  rhrunic  niinenil  iiiUixicutioii  t-iiiild  with 
(rrtaiiity  lie  ••xciiuU'd.  TIh-  |)ussil)ility  «»f  infwtiuii  U-inn  the  caiisi-  of 
iimiiy  cast's  of  diruiiic  nephritis  was  pointed  out  in  the  pa|)er  jnst  refcrrnl 
to.  In  eiffht  eases  of  ehronie  purencliyniatous  nepliritis  minute  <h|ilci- 
eiH'ci  were  found  in  four;  in  one  ease  of  ehronie  );h)inernhtis  tlie  siuiic 
diploeoecus  was  present;  in  the  chronic  <lifTuse  form  (11  in  ninnlitii, 
bacteria  were  met  witli  in  all;  in  10  ctises  of  ciironic  interstitial  nepliriiis, 
niinute  diplococci  were  found  in  every  instance.  Altojjether,  in  4")  cax's 
of  chronic  nephritis  of  all  forms,  minute  diplococci  were  stn-n  in  J'.t 
and  bacilli  in  4  more.  The  germs  in  question  were  \isually  foiiml 
in  the  areas  of  interstitial  round-<-elle<l  infiltration,  su({gestinp  a  ciiiimiI 
relationship.  The  source  of  thest'  bacteria  is  difficult  to  my,  Imi  it 
may  In-  remarked  that  in  nearly  41  yter  cent,  of  the  cases  there  \mi>  a 
definite  history  of  prwetling  pastro-enteric  disturbance. 

Kio.  197 


Acuio  parpncliyinatnu!^  ner>hrili>.  'J"he  sectiim  sliowr*  wi'U  the  npcrn^iw  of  th.-  -i  i.Miiir 
tiilMile^.  HcicbiTt  iibj.  No.  7,  williDUt  utular.  (Knim  the  I'atlujIoKioal  l.a  KiralHry  •  Mi. ill 
I"iiiverr*ity.) 

Simple  or  Non-suppurative  Nephritis.  —  Acute  Parenchymatous 
Nephritis.  —  (Synonyms:  acute  degenerative  parenchymatous  ihihiiii-^, 
acute  tubidar  nephritis,  desquamative  nephritis,  catarrhal  or  ir  'Ihhis 
nephritis,  acute  Hright's  disease.) 

This  form  of  nephritis  is  of  frequent  occurrence  and  is  cham  ■■  lizttl 
in  the  main  by  marked  degenerative  changes  in  the  secretin;;  i  I'mlts, 
such  as  cloudy  and  fatty  degeneration.  With  this  there  i-;.  ii.  v>.ver, 
congestion,  exudation  of  serum,  and  desquamation  of  the  secit  n  -  '  iH>' 
In  the  earlier  stages,  the  condition  is,  no  doubt,  identical  witli  r      iiiiple 


SEPIIHITIS 


74.} 


Iiarcnclivmutous  (h-jiUMHTation  Jlmt  is  .so  /oTiiiionlv  found  us  u  n-snh  of 
intoxications  unil  infi><noMs  of  various  kinds.  In'  fact,  it  is  .sometimes 
iiiipossihlf  torlniw  the  line  In-tween  cioudv  swellirnj  and  actual  nephritis. 
riie  vascular  chanj^t-s.  tlu-  des<|uaniution'«)f  the  < ells,  and  certain  «har- 
ii.  teristic  <han>,'es  in  the  urine,  are  usualls  sufficient,  however,  to  na.ke 
t'lr  diagnosis. 

I'iie  kidneys  an-  usually  more  or  less  enlarj;ed  and  ledematous.  The 
(•ii|)sii!e  i)eels  off  with  more  than  normal  ease,  owinj;  to  the  swelling  of 
ihf  kidney  suhstaiae,  w  Inch  tends  to  l)id>,'e  throu>;h  the  cut.  'I'he  surface 
is  jmle,  the  stellate  veins  inje<t«l,  and  the  loi)ules  well  indicated.  The 
cpilex  is  sw.)llen,  pale,  ami  cloudy,  pn-sentiiij;  a  marked  contrast  to  the 
liiirk  red  or  lihiish-red  medulla.  In  .s..!,i,.  ca.s«-s  the  cortex  is  .somewhat 
cotijresfed.  Minute  |K"te«liial  hemorrlia);es  can  frcpientlv  Ik-  seen 
s<  iiltered  over  the  cortital  surface  and  throu>;hout  its  suhstanc'e. 

Microscopically,  the  structures  <hiefly  affected  are  the  contorted 
lul.ules.  The  secreting  cells  are  swollen,  cioudv  or  granular  often 
vii(iiolate<l.  while  the  nuclei  stain  hadly  or  not  at  all.  W  ithin  the  lumina 
of  the  tul.ules.  es|x-<ially  in  the  colle«fin>;  portion,  are  to  U-  seen  hvaline 
or  granular  casts,  and  .Iroplets  of  alhiimin.  It  is  not  inicomimm  to  find 
the  Iminj;  cells  of  the  tul.ules  lyinj;  free  within  the  hasement  membrane 
111  all  stajjes  of  fatty  aiul  hyaline  <le>;eneration.  In  some  cases  the  tul.ules 
(oiitam  I.I(hkI.  'I'he  jflomeridi  alsc.  show  evidences  ..f  defeneration 
t  "■  epithelium  lining;  the  Bowman's  capsules  hein>;  swollen  and  often 
'l<><|namated.  while  structureless  ma.sses  of  all.umin  <an  he  seen  within 
ill''  spaces.  Hemorrhaj,'e  into  the  capsules  is  noted  in  some  cases 
1  hi-  amoin.t  of  effu.se<l  I.KmhI  may  he  .so  jrrcat  tliat  free  I.KhmI  and  LIckI 
rasts  a|.|H'ar  m  the  urine,  warranting  the  term  luuU  hcmorrhut/lr  inulmth 
Ihc  iiterstilial  substance  is  swollen  and  (edematous,  and  there  is 
si.ni.times,  althoiifrh  not  invariably,  a  small  amount  of  round-celled  in- 
tilii'*  n  a-  1  a  deiM.sit  of  fibrin  in  the  interstitial  stroma.  'I'he  extent 
"'  ■""*■■'*  '"  «lifft'rent  cases.     As  a  rule,  the  contortetl  tubules 

■'"■■  res  first  and  chiefly  involved,  but  the  hw.ps  of  llei  le  and 

"        '  Uibules  do  not  always  escajK-. 

.  case-  glomerular  chaii^'es  so  dominate  the  picture  that  we 
<aii  |,,.,|.crly  sp.  k  of  actdr  tjhimiruUtis  or  (jlomiruUmvphritix  This 
tomi  IS  most  commonly  met  with  in  scarlatina  and  diphtheria.  T(.  the 
fak.Ml  eye  the  kidney,  as  a  rule,  shows  very  little  chan^H.,  ,,t  most  beinir 
somewhat  clou.ly  and  hyperemic.  The  glomeruli  are  swc.lh-n  and  show 
ii|>  as  reddish  or  pale  grayish  dots. 

Microscopically,  both  degenerative  ar.d  pr<Kluctive  changes  in  the 
;;l-n.cruli  are  found,  so  that,  according  as  one  or  the  other  prech.mi- 
iMt.p,  we  may  differentiate  a  degenerative  and  a  proiluctive  glonienilo- 
I"  I'l'ntis  In  the  former  variety,  the  capillaries  of  the  glomeruli  are 
«on;:,.sted  o.'  show  hyaline  .legenerafion.  while  the  epithelial  cells  liniiur 
111'  liowman  s  capsules  are  degenerated  and  des(,uamating.  The  B(.w- 
"'■"'  space  IS  filled  with  degenerate<l  epitheli.d   cells,  red  and  while 


■ii"is.les.  albumin,  and  granular  detritas.     I„  the  latter  form,  the 
ir'  fHls  and  the  variou.s  endothelia  show  proliferative  changes. 


744 


THE  KIDNEYS 


DasqiumAtiTt  PapUlujr  Haphritia.  -A  Ie.s8  iuipurtuiit  variety  is  ilir 
six-alltHl  desquainutive  pupillary  nephritis  in  which  the  lesions  are  chit-flv 
confine<l  to  the  tiilxiies  in  the  papillary  portion,  the  cells  of  which  art' 
swollen  and  ilesqimnmtin);. 

Acuta  Intentitial  Maphritia.  (Synonyms:  acute  productive  neuhriiis, 
"  lyniplioniatous"  nephritis  of  Wagner.)  An  interesting  form  of  mfluiii- 
mution  is  the  acute  inter.^dlial  nephritis. 

This  affection  is  found  more  especially  in  scarlatina  and  diphtheria. 
It  also  occurs  in  measles,  pneumonia,  wiuwping-cough,  acute  endix-ar- 
•litis,  un«i  epidemic  cerebrospinal  meningitis.  The  condition  is  probaMv 
due  to  the  at;tion  of  bacteria.  The  pyogenic  cocci,  the  B.  coli,  the 
Klelw-Loeffler  bacillus,  and  the  Pneumococcus  are  the  niicroorguiiisuis 
that  have  lieen  found  in  association  with  it.  Councilman,'  in  u  study 
of  such  cases,  would  lay  no  stress  upon  the  preseine  of  these  gcrnis,  us 
he  found  them  in  the  kidney  in  the  same  proportioits  in  cases  other  lliaii 
interstitial  nephritis.  It  may  be  remarked,  however,  that  the  proiluctioii 
of  nephritis  probably  depends  on  other  factors  than  the  mere  presence  of 
bacteria,  namely,  on  the  number  and  virulence  of  the  germs  and  the 
vulnenii)ility  of  the  tissues,  so  that  we  need  not  refer  any  form  nf 
nephritis  to  the  selective  action  of  parti<-ular  microbes.  The  infective 
tirigin  is  supported  by  the  obser\ations  ..f  Letzericn,'  who  has  dcscriUd 
an  epidemic  of  acute  interstitiid  nephritis  due  to  a  bacillus,  wliidi 
morphologically  resembled  the  B.  tul)erciilosis  and  o:  injection  intu 
animals  produced  nephritis. 

In  this  form  the  kidney  is  somewhat  enlarged,  the  capsule  strii» 
easily,  ami  its  consistence  is  diminished.  The  cortical  surface  is  mottled 
and  of  a  <;ray,  grayish-white,  or  grayish-red  color.  The  stellate  veins  are 
injected.  On  section,  the  cortex  is  greatly  swollen,  paler  than  the 
medulla  and  of  a  streaky,  opa(|ue,  grayish-white  appearance.  The 
striate*!  appearance  cliaracteristic  of  the  normal  pyramitls  Is  lost.  The 
kidney  substjitu-e  is  soft,  moist,  and  friable.  The  changes  are  iii 
marked  in  the  intermediate  zone. 

Microscopically,  the  degenerative  changes  in  the  secreting  celK  .iiid 
the  Mulpighiaii  tufts  are  reduced  to  a  minimum  and  the  characteri^iic 
feature  is  a  more  or  less  irregularly  distributed  accumulation  of  niii.iII 
round  celU  in  the  interstitial  substance.  This  infiltration  is  in  mh.iII 
patches  and  is  particularly  marked  at  the  bases  of  the  pyramids,  li. mvili 
the  capsule,  and  around  the  glomeruli.  The  cells  found  are  of  the 
tyjH'  of  lympliocytes,  with  some  plasma  cells. 

The  Kidney  of  Pregnancy. — What  may,  for  the  present,  be  convenii  iily 
called  the  "kidney  of  pregnancy"  is  a  peculiar  condition  met  uiih  in 
pregnant  women.  It  has  not  yet  been  .settled  whether  the  coinliii'i  i^ 
purely  degenerative  or  whether  it  is  in  part  degenerative  and  i'l  i'Ht 
iiiHannnatory,  but  the  lesions  on  the  whole  correspond  fairly  J    .ly 


'  Joum.  Exper.  Med.,  .•?:  1898:  393. 

'  L'ntersuch.  u.  licDbacht.  uel)er  Nephritis  bacillosa  intemtitialin  prini:!i 
f.  klin.  .Med.,  13:  ISM7:  33. 


Xeit. 


THE  KIDNKY  OP  PRKdSASCY 


745 


with  th«9«'  fi>uiid  ill  what  we  Imw  lielow  culled  acute  diffus*;  nephritis. 
Ii  is  iiiipurtiiiit  t<i  note  that  the  pn'^iiaiit  woman  may  Ik-  the  .subject 
i.f  1111  acute  nepl'-iti.s  exactly  in  the  .same  way  us  uther'individuals  iiiav 
on  ix'casioii  Ih-  attacked,  and,  apin,  thut  prennuncy  may  ocrnr  in  one 
iiiready  sufferinjj  from  Hrij;ht's  disease.  Hut .  apart  friim  these  fortuitous 
asscKiations,  the  kidney  may  liecome  affected  during  the  course  of  prcj;- 
iiaiicy,  uiul  apfwrently  in  soiie  way  a.s  the  result  of  it,  without  the 
ordinary  etioloKical  factorH  liei  /  «J''coveml)le.  'I'hi.s  is  the  coriditioii  of 
ihinjis  which  is  .so  often  a.s.sociate<l  with  e<'laiii|>sia.  The  affection  in 
i|iic.stion  iLsiially  arises  during  the  latter  half  of  pregnancy,  and,  prefer- 
al>ly,  in  young  primiparic  and  in  twin  pregnancies. 

The  kidney  varies  .soinewliat  in  different  <-a.ses.  hut  is  usually  enlarged, 
the  capsule  jieels  off  reailily,  the  <-orte.x  is  siniM)th,  pale,  and  of  a  yellowish, 
color.  Oil  section,  the  <ortex  is  swollen.  Mi<ros<-opically,  the  lesions' 
arc  thas«'  referable  to  an  acute  parenchymatous  degeneration,  while 
III.'  interstitial  siilistance  is  but  little  affected.  Citses  have  oc<-urred  in 
which  complete  necrosis  of  the  parenchyma  (M<urre<l  (Klotz,'  Rose 
nradfonl,.lardine). 

The  condition  has  ix-eii  referre<l  to  auto-intoxication,  the  kidnevs 
litiiig  inadciiuate  to  eliminute  waste  prodiwts  for  lx>th  mother  and 
ciiild;  to  infection  and  to.xemia;  to  increa.se<l  intra-alxlorninal  and  intra- 
jxivic  pressure  e.xerte*!  upon  the  renal  veinis,  the  ureters,  or  the  coeliac 
itanj;iiu;  to  the  absorption  of  toxic  prtxiucts  derive«l  from  the  placenta. 

While  for  purposes  of  description  it  is  ccmvenient  to  refer  to  inflamma- 
tion of  the  kidnev  as  "  iJarenchymatous,"  "glomerular,"  or  "  interstitial," 
iKcording  as  the  lesions  are  chiefly  manifested  in  the  secreting  cells, 
tin-  capillary  tufts,  or  the  siipporting'strorr.a,  it  would  lie  far  from  correct 
to  think  that  the  pathological  process  in  any  ca.se  is  confined  to  the 
siriictiircs  named  to  the  exclusion  of  the  resi.  Kvery  acute  and  sulmcute 
Mcpliritis  is,  i>  i  sense,  "diffuse,"  in  thut  all  parts  of  the  kidnev  are 
iiivolvjii,  fh(\  it  may  lie  unetpially.  We  name,  tlierefon-,  the  various 
forms  accord-  to  the  predominating  features  of  the  morbid  changes. 
When  we  speak  of  acute  diffuse  nephritis  in  a  sj)ecific  .sense  we  mean 
liiat  ly|H-  ill  which  tiie  inflammatory  phenomena  are  more  or  less  iini- 
foriiily  manifested  throughout  the  secreting  and  the  supporting  structures 
(if  tli«'  organ.  To  cloudy  swelling,  fatty  degeneration,  and  nwrosis  of 
tlic  secreting  tubules,  are  added  iitlema  and  leukocytic  infiltration  o.'the 
mil  rstitial  tissue.  As  might  l)e  expected,  however,'  the  lesions  are  ii  wt 
niuiked  in  the  cortical  portion,  tlmt  lieiiig  the  region  of  the  greatest 
fiiMdioiial  activity,  and  consequently,  the  most  vuliieniblc.  'I'he  con- 
f:iM ion.  which  is  a  striking  feature  of  all  inflamm.itions  in  their  earlier 
>i  ips,  is  chiefly  iiiaiiifeste<l  in  the  pyramids,  the  vessels  of  the  cortex 
1"  ill.:  rendered  anemic  ow  g  to  the  swelling  of  the  cells  of  the  tubules 
■in.l  the  j)res.surc  of  the  effuswl  inflammatory  prixlucts.  The  diffuse  form 
i<.  perlijips,  the  most  common  type  of  acu.e  and  subacute  nephritis. 

'  Joum.  of  Olistet.,  October,  lUOS. 


aiUI 


746 


THK  KinXKVS 


Ohraik  DifloM  Vaphridi.  Tlit*  ntTet-tion  known  as  i'!ir<>ni<-  ilitTiiM' 
n<*|>hriti.s  ((•hn)ni<-  |Ntn>iM-liynuUi>u.<<  ncpliritis,  inflanitnutory  TaUv  kitlmv ; 
luiyi'  wliiti"  kiihx'v;  varii-pit«Hl  kiiln«"  :  clironir  ilfs(|niu native  iu-pliriiis 
."MM'iHiil  Miinv  of  Hri>»lit's  <lis«'a.H«0  may  «>«ciir  as  tlu-  s«'«|n»'|  of  tin-  ai  iiir 
<litTu.H«>  form,  dejri'iwrativr  clmnp's  in  tin-  *-pith<>liiirn  aiul  inUTsiiiinl 

inKltnttion   iMi-oniing  .ntill   njore  marktil  an<l   th«'  < liiion   imsMii;; 

im|H>r(f|itil>ly  from  the  acjite  to  the  stilHtctitc  un<l  finally  to  the  cliriinir 
state,  or.  nion-  often,  arising  insidiously.  The  anatomieal  eliaiips 
an-  strietly  eompaniMe  to  those  found  in  the  aeute  and  snltacnte  staJ.'l•^. 
hut  are  more  extreme.  Thus,  we  may  have  chroulr  parinrhifniitlittiH 
nruhritin,  rhronir  himorrhayic  nrphritm,  and  chronir  gfomvrulitlK. 

To  }{n»ss  apiK-anince  the  most  striking;  features  are  the  inHainniaiiTv 
swelling  and  the  [)eenliar  color.  The  kidney  is  enlar^l,  soinevvli.it 
soft  and  donphy  in  eonsisttiice,  the  eapsule  peeli  off  readily,  aiul 
the  surface  Ls  smiN>th  and  (  i  a  grayish-yellow  or  uniyish-white  color, 
iK-casionally  presenting;  diluted  .stdfate  veins  or  minute  heinorrlm^'ic 
s|M*t.s.  The  jwle  color  of  the  exterior  may  l»e  uniform  in  intensity.  Imi 
not   infr«-<|uently  is  irregular,  patches  of  coiif^'stion  alternating'  vvidi 

■as  of  pallor,  pvinR  the  orjjan  a  somewhat  variepited  ap|H-ariiiMi . 
(  4ection,  the  cortex  is  swollen,  of  a  uniform  or  |)at<hy  pallor,  similar 
to  that  of  the  surfatr,  with  o«-casional  areas  of  congestion  or  hcnioirliii^'if 
extravasation.  'I'he  jK-c-uliarity  in  color  is  due,  in  jwrt,  to  necrosis  .mil 
fatty  chan^'es  of  the  setretinn  cells  of  the  tubules  anil  in  |)jirt  lo  tlic 
anemia  priMluceil  l»y  the  pre.ssure  of  the  effused  inflammatory  malt  rial. 
I'ntil  recently  it  was  held  that  fatty  degeneration  of  the  tuhulurepilln  limn 
was  a  cardinal  fcaturi'  in  this  form.  We  know  now,  however,  lliat  in 
some  ca.ses,  at  all  events,  the  fat  Ls  present,  not  as  free  fat,  hiK  i  cun- 
hined  in  the  form  of  soaps.  The  medullary  {x>rtion  is  more  or  li -> 
congestwl,  and  of  a  dull  red  color,  contrasting  mi.rkedly  with  flic  |i:illiil 
cortex.  In  the  m<xst  extreme  forms  of  this  tyjK'  the  kidney  mav  1..  n| 
normal  size,  the  surface  slightly  pitted,  and  the  capsule  sonic  uliai 
ailherent,  indicating  the  onset  of  atrophy  autl  fibrosis.  Winn  ilic 
amoiMit  of  hemorrhage  into  the  kidney  substance  is  considerable  ii  ni:iy 
justify  the  term  chronic  hrmorrhaglc  mphrit'iH. 

Now  and  then  cases  are  met  with  in  which  the  organ  is  not  >|p« .  i  illy 
enlarged  and  presents  no  marked  deviation  from  the  normal,  ai  li  ast 
so  far  as  miuToscopic  appeanince  is  concerne<l.  These  are  the  l•a■•■^  in 
which  the  inflaunnatory  changes  are  chiefly  confined  to  the  gloin.  inli, 
while  the  rest  of  the  tisytjes  oractically  escajH'  (chronic  glomiriilili    . 

.Microscopically,  the '-    '   u  changes  vary  considerably.     In  tin 
acteristic  "large  white  kiuiiey"  the  most  notable  feature  is  the  ]<v< 
of  fat  or  soaps  which  are  .somewhat  wide.spread  in  the  epiilnii, 
the  glomeruli  and  the  secreting  tultules,  and  even  in  the  liiiini: . 
the  I)Umk1  vessels.     With  this,  there  is  to  W  olaerveil  a  more  or  i' 
tensive  inflammatory  infiltration,  cedema,  and  leukocytic  exiulaii 
the  interstices  of  the  interstitial  stroma.     In  the  more  iidvanc 
there  may  i>e  indications  of  atrophy  of  the  glomeruli  and  secicii 
with,  possibly,  a  slight  amount  of  secondary  fibrosis. 


'lar- 

iiir 

:'.,  of 

li-of 

■    IX- 

MllO 


CIIHO    !C  IXTKHSTITIAL  XKPIIRITIH 


Tin-  jrldiiMTiili  in  inanv  vhm-h  may  show  futty  (li'){i>n«Tiitiori  of  tli<' 
i'|iitlii'liiiMi  of  tlu'  tiift.H  iiihI  tlu"  liowinun's  <ii!  iiU-:*;  in  other  mtrs, 
^vvclHn^;,  prohfenition,  and  (h>s(|uunmtion  of  the  cpithchal  «-lis  are  more 
protnintMit,  though  not  infn>4|Ui>ntly  tle^nrnitive  aiul  reiwrative  priKt-HM-s 
limy  Ih-  coniliinitl.  In  the  Bowman's  .s|Mi(t>.s  there  is  un  etfuition  of 
iilliiiniinoiis  flniW  which,  owin^  to  the  niethixi  of  hanieniii);,  has  lieen 
('iHtpiiatf«l  into  ilroph-Ls,  );nimilar  or  fihrimtiil  maxsea.  lH>ukoevte.s 
iiiKJ,  in  the  lieniorrhanic  case's,  red  hhxid-i'ells  may  also  lie  found.  The 
(rloineriiH  themselves  are  often  conipresstil  froni  the  a<  -inniihition  of 
tliiid  mid  iiiHamnmtory  eells.  the  epithelium  is  fattily  ^'enerateil,  the 
cn|iillary  vessels  are  thiekenetl.and  may  contain  leukot  ".s  and  hvah'ne 
liiroiiil)i.  The  capiHaries,  Muff  thus  filled  with  r  aunnatorv  aixl 
dejtenerative  pnMhicts,  liecoine  l>hK-ke«l  and  may  in  time  lie  converted  hv 
urbanization  into  solid  strands.  F^•entually,  a  certain  number  «>f  the 
glomeruli  shrink,  are  traiLsfomied  into  minute  hyaline  masses,  p«H)r  in 
or  devoid  of  nuclei,  and  surroundeil  by  a  contractetl  and  thicke!:ed 
capsule. 

The  secretiiiff  cells,  particularly  those  of  the  contorte*!  tubules,  show 
iidvanced  necrosis  and  a  de|Nisit  of  fats  and  soaps  in  their  substan<e. 
wiili  cmise(|uent  exfoliation,  either  in  multiple  isolated  areas  or  uni- 
tuniily  ihrouj;hout^  the  cortex,  though  the  colle<'lin>f  tubules  do  not 
tiilirely  escafM*.  The  luinina  of  the  tubules  not  infre<|iiently  are  filled 
with  (hxenerated  cells,  leukixytes,  pi^;iiient  and  fatty  jiarticles,  together 
with  granular  detritus.  The  lining  cells  are  flattenwl,  cansinjj  the 
iiiiiiiiiii  to  up|)ear  relatively  enlai^.  They  may,  however,  lie  diluted 
from  obstruction.  In  hemorrhagic  cases  the  tubules  contain  numerous 
red  liliKxI-cells.  fasts  of  various  kinds  may  be  also  detected.  These 
(•himj;e.s  in  the  tubules  are  usually  conspicuous  and  are  only  of  trifling 
t\t<iil  ill  the  form  known  is  chronic  glomeruli  ' 

The  interstitial  connective  tissue  is  trdematous  uul  presents  ."  and 
there  small  areas  ()f  cellular  infiltration.  In  the  hemonhagic  f  s  the 
stroma  also  contains  pigment  granules.  !n  the  m'JSl  adv.ineed  cases 
the  supporting  stroma  is  increased  in  amount  and  give;  lefinite  evidence 
of  proliferation,  while  the  Bowman's  capsules  are  also  '  i.  kemd.  Such 
(liaiiges  arc  found  in  those  kidneys  which  i  •  i  .•^inning  t  ,  .--liow  evidences 
of  atrophy  and  contraction  in  their  smu  •  size  and  .stightlv  .scarred 
rortex. 

Chronic  Interatitiil  Nephritis.— This  form  of  chronic  nephritis  pas.st., 
iiiiiMTceptibly  into  the  next,  chronic  interstitial  nephritis  (chronic  pro- 
din  tive  nephritis;  chronic  indurative  nephritis;  granular  kidney;  chronic 
•iitliise  nephritis  with  induration;  contracted  kidney  seconllarv  con- 
timtiHl  kidney;  fibroi<l  kidney;  cirrhotic  or  .sclerotic  kidney;  third  stage 
of  llright's  disease). 

It  is  generally  held  at  the  pre-sent  time  that  the  contracted  kidnev 
IS  of  four  types;  the  first  arising  as  a  .setjuel  to  the  large  white  kidnev 
^^Kwiilcnj  cnntract'fl  kidney);  the  .seciind,  nrigitutfing  in  an  acute  neph- 
iiiH  and  apparently  not  passing  through  the  large  white  kidnev  stage 
<l"-im<irif  contr-i^ted  kidney);   the  tiiird,  due  to  scU.osis  of  the  renal 


l!  ! 


74S 


THE  KlDi\E\S 


vessels,  ami,  Jlierefore,  of  a  degenerative  rather  tlian  an  inflaniniatorv 
nature  (nrterloncliroiic  kidney;  see  p.  7.^3);  and  tlie  fourth,  tlie  senile. 

From  tlie  nature  of  the  ease  it  is  extremely  diHicult,and  in  some  in- 
stjuices  impossible,  to  make  j)Ut  the  exact  sequence  of  events  in  these 
various  fornts.  The  doubtful  points  are  lianlly  likely  to  In-  cleared  up 
until  we  have  the  results  of  more  extendt>d  experimentation  at  our 
conunand.  Time,  therefore,  may  m<Mlify  our  present  conceptions  of 
renal  inflammation. 

In  a  well-marked  case  of  chronic  interstitial  nephritis  of  the  secoiidiirv 
contracted  type,  the  kidney  is  usually  diminished  in  size.     In  eonsisteiue 
it  is  firm  and  hard,  somewhat  elastic,  and  cuts  with  more  or  less  resistiincf, 
resemblinff  in  this  other  fibroid  structures.     The  capsule  is  somewiiut 
thickened  and  is,  in  places,  adherent  to  the  cortex.     On  removiiif;  it 
small  portioas  of  the  cortex  are  torn  away.     The  surface  of  the  kidnev  is 
irregular,  warty,  or  granular,  being  studdtnl  with  prominences  of  some- 
what uneven  distribution,  and  of  greater  or  smaller  size.     (Jccasioind 
<'ysts,  containing  a  ch-ar  colorless  or  straw-colored  fluid,  are  usuiillv 
to  l)e  seen.    '1  lie  color  of  such  a  kidney  varies,  and  it  may  Ik?  mentioned 
in  passing  that  the  terms  "small  white  kidney"  and  "small  red  kidnev," 
which  have  l)een  so  often  employed,  <lo  not  really  indicate  any  inipor(;iiit 
difference  in  tyjH',  the  color  of  the  organ  iM'ing  dejiendent  largelv  on  the 
amount  of  bhunl  which  it  contains,  though  also  to  some  extern  ii|ii>ri 
the  degree  of  atrophy  and  fatty  changes  that  it  has  undergone,     (lend 
ally,  the  kidney  is  somewhat  tran.slucent  and  of  a  dull  red  color,  lint  ii 
may  be  grayish  or  grayish-white,  inottle«l,  or  even  (|uite  white  and  opm  |iif. 
The  superficial  furrows  are  usually  of  a  brighter  red  color  than  arc  ilic 
granulations.     On  section,  the  nuHlullary  portion  is  usually  sonnwli.ii 
brighter  colore<l  than  the  cortex,  but  may,  again,  resemble  it  in  liiii-. 
As  a  rule,  the  cortex  is  diminislu'd  in  thickness  and  this  is  more  es|)((  i:illv 
the  case  in  those  parts  imiiMHliately  in  ass(K-iatioii  with  the  «« |.ressi(iii>  (if 
file  surface.     It  may,  however,  hapjx'ii  that  in  other  regions  the  inrt<\ 
is  of  normal  size,  or  even  increased,  owing  to  a'denia.     The  larger  vi— (  K 
usually  show  some  thickening. 

The  histological  features  may  W  epitomized  as  atrophy  and  ilffxcni m- 
tion  of  the  st-creting  structures  and  relatively  diifuse  new-fonn;ith>ii  of 
connective  tissiu-.  Tlu-  relative  extent  of  these  factors  de|MMi(ls  on  the 
nature  of  the  case  and  how  closely  the  condition  approxiinnii-  to 
the  chronic  parenchymatous  form.  The  glomerular  epithelinni  i  .  in 
the  l«-ss  advanct'd  cases,  swollen  and  des(|uamating,  but  this  is  nt\(  i  mi 
marked  as  it  is  in  the  chronic  parenchymatous  form.  Later,  tiie  ltIimui  r- 
nlar  tufts  lose  their  epitiieiium  and  the  vessels  Imvoiiic  tiiickiii.il  .md 
inijM-rvions.  Kvenlnally,  many  of  the  glomeruli  are  coiiverlid  inici  a 
structureless,  hyaline  mass,  devoid  or  almost  d«'void  of  iniclei.aml  in.  toi 
less  lobnlated,  so  that  they  come  to  resemble  a  trefoil  or  nwtii  Not 
a  few,  however,  can  be  seen  which  have  evitlently  n-talned  their  fiiin  inns 
ami,  in  fact,  have  undergone  a  com|H'iisatory  hyjM'rtropliN.  I  lir 
capsule  at  the  same  time  shows  evidences  of  pn)liferation  anti  thii  l,i  lin::. 
The  changes  in  the  epithelium  of  the  convoluted  tubules  air    intiy 


CHRONIC  ISTKHSTiriAL  Xhl'/llOns 
Fiii.  198 


r49 


(•Iir..ni.'  iiiler^ijliiil  riephriti-.  ^h"wiIlK  ntnipliy  iif  tubulen  and  certain  iif  the  Klnmeruli; 
piTiKli.niiTular  tilinisi»:  ililuliilioti  ..f  tiiliiilex.  I.eiti  i)bj.  Nii.  H,  willnmt  ocalar.  (From 
chi' i-..lli'.Mi,,M  iif  t>r.  A.  (1,  Ni.-li(.lls.) 


I'll;.   III!) 


3  ^    I 


t  lifriif  interstitial  nephritis; 
without  oeular. 


ililalalinn  iif  the  liiliiiifK;   hvuliue  cantn.     f.eitj 
(Kn>ni  the  i'nllceti"ii  nf  Dr.  A.  G.  Nieholls.) 


i.l.j.  N...  7, 


750 


THE  KIDNEYS 


%     t 


coniparahle  to  thase  (XTurrinj?  in  chronic-  parenchymiitons  nephritis, 
l)Ut  are  rarely  so  pronounced.  In  many  parts,  where  the  interstitial  tissin- 
is  increased,  both  secreting  and  collecting  tubules  may  l)e  compresscil 
or  collapsed,  and  are,  therefore,  smaller  than  normal,  Vin^r  lined  wiih 
cubical  cells.  Not  infrequently  it  will  l)e  found  that  certain  tulmlts 
have  entirely  disappeare*!,  or,  apiin.  their  places  are  indicated  by  a 
rinj;  or  double  row  of  simple  nuclei.  Such  epithelial  cells  as  remain  arc 
small,  atniphic,  granular,  vacuolattnl,  or  fatty.  In  those  parts  of  tli,' 
kidney  where  the  fibroid  induration  is  less  marked  a  different  picture  is 
to  l>e  seen.  Here,  the  tubules  are  often  dilated,  some,  indeed,  bcinj; 
cystic.  The  lumina  of  such  tul)ules  are  dilated  and  contain  gramilar 
debris  and,  j)erhaps,  an  occasional  cast,  while  the  lining  cells  are  flattened 
centrifugally  from  vertical  pressure  and  are  extended  laterally  to  cover 
the  increased  surface  of  the  basement  membrane.  The  epitheliinn  is 
also  fatty  and  shows  other  evidences  of  degeneration.  The  dilatation  of 
the  tubules  is  to  be  attributed  to  obstruction  of  the  lumina  in  some 
portion  of  their  course,  owing,  either  to  the  encroachment  of  the  newlv 
formed  connective  tissue,  or,  again,  to  blocking  by  casts,  cellular  (iel.rjs, 
and  precipitated  salts. 

In  all  cases,  there  is  an  increase  of  the  interstitial  connective  tisMie, 
the  amount  varying  according  to  the  nature  of  the  case  and  the  clironidty 
of  the  disease.  The  depressions  of  the  surface  are  contimions  witii 
bands  of  connec-tive  tissue  which  extend  deeply  into  the  cortical  sul)staM(e 
and  even  into  the  labyrinth.  These  bands  unite  freely  in  the  lieep.r 
jwrtion,  thus  dividing  the  kidney  into  a  series  of  loi)ules.  In  such  ureas 
of  hyperplasia  there  may  l)e  seen  accumulations  of  round  cells,  uliile 
here  and  there  can  W  made  out  developing  fibroblasts.  In  x me 
few  cases,  the  fibrous  tissue  is  very  dense  and  fibrillar.  Tlic  };loni(riili 
and  tubules  in  these  districts  are  in  all  stages  of  atroj>hy  and  degeneration 
and  in  large  part  have  disapjM-ared  altogether.  Hetween  the  lil.rmis 
patches  the  secreting  structures  that  remain  may  be  <(nn|)araii\riv 
normal,  I)ut  not  infrequently  show  a  certain  amount  of  fatty  clianirf. 
Occasionally,  evidences  of  regenerative  hyperplasia  can  In-deirt  ie.|. 
It  is  by  no  means  uncommon,  moreover,  to  find  the  lesions  of  an  adiie 
parenchymatous  nephritis  sufierimposed  on  those  of  the  clironii  initr- 
stilial  form.  The  vessels  in  the  fibroi<l  areas  show  some  tiiiek(  nin.'  of 
the  adventitia  and  usually  of  the  intima  also,  leading  to  more  nr  less 
obstruction  of  the  lumina.  Some  of  the  vessels  may  indeed  lia\'  dis- 
ap|M'ared. 

-\n  im|K)rtant  form  of  chronic  Hright's  disease  is  that  known  s  /,, ;,  ./r^ 
rhrnnic  inftrstitial  niphrlti'n.  It  has  l)cen  called  also  the  "goni  kil  uy," 
the  "  genuine  contracted  kidney,"  and  the  "  red  granular  kidney.  Aiia- 
toinically,  it  resembles  closely  the  other  typs  of  chronic  inti  -  iiial 
kidney,  and,  indetHl,  it  is  difficult  to  separate'it  from  them,  'i'ln  ir  .ms 
for  rtHognizing  this  variety  as  a  separate  entity  are  largely  clinic  a  I  i'lie 
disiMsc  begins  insidiously,  ilicre  In-ing  no  history  of  any  ami-  inai 
inflammation.  When  symptoms  manifest  thenis'elves,  the  kiiv  i> 
already  contracted.     The  affection  is,  therefore-,  Ix-lievcnl   noi  ;     pass 


ACUTE  HKMATOdENIC  SUPPURATIVE  NEPHRITIS  75] 

ihroiiph  the  "large  white  kidney"  stajje.  The  process  is  primarily 
a  cliroiiic  one.  The  etiology  is  often  obscure.  In  mast  cases  there  is 
..  liis((iry  of  alcoholism,  gout,  or  lead  poisoning.  Sometimes  the  patient 
has  suffc'red  from  some  acute  infective  illness  years  Ijefore.  Syphilis, 
(lialK'tes,  and  mental  strain,  are  also  mentioned  as  causative  factors.' 
Heredity  seems  to  play  a  part  in  some  instances. 

In  this  form  the  kidney  is  usually  very  small,  smaller  than  that  of 
scconihiry  interstitial  nephritis,  hard,  and  granular.  The  granulations 
art"  unusually  fine.  The  capsule  is  firmly  adherent  and  the  organ  is 
jrttierally  of  a  dull  re<i  color.  Cysts  are  present  on  the  surface,  containing 
iiicxlified  urine  or  yellowish-green  colloid  material.  The  cortex  is  ex- 
tremely thin  in  places  practically  absent.  The  pyramids  are  also 
reiluced  in  si/.c,  though  relatively  increased  in  proportion  to  the  cortex. 
Ill  tin-  gouty  cases  calcareous  and  uratic  deposits  may  be  found  in  the 
sul)stance  of  the  organ.  The  branches  of  the  renal  arferv  are  usuallv 
frreatly  sclerosed.  The  pelvis  of  the  kidney  contaias,  as  a  rule,  an  in- 
creased amount  of  lat,  and  the  atrophietl  organ  is  also  embedded  in  a 
larfTc  fatty  mass. 

Histologically,  the  pathological  changes  do  not  differ  materially  from 
tliose  descrilwd  in  the  secondary  form,  except  that  thev  are  even  more 
Miieiise,  and  widesprend.  Tiie  newly-foniM-d  fibrous  tissue  is  particularly 
ilense.  Compensatory  regeneration  is  also  met  with  here  in  the  cells  (if 
the  tul>ulcs. 

Suppurative  Nephritis.-  In  this  form  of  nephritis,  the  inflannnation  is 
.lefmitely  due  to  the  action  of  infective  agents,  usually  the  staphvKKwcus 
and  streptix'occus,  which  are  brought  to  the  kidnev  from  sonie  distant 
|M>iiit.  The  pyogenic  microorganisms  in  question"  reach  the  organ  in 
one  „r  other  of  four  ways:  (1)  through  the  bloo<l- hematogenic 
form;  (2)  through  the  urinary  tubules;  (.i)  bv  direct  intnxluction  from 
wiih()ut_  woimd  mfection;  (4)  and  by  extension  of  inflammatory  pro- 
(•esses  from  adjacent  parts- suppurative  nephritis  per  cxfnix'm„nn. 
1  he  most  connnon  methcxls  of  infection  are  through  the  blotnl  stream 
\.U^<;mlniri  nifluwmotkm)  and  through  the  urinarv  passages  (aumuUm, 
nitldiiimntion).  ' 

Acute  Hematogenic  Suppurative  Nephritis.—Acute  hematogenic  suppu- 
ran\e  nephritis  is  usually  the  result  or  accompaniment  of  suppurative 
proresses  elsewhere  in  the  body.  It  is,  therefore,  part  and  parcel 
'•I  a  generalized  septicemia.  The  most  important  predisposing  con- 
'li'H'Ms  to  which  this  form  of  nephritis  is  secondary,  arc  ulcerative 
eiMl.Kar.litis,  osteomyelitis,  puerjH-ral  sepsis,  .lecubitus.  piilmonarv 
tul.ereul.,sis;  less  often,  typhoid  fever,  dvsenterv,  lobar  pneumonia 
^'  M,  atma  variola,  and  actinomycosis.  The  offe.uling  microorganisms 
HMrl,  the  kidney  either  in  the  form  of  definite  emboli  (rmhollv  mvtmfntiv 
'"iM  ot  ()rth),  or  singly  or  in  small  numbers,  when  thev  become  en- 
taii:;^!..,!  withm  the  vessels  and  proliferat.-  there  [.vmplr  mvtaxlath-  form 

Ill  typical  and  well-marktHi  cases  of  this  affection,  we  have  all  the  feat- 
II"-  <il  an  acute  parenchymatous  inflammation  plus  the  characteristic 


752 


THE  KIDXEiS 


manifestations  of  a  suppurative  prot-ess,  namely,  alwcess-fonnutiiHi, 
Both  kidneys  are  usually  involved,  as  mipiit  l)e  e.\p«'te<l.  They  nre 
swollen  and  (edematous,  and  the  capsule  peels  off  with  ease.  The  surfiicc, 
which  is  paler  than  normal,  is  studded  with  a  variable  numljer  of  .small 
aiiscesses  that  present  as  minute  elevations  of  an  opaiiue,  yellowish, 
white  color,  surrounded  by  a  congested  or  hemorrhagic  zone.  In  niiinv 
instances  the  abscesses  are  not  larger  than  a  pin-head  in  size  or  even  less, 
and  are  equidistant  one  from  the  other  throughout  the  cortex.  This 
arrangement,  when  present,  should  always  suggest  the  emlwlic  nature  of 
tlie  case,  inasmuch  as  the  abscesses  resulting  fn)ni  ascending  infection 
from  the  lower  urinary  passages  are  massed  in  little  groups,  scparateil 
by  areas  of  comparatively  healthy  tissue,  corresponding  to  the  (JMsttrs 
of  papillary  tubides. 

On  set'tion,  Imth  the  kidneys  are  found  to  l)e  riddle<l  with  iilisres>,  , 
chiefly  in  the  cortical  portion  but  also,  to  some  extent,  in  the  niediillu. 
Tile  cortex  is  pule,  cloudy,  an<l  swollen  and  presents  in  the  neighborhoiHl 
of  the  abscesses  all  the  features  of  an  acute  parenchymatous  inflainiuatioii. 
The  abscesses  in  the  cortex  are  rounded,  while  those  in  the  medulla  tciul 
to  \te  eK>ngat«Ml,  following  the  course  of  the  tubules.  Exceptionally,  ( rr- 
tain  of  the  abscesses  nuiy  reach  the  size  of  a  haz.el-nut.  In  the  simple 
metastatic  form  of  Orth,  the  abscesses  are  usually  found  in  tlic  pyramids 
( nii/rotic  papillary  nephrltii). 

The  histological  apjiearances  vary  in  different  parts  according  to  the 
age  and  intensity  of  the  infective  pro<ess.  Thus,  in  the  earliest  >ta;.'e 
of  abscess-formation  we  <'an  dete<'t  by  suitable  metluKls  of  staiiiiiij; 
(lumps  of  bacteria  within  the  glomerular  and  j)eritubular  capillaries. 
In  the  innnediate  vicinity  the  epithelial  cells  present  degenerative  a-id 
even  n«>crotic  changes.  When  the  lesion  is  more  matured,  niiinliirs  of 
leukcK-ytcs  are  foinid  to  be  massed  within  tlie  capillaries,  within  the  How- 
man's  .space,  and  in  the  interstitial  stroma  in  the  neighlK)rli(MMl  of  the 
tufts.  When  the  abscess  is  fully  formed,  we  get  clinnps  of  liaderia, 
surrounded  by  a  zone  of  ne<'rotic  ti.ssuc,  and  boimded  externa'lv  liv  a 
iiia.ss  of  leukcK'yfes.  In  the  innnediate  vicinity  of  the  abscesses  th  kiilnev 
substance  is  markedly  congested  and  (edematous,  and  the  Mcreiin;; 
cells  are  swollen,  cloudy,  and  degenerating.  In  the  inyiotie  |i.j|iillarv 
form  the  apjiearances  are  similar,  but  the  bacteria  are  usually  foiiiui  in 
the  secreting  tuludes  of  the  papillse  and  the  median  zone  of  the  pyrainiiU, 
indicating  an  attempt  at  excretion  and  elimination  of  the  otlmiliii}; 
inicroorgaiiisnis. 

Suppurative  Pyelonephritis  and  Pyonephrosis. The  type  f  ilie 
a.scending  iiifectioti  of  the  kidney  is  the  di.sease  known  as  siipji:  ralive 
pyelonephritis  or  "surgical  ki<lney."  In  this  form  the  infective  iprits 
reach  the  kidney  by  way  of  the  urine.  Inflammation  of  tin  'Mlmi 
(urethritis),  bhuider  (cy.stitis),  ureters  (ureteritis),  or  the  pehi  '>i  the 
kidney  (pyelitis)  may  all,  therefore,  be  the  innnediate  pre<i' 
suppmative  nephritis.  The  liability  to  infection  is,  monov.  : 
increased  by  fermentative  changes  in  the  urine,  obstruction  in 
flow,  the  presence  of  animal  parasites,  or  by  nuH'hanical  irr :     .m.  as 


.,rs  of 
iratly 
1    out- 


M. 


!»P?t' 


SUPPURATIVE  PYELOSEPIIRITIS  AND  PYONEPHROSIS       753 

from  the  presence  of  calculi.  In  some  few  instances,  the  process  is  in 
the  first  instance  a  descending  one,  the  offending  microorgp.nisms  being 
excreted  by  the  kidney  into  the  urine,  and  exerting  merely  a  passing 
influence  on  that  organ,  until  they  are  resorbed  from  the  lower  urinary 
passages.  Here  we  have  the  combined  effects  of  soluble  toxins  upon 
the  kidney  substance  and,  later,  of  the  actual  growth  of  the  germs 
within  the  kidney  substance. 

The  bacteria  chiefly  concerned  in  bringing  about  this  form  of  nephritis 
are  the  B.  coli,  the  various  pyogenic  coc-ci,  and  the  Gonococc  s.  The 
(ii-scending  or  excretory  t>-pe  of  the  affection  is  met  with  in  such  diseases 
a-s  typhoid  fever,  scarlatina,  variola,  septicemia,  vholera.  The  process 
may  attack  a  previously  intact  kidney  or,  again,  one  the  site  of  hydro- 
nephrosis. The  cases  in  which  tlie  pelvis  of  the  kidney  is  filled  with  pus 
are  termed  suppurative  pyeUt  i.  Sooner  or  later  the  kidney  substance 
iKHomes  involved,  a  condition  that  is  spoken  of  as  rappantive  pyelo- 
nephritis. 

In  a  case  that  is  not  too  far  advanci  d,  one,  and  usual'  both  kidneys, 
are  swollen  and  cedematous,  soft,  and  congeste<l.  On  'ion,  opaque,' 
\vll()wish  streaks  can  often  l)e  made  out  in  the  pyramids  extending 
into  the  cortex,  their  long  axes  running  in  th.  direction  of  the  collecting 
liibulcs,  iKHmded  by  a  hyperemic  zone.  In  the  cortex,  too,  are  similar 
areas  of  globular  shajie,  aggregated  into  the  little  clusters,  and  separated 
from  each  other  by  comparatively  healthy  kidney  substance.  The  streaks 
in  (luestion  are  due  to  the  in  lammatory  products  which  have  accumu- 
lated in  the  tubules  and  the  neighboring  lymphatics.  The  opaque 
areas  in  tl  e  cortex  are  minute  abscesses  in  the  coimective-tissue  stroma 
of  those  parts  correspjtiding  to  the  various  lympiiatic  districts. 

In  more  advanced  cases,  ho  ever,  the  abscesses  are  larger,  more 
.lUnuTous,  and  the  regional  distribution  is  not  nearly  so  evident.  When 
the  abscesses  iiecoine  confluent,  they  may  attain  a  considerable  size  and 
may  extend  through  the  greater  part  "f  the  thickness  of  the  kidney. 
I  hey  inay  from  the  first  communicate  with  the  pelvis,  and  if  the 
ilestriKtive  process  be  extensive,  the  organ  may  be  converted  into  e 
tliiituatmg  sac  containing  pus  and  necrotic  tissue'  the  walls  of  which  are 
composed  of  the  ki<lney  c.psule  and  shreds  of  disintegrating  kidnev 
suhstunce  (pyonephrosis).  When  the  patient  lives  long  enough  the 
smaller  abscesses  may  be  encapsulated  by  the  forminion  of  fibrous 
tissue,  but  where  the  process  is  extensive  the  inflammation  mav  extend 
to  the  capsule  of  the  kidney  (perinephritis)  or  even  to  the  fat  and  con- 
nective tKme  about  the  organ  (paamephriWj).  Thus,  the  whole  of  the 
secreting  substance  may  be  destroyed,  aru  the  place  of  the  kklney  is 
mil!  'ated  by  a  mass  of  connective  tissue  containing  often  inspissated  "pus 
anil  calcareous  salts.  In  cases  due  to  calculus  we  m.iv  find  merely  a 
filHoiis  contracted  sac  filled  with  stones. 

llMologically,  it  can  be  made  out  that  the  inflammatory  process  begins 
thn.iigh  nifection  of  the  collecting  tubules,  beginning  in  the  pyramids 
an.  extending  up  into  the  cortex.  The  kidney,  as  a  whole,  is  congested, 
an.!  .specially  so  in  the  neighborhood  of  the  infected  areas.    The  lymph- 


754 


THE  KiDyms 


Btics  are  often  distcmle<l  and  filled  with  leukocytes,  an  ong  which,  l.y 
suitable  methods  of  staining,  bacteria  can  be  detected.  Ihe  secretiiiR 
cells  of  the  tubules  near  bv  are  swollen,  cloudy,  and  often  degeneral.d. 
As  the  process  goes  on,  leukocytes  are  massed  at  the  part,  central  n«  ro- 
sis  if  the  infiltra  e.i  area  takes  place  and  an  abscess  is  formed,  pusliMiR 
,  side  the  adjace  It  tubules.  Later,  in  .sot.  •  prolonged  cases,  a  (  lam 
amount  of  connective  tissue  hyperplasia  can  be  made  out  at  the  periplury 
of  the  necrotic  areas.  . 

Tnanutie  Suppuntlye  Hephritii.— Traumatic  suppurative  nephritis 
may  result  from  stabbing  cr  gunshot  nouiuLs,  or,  again,  arise  in 
coiwequence  or  as  a  sequel  of  surgical  operations.  In  such  cases  the  in- 
fectinc  agents  ar-  intnxlucetl  direc-tly  from  v  uhoiit  (vound  uifirfion). 
The  condition  mav  also  arise  from  contusion.  This,  by  l.)weriiig  tl.e 
resisting  power  of  the  kidney,  renders  it  an  easy  prey  fo.  .aicrooreanisnis 
which  may  reach  it  from  the  lower  urinary  pa-ssages  or  by  way  of  the 

blood  stream.  .  .  . 

Pmnephiitii.— Suppurative  nephritis  arising  per  exiensionem  is  m- 
variably  associated  with  paranephritis,  of  .  hich  affection  it  foniis  ...w 
phase  The  infection  arises  often  from  some  quite  remote  part  and 
attacks  the  kidney  by  wav  of  the  connective  and  fatty  tissue  surrDund. 
ing  it  The  chief  etiological  factors  are  traumatism,  lumbar  :-.iid  psoa* 
abk-esses,  suppuration  of  the  retroperitoneal  glands  Among  the  mrei 
causes  mav  1*  mentioned  empyema,  abscess  of  the  liver,  aKscess  ;«f  tht 
ligainentum  latum,  cholecystitis,  perforation  of  the  bowel,  and  ,.ura 
tv-phlitis.  As  might  be  expectetl,  we  do  not,  in  this  affection  hml  th( 
multiple  small  abscesses  so  characteristic  of  suppurative  nephritis,  mi 
rather  a  single  large  abscess,  localized  to  one  part  of  the  organ.  1 1« 
process  may  assume  the  type  of  a  gangrenous  as  well  as  a  suppurativt 
inflammation.  , 

Besides  the  tvpe  of  disease  just  described,  paranephritis  may  rtsul 
from  infective  processes  originating  in  the  kidney  itself.  Ihus,  sup 
purative   pyelonephritis,   with   or   without   nephrolithiasis,   is  a  inos 

important  cause.  „      •     i       , »  • 

Paranephritic  abscesses  are  often  large  and  usually  single.  ( )win( 
to  the  loose  nature  of  the  cellular  tissue  about  the  kidney,  they  .Men, 
rapidlv.  Ill  some  few  cases,  generally  those  due  to  pvel.)ii.i.l.rm> 
multiph  small  abscesses  develop,  which  may  undergo  absorption  o 
fuse  into  larger  ones.  Where  the  patient  sur^■ives  long  enoiigli,  :i  hirf 
amount  of  fibrous  scar  tissue  is  formed,  so  that  the  kidney  l..,.,u.. 
embedded  in  a  dense  cicatricial  mass  of  almost  cartilaginous  hMi.lims> 
Orth  has  reconled  a  case  of  this  kind  which  le.l  to  thrombosis  of  thi 
renal  arterv  and  necrosis  of  the  kidney.  Where  operative  int.  il.Tinoi 
is  not  resorted  to,  a  paranephritic  abscess  may  burrow  widelv.  »u'\  ina; 
rupture  externallv  or  into  some  viscus.  It  usually  points  m  ih.'  \ou 
or  at  Poupart's  ligament.  More  rarely,  it  presents  l)elow  thr  -Infa 
maximus,  between  the  biceps  and  sartorius,  or  at  the  ingiii|  ■  i'"*. 
When  not  discharging  externally,  the  abscess  may  empty  into  H"  <oioii 
the  pleural  cavity,  or  into  the  lung,  into  the  peritoneal  cavity,  tin  kuiiie 


TUBERCULOSIS  OF  THE  KIDNEY 


755 


p Ms,  urethra,  bladder,  and  vagina.    One  of  us  (A.  G.  N.')  has  reported 
a  unique  case  in  which  rupture  took  plate  into  the  stomach. 

Specific  Nephritis.-  Tub«rciUo«ii.—Tulierculo3is  of  the  kidney  is  by 
11.)  means  uncommon.  The  infwtion  is  usually  hematogenic,  but  may 
be  an  ascending  one,  arising  from  other  parts  of  the  genito-urinary 
system.  Occasionally,  it  is  due  to  the  extension  of  tuberculous  disease 
fr  .111  adjacent  structures,  as  from  the  suprarenals. 

llie  affection  manifests  \t<f](  in  two  forms,  an  aente  miliuy  tnber- 
ealosif  and  a  chronic  local  fiowcnl'.ili.    The  first  .ariety  i^  probably 
always  Secondary,  and  is  usually  but  a  manifestation  of  a  generaliz<jd 
systemic  tuberculosis.    Occasionally,  the  primary  focas  is  quite  small  v  nd 
the  kidneys,  either  one  or  both,  are  the  only  o  gans  presenting  mi'l-ary 
involvement.    The  bacilli  reach  the  organ  through  the  renal  artei^ 
and  Its  branches  and  are  often  entangled  in  the  glomerular  capillaries 
They  may,  however,  get  into  the  tubules,  evi'sntly  as  the  result  of  an 
attempt  at  excretion  (elimination  iuhtrnilosii,  of  Cohnheim  and  Meyer) 
The  lesions  characteristic  of  this  affection  appear  as  minute  tubercles 
or  iiiilia,  of  a  grayish-white  color,  at  first  somewhat  pearlv   later  dull 
and  opaque,  which  appear  usually  as  circuinscril)ed  nodules,  but  some- 
(iines  as  indefinite  streaks.    These  are  generallv  bounded  by  a  hvperemic 
zone.    The  tuln-rcles  may  l)e  few  in  number    {K-rhaps  restricted  to  a 
sinjrle  arterial  dislnVt,  or,  again,  are  abundant  and  .sc-attered  throughout 
I  he  organ.    1  hey  are  most  numerous  in  the  cortical  region.     Oce^ion- 
ally,  two  or  mor«  mpv  lonlesce  to  form  a  larger  focus. 

Microscopically,  ..le  lesion  is  that  t>T,ifal  of  an  acute  tuln-rculosis 
lliere  is  a  small  luxle  of  monoruclea»  or  Ivmphoid  cells,  I  ,  or  near 
a  glomerulus,  or  in  some  part  of  the  intertuhular  connective  tissue 
1  lis  may  Iw  the  sole  manifestation.  'I'he  older  and  larger  foci  present  in 
a.i.lition  a  small  amount  of  central  caseatio.i.  'I'he  ves.sels  in  the 
iififililMjrliood  of  the  tuljerde  are  congeste«l,  while  those  within  the  node  are 
oLsiriicted  by  inflammatory  products  or  by  thickening  of  the  intima 
Inasiimch  as  the  process  is  usually  an  acute  and  terminal  one  we  do  not 
h!ul  any  attem{)t  at  healing  in  the  form  ot  fibrous  hvperplasia.  Giant 
lells  iirc  also  absent  or  scaiitv. 

Chronic  local  tuberculosis  of  the  kidnev  is  either  hematogenic  or  ascend- 
iiif:  111  Its  origin.  One  or  both  organs  mav  be  involved.  It  is  usual 
at  autopsies  to  find  both  kidneys  affecied,  but  not  infretiiiently  the 
ilis.|p.  IS  much  more  advanced  in  one  than  the  other.  The  right  kidnev 
IS  air. ,  te.l  as  o  ten  as  the  left.  A  .piesiion  that  has  given  rise  to  some 
(iH,:,t,.  ,s  whether  genito-urinary  tuberculosis  is  ever  priniarv.  Inas- 
mu.li  as  a  tuberculous  septicemia,  without  a  local  lesion,  has  been 
(lemon.trafetl  as  a  possibility,  it  cannot  be  denied  .iiai  primarv  genito- 
urinary tuberculosis  can  occur.  It  is,  howev.-.,  never  safe  to'  assume 
Uat  this  is  the  c-ase,  unless  the  most  exhaustive  searcii  has  failed  to  reveal 
tul..„  P|„„s  lesions  elsewhere.  The  further  point,  whether  in  .^enito- 
un.„M     tuherculosi-    he  affection  begins  in  the  kidney,  subseq^uently 

'  Montreal  Med.  Jour.,  27: 1S98: 119. 


756 


THE  KIDSEYS 


it  ' 


extending  and  aesi-eiidiiiR  t«i  the  kidney  |H-lvis.  ureter,  ind  blttd.ler  (.r 
vhether  it  originates  in  the  >,rt.nitaliu  or  l)lad<Jer  and  trax  N  upward,  is 
verv  iliffieult  to  decide.  The  prei>onderance  of  evidence  at  the  pr.Mnt 
time  favors  the  view  that  in  most  eases  the  infeitiou  is  a  descend .!.« 
one.  the  bacilli  passing  through  the  ki.lney  and  settmg  up  disease  .Is,- 
where,  a.s,  for  example,  in  the  ureters  and  l.hul.ler.  I ^iter.  the  ..rganisins 
are  carried  l)ack  and  attack  the  ki.lneys. 

Three  main  anatomical  tyin-s  have  Ihtu  des<r.lH-d.  Ihe  hrst  and 
commonest  is  the  maimit'i',  raneoM,  or  ula-r,iliir  form.  Here  the  pr.H.ss 
usually  lieirins  at  one  iH)le  .>f  the  organ,  geia-ndly  the  lower,  and  exl.'M.is 
by  local  metastasis  until  the  whole  organ  (.ccomcs  mvolve<l.     At  hrst 

appearing  as  a  small,  grayish  n.nlule,  the  tulH-nle  enlarges.  \m us 

caseous,  and  finally  softens.     In  this  way  caseous  abscesses  arc  f..rinnl 

Fio.  200 


Chronic  «>*..«.  ,ubercul.«i8  ..f  the  kiJn.^y.     iKn.in  the  I>ath,.l„gioal  Mu-run,  nf 
McUill  Vnivemity.) 

which  in  time  open  up  comnmnication  witii  the  pelvis.  Tlir  kidnev 
is  thus  converted  into  a  series  of  loculi  comnuniicatnig  more  <.r  !.■.>  trwiv 
with  its  cavit  V  and  fille<l  with  a  soft,  pnltaceous.  or  curdy  necroti.mut.nal. 
These  loculi  are  separated  one  from  tlie  other  by  septa  formed  ..I  Mi} 
and  disintegrating  kidnev  substance.  The  organ  is  usuallv  .  nlar}:n . 
although  its  shape  is  preserved.  To  the  tou.h  it  presents  m  i.la. , , a  soft 
fluctuating  .sensation.  Occasionally,  the  surface  will  show  a  ri.s  oi 
large  bosses  of  <l()Ughv  or  elastic'  consistence,  over  which  the  '.>\<>nU'  i> 
firiiilv  adherent.  On"  section,  the  kidney  is  convened  into  .  nunil;.': 
of  .sacs,  manv  of  them  cominiinicating  with  the  pelvis,  iin.l  .  u.|>.lin|. 
up  into  the  co'rtex.  When  the  nciiotic  material  lllltt.g  the  ^\»'-.-  - '>  '**;" 
washe<l  awav.  the  walls  appear  either  smooth  or  covere.1  witli :.  .u.f.fmc 
membrane.  '  In  advance.1  cases  the  kidney  may  1  -  t..tally  d.si  y.,l.ai. 
is  representeil  bv  a  shrunken  mass,  consisting  of  a  thin  shell    ;  Kiun.. 


TVBERCrWSIS  OF  THE  KIDXEY  757 

Milistiince,  or,  {M>rhu|).s,  nierely  llif  cuiMtile,  encldsiii^  inspksatetl  ca-seous 
material.  Tlie  inflanirnutorv  protrss  fr«nipntly  involves  the  kidney 
(itpsiile  (tnbtrcnlmi  perinaphritii),  or,  again,  may  extend  to  the  sur- 
roMiuliiig  c-onnet-tivc  tissue  (tab«rculotti  pmnapbritii).  The  fibro-fatty 
tissue  surroundinK  the  ki<lney  Irt-conies  thereby  greatly  indurated  or 
tlif  seat  of  aKscess-forniatioii.  Another  sequel  of  tulxrinilous  nephritis 
is  tliHt  the  inflannnation  extends  to  the  mucous  membrane  lining  the 
IHJvis  and  thence  t(»  the  ureter  anti  bladder.  The  pnx-ess  here  is  mani- 
fested by  the  ap|)earan<e  of  scattered  elevated  tuWrcles  of  gravish  color 
on  the  mucous  surface.  These  are  not  unconunon  in  the  mucosa  of  the 
l)liid(ler  near  the  orifi<es  of  the  jireters.  In  advance<l  cases  the  ureter 
limy  iHToine  oKstructed  either  by  swelling  of  the  mucosa  and  thickening 
of  llie  wall,  or  by  the  lodgement  therein  of  detritus.  If  there  be  not  com- 
plete destruction  of  the  secreting  portion  of  the  kidney  the  organ  liecomes 
jtreatly  enlarged  and  distendnl,  owing  to  retention  of  the  urine  (tnb«r- 
culoM  pyonepfaroiii).  Finally,  the  destructive  inflammation  mav.open 
up  the  renal  \ ein,  and  we  then  get  u  generalized  milirry  tul)ertulasis. 

Ill  tile  second  tyjie  of  renal  tuU-rculosis,  the  proi'ess  liegins  in  the 
pyramids  and  leads  to  ulceration  of  the  apices  of  the  papillw.  Hematuria 
is  an  early  and  marked  symptom  in  these  cases. 

'I'iie  thinl  variety  is  characterized  by  the  fact  that  the  organ  is  uni- 
formly studded  with  numerous  firm,  grayish-white  no«lules,  varying  in  size 
from  that  of  a  pinhead  to  that  of  a  pea,"  which  show  little  or  no  tendency 
to  lurrosis.  The  <ai)sule  is  adherent,  and  when  removed  reveals  small, 
elivalnl  luxlules  upon  the  surface  of  the  kidnev.  This  is  probably 
.■imI)o1ic  in  origin  and  merely  a  sj)ecial  form  of  mil'iary  tuberculosis. 

All  affection  of  the  kidney  closely  simulating  tuberculosis,  and  due, 
as  w.-  know  now,  to  a  strcptothri.x,  was  descriljed  bv  Eppinger  in  lS9l] 
iiiitlir  the  name  }mut1ofuhiriulo.ils  cladot/inclcn. 

The  final  pr(M)f  of  the  existence  of  tulH-rcnlous  inflammation  of  the 
kKJii.  y  and  urinary  passages  is  afforded  bv  the  detection  of  the  Kacilliis 
tiibernilosis  in  the  urine.  This  is  by  no'  means  alwavs  an  easv  task. 
ill.'  <.'<Tiiis  may  lie  (|uitc  few  in  niinil«>r.  It  is  then  necessarv  to  keep 
the  iirim-  for  twenty-four  noiirs,  allowing  it  to  deposit  in  a'  suitable 
v(Ns.|  (entnfugalizing  if  necessary,  aiul  finallv  examining  micro- 
s<(>|M(aily. 

A  fiirther  difficulty  lies  in  the  fact  that  the  tulK>rcle  bacillus  doselv 
rjMMil.les  morphologically  certain  other  men.lHTs  of  what  an-  known  as 
the  •acid-fast"  group  of  bacilli,  of  which  the  most  important  is  the 
MM.  j-,na  bacillus,  found  in  smegma,  on  the  skin,  in  the  mouth,  and  in 
liMii,'  1  avifies.  One  point  of  some  assistance  is  that  where  the  bacilli  of 
tnlM. miosis  are  pn-sent  in  numbers  thcv  arc  apt  to  lie  in  fairiv  large 
and  dense  clumps,  while  •he  smegma  bacilli  are  more  scattered.'  It  is 
|M.-.-.il.lc,  liowever,  to  differentiate  the  two  organisms  bv  means  of  certain 
sniiMii^r  reactions.  It  should  1h>  jx.iiitt-d  out,  however,  in  this  connec- 
tion iluit  the  time-honored  Gablu-tt's  methcxl  is  absolntclv  unreliable, 
<<'n..ii,ly  in  the  examination  of  urine,  ami  it  would  undoubtedlv  lie 
•'at-'  !"  (hscontinue  its  use  in  the  examination  of  sputum.    A  better 


758 


THE  KinSEYS 


mt'thutl  is  to  stain  in  tin-  «.r<iiiiury  way  with  <arJK.l.fiKhsin.  ih-wlon/e 
with  M)  iKT  t-eiit.  mineral  arid  for  thirty  stn-onds.  ami  then  with  u\>-i>. 
lute  alcohol  for  three  minutes,  finaiiy  eounterstainiiiK  with  methyl,  n.' 
blue.  Or,  one  may  employ  1  |rt  e«Mit.  rosolii-  arid  in  absolute  ahohul 
for  five  minutes  as  a  ilei-olorizer.  Kven  tliese  metho«ls  have  been  shown 
mrntly  to  l>e  open  to  objeetion.  C  Basile  re<-ommends  the  um-  ..f 
a  2  Jje'r  cent,  solution  of  laetie  acid  in  absolute  alcohol.  The  tuUrcle 
bacillus  will  ri**ist  decolorization  with  this  for  half  an  hour,  wliilc 
the  smegma  and  other  acid-fast  orgunisms  lose  their  w>lor  in  a  few 

minutes.'  ,        .  i 

Another  p<)i»t  of  pra«tical  importance  is  that  the  urine  to  Itc  tested 
should  'Iwavs  l)c  drawn  off  by  cath«fer,  after  preliminary  wushinK  .)f 
the  external  genitalia.  With  this  po'caution,  the  entram-e  of  tlie 
smegma  bacillus  is  n-nilere»l  much  less  likely. 

SyphiliB.— The  manifestutions  of  .syphilis  in  the  kiclney  are  v.ry 
variable.  As  in  the  case  of  most  infectious  diseases,  «'e  may  get  nephriiii 
of  an  acute  or  sulwcute  tviH',  which  may  n'sult  eventually  in  clin.nic 
interstitial  change.  Then-'  may  »>e  nothing,  however,  but  the  hislorv  of 
the  case  to  identify  the  lesions  as  syphilitic.  Syphilitic  en«larteritis  iiu.v 
lead  t«>  gnulual  oiclusit)n  of  the  briuuhes  of  the  renal  artery  willi  ilie 
formation  of  a  tvpical  arteri.Hclerotic  kidney.  According  to  Slr.HlH-, 
intm-uterine  syphilis  may  result  in  hyjM)plasia  of  the  se<-«'ting  slll.^lall.■e 
of  the  kidnev'with  a  coiniH-nsatory  increase  of  the  fibrous  stroma.  A 
.striking  feature  is  that  the  kidney  is  imperfwtly  «Uvelo|H-d.  Inmiaiiire 
glomeruli  are  to  In-  swn  in  the  cortex,  apparently,  in  many  cases,  with.-iit 
proper  communication  with  the  se<rett>ry  tubides. 

The  characteristic  lesion  of  syphilis,  the  gununa,  is  rare  m  the  ki.lii.  v. 
Gummas  <lo  (xcur,  however,  and  may  Ik-  fairly  lunnert.us.  Tlu>  \an 
in  size  from  that  of  a  pin-heatl  to  that  of  a  hazel-nut,  ami  are  surroun.K'.l 
bv  a  grayish  or  '.vpereniic  zone.  Occasionally,  they  are  soft,  rcsiMiil.lii« 
abscesses.  As  diev  heal  thcv  give  place  to  deep  Hssun's,  resulliiij:  fmm 
the  contraction  of 'the  fibrou's  cicatric-ial  tissue  that  is  gradually  fonii.'.i. 
The  kidnev  mav  thus  \h>  divided  into  a  series  of  lobules,  rt-iiiil'lnf 
closelv  the  "condition  t)f  things  met  with  in  the  syphilitic  liver  iM.-.allnl 
heitar  lofntum).  Bowlbv'  has  descrilM-d  a  .litTnse  gumniat<.ns  mliliRi- 
tion  leading  to  a  notable  enhirgenient  of  the  kidney.  Miliary  umiMiia-^ 
(X'cur  but  are  extreniclv  rare. 

Actinomycosis.- This  afTwtion  in  the  kidney  is  usually  s..  Mi.larv. 
the  primary  lesion  l)eing  in  some  part  of  the  'tlimentary  tract.  hmmiiIi. 
pharynx, or  intestine.  In  the  only  instance  wc  have  met  with, both  ki.lney,* 
contiiincil  small  cavities  Hlled  with  a  thick.  yeUowish,  homo-.  r„.,>u>- 
Umking  material,  resembling  pus.  In  this  the  threads  of  the  fim-i-  w^re 
readily  demonstrateil.  The  primary  lesi.m  was  in  the  livir.  miI  th»; 
involvement  of  the  kiilneys  was  clearly  embolic.  Israel'  has  :  i.ori^ 
what  he  considered  to  l)e  a  ca.se  of  primary  renal  actinomycosis. 

■  (liorn.  Internaz.  <1.  Seieii.  Mel-,  Xaplps,  30: 1'.tOH:  577. 

'Trans.  l'.itli.  Soc.  of  I,()iiilc)ii,  IS:  ls',)7- 128. 

•Chir.  Klin,  der  Xierenkrank.,  I'JOl;  Ilandb.  der  prakt.  Cliir. 


i" 


ftYDROS/  "UROSIS 


75d 


i'lo.  201 


(HAadtn.— Glunilers  is  rurc  in  the  human  kidney.  It  in  not  uncom- 
iiiKii  in  horsM's  uffecttil  by  tin-  ilisfHsc. 

Leprosy. — ('hmnir  piirf'nrhymutoUH  and  interstitial  nephritis  may  Ite 
fiiu.nl  in  cases  of  lepmsy,  Imt  are  non-s|M>(-ifi<-  so  far  as  their  anatomical 
fHH'iiiiarities  are  eoncerneii.  Amyloid  de(;eneration  has  also  lieen  «K>- 
srril>ed.  In  ov.e  iitstatice  a  leprous  (granuloma  was  found  in  the  kidney 
of  u  leper  (Iledenius;  HuU's'). 

BITROORUSIVI  MITAMORPHOfU. 

Atrophy.  Atrophy  of  the  kiiliieys  <Kfurs  in  ^neral  marasmus  and 
us  II  senile  chanf^e.  In  the  fonner  < ondition,  )he  orj^iLs  are  small,  the 
|HTir*-nnl  fat  is  scanty,  nn<l  the 
secretin);  cells  are  diminutive.  In 
the  senile  form,  the  kidneys  are 
small,  firm,  dark  colore<l,  and  the 
surface  is  finely  );runular.  The 
^niiiulation  is  due  to  atrophy  of 
tlie  secreting  structures  and  rela- 
tive increase  of  the  fihroas  stroma. 
Ill  many  cases  there  is  an  actual 
proliferation  of  coimective  ti.s.sue, 
lo'.'ether  with  fibrosis  and  hyaline 
<ie};eneration  of  the  glomeruli,  a 
condition  no  doubt  to  lie  attril>- 
utfd  in  jtreat  measure  to  the 
arteriosclerosis  so  often  present  in 
aiivariced  life.  Secondary  atrophy 
of  a  kidney  may  follow  obstruction 
of  the  ureter,  as  from  stone  or 
oxtcmal  pressure,  nephrolithiasis, 
ami  clinuiic  tul)erculosis. 

Hydrouephrosig.  —  Hydrone- 
phrosis is  the  result  of  some  ol)- 
stniition  to  the  free  evacuation  of 
urine.  Tin.  'suallyde()ends  upon 
the  presenceo^ a  calculus  impacted 
ill  the  ureter,  stricture  of  the 
uri  ttr.  or  pressure  exerteil  upon 
it  liy  a  tumor  or  fibrous  l)anil. 
Mil  iir  grades  of  the  affection  may 
lif  ppnliiced  by  an  enlarged  pros- 
tat. ,  or  stricture  of  the  urethm. 

riie  condition  l»eirins  with  dila- 
te! :.  of  the  pelvis  and  ureter, 
hiii  .1-  a  result  of  the  constantlv 


Ilyilroiieplirit-i'..  'Mir  !«Ii»*II 
ataiiet*  i.-*  stvn  t»>  tlie  I..ft: 
dilatptl  f>flvi!4  t<i  the  rifc  t. 
kiiikt'<l     :irid     niiMirtirtptl    hy    i 


lit    Itidnpy    sul>- 

ttie    eiioriuouiily 

The     ureter    is 

tibniu..     bund. 


(From     the 
University.) 


Path<il'«ica|    Muwum    uf    McGill 


'  I'ntersuchungfu  uber<leu  Luprubuciltu:*,  Ikriiii,  1898:80. 


ill 


780 


THE  KinsKY/i 


immisiiiH  prejisuiv,  llie  kklwy  suJwtam-e  atrophiw,  thr  orpin  ililiid*. 
ami  is  eveiit\Hillv  «onvfrJ«Hl  into  tt  large.  l(Mulat«l  juio,  /"ni^wl  l>v  a 
thintht'll  of  kHlnfv  sulwttance.  jonlainiiiR  tlear, watery  fluUI.  ThefiiiM- 
tion  <)f  the  kkliiev  is  s«Mmer  or  later  «le»itroy«l.  1h  this  way  a  very  liirn.- 
tumor  inay  I*  'fonne«l  in  the  fljir  k,  which  is  iwually  iroewed  in  front 
diaKonally  bv  a  eoil  of  larj{t«  intesiine. 

D«ffMI«ntion.-  Olondy  fwclUnc  or  Albmnlsou  D«|tn«nUoii.  (  Iimi.Iv 
swelling,  or  albuminous  jU-genenition,  is  a  <onslant  .n-iiirreme  in  all 
infective  fevers,  hut  particii'arly  in  iliphtheria,  .s<arlalina.  ty|)lioul, 
and  variola.  It  is  found  also  in  certain  fonus  of  mineral  |M>iHoiiin);, 
dialK'tes.  hemcvl<»hiiM'niia.  gout,  and  is  invariably  present  in  Hriglit's 
disease  and  all  fonns  of  lo.al  iuHamniation.  Kidm-ys  so  affee«.ii  ar.- 
usually  slightly  eidargwl.  the  consisteiuy  is  relax«sl.  the  eortex  is  u  liiilf 

Fio.  2<U 


(•l.m.lv  -wllir.K.     I.HiI.  .  l.j    N"    7.  withcll   .Kul,.r.      ri.i'  ^-.ti...!  »h..»-  ih.-  -».'lliiv    f  'I"- 

tiibulnr  .•iiithHiiiMi.  till-  ..l.llale  luniina,  an.l  <1ip  t)a.llj-i.l»imni«  nmlri.     drum  ilir  ."I I 

Itr.  A    (;.  Niclinll-  1 

swollen  and  is  somewhat  pah-r  than  tlit-  pyrmnids.  being  of  a  dull  mMi-li- 
grav  color.  Microscopically,  the  st^reting  cells  of  the  contorlcd  I'll.iil.s 
are'  the  parts  chieflv  involved.  They  are  somewhat  swolK-ii,  riiLid, 
and  the  nuclei  freipientlv  fail  to  stain.  The  lumina  of  the  tiil.nl. .  art" 
no  longer  cin-ular  but  stellate  or  irregular.  When  ii  fresh  s<ri  ion  is 
exuminwl,  the  cells  are  opacpie  and  gnimdar,  U-ing  fille<l  witii  iinimif 
refractile  particles  which  obscure  the  nuclei.  When  treated  uii!;  i-etu 
acid  the  gramdes  disappar.  the  protoplasm  Ix-conu-s  clear,  .n.l  llie 
nuclei  are  again  apparent.  The  condition  is  apt  to  pass  im-  fatty 
degeneration  and  inHaimiution. 


PLATE  VIII 


Fin  1 


FIG   2 


Two  Se.  lions  from  the   Snme    Kulney  or  a    RabD.l  T.eate.l 
will,    Injections  of  Corrosive   Sublimate.      (Klotz.. 


I         1   -S,.,-,i..,  -„„,..,i  „„l,  S,„h„,  III  .„.l,.,n„„-,r:.>,.  r:,l.v  ,1..^,.,,,.,  :■,„,„  „f  ,.,.r,:,i„  , ,|,... 

•It-  in   III,.  -Ml 


.,„„,       -    -^'■'■"";'.-'-; I  »"l'  -i ■  rii.r:,,,.  „i„„Mra>,.  ,.„l,.ar ,-  ,1,. „.  „i   i,„.  ., „,,„,„  „, 


"ii>  rt-aiiinit<.) 


''^^H 

1 

il^::|M||g| 


AMYLOID  DEGENERATION 


761 


Fttty  Degenention. — Fatty  degeneration  is  a  common  sequel  of 
adviinced  cloudy  swelling,  and  is  met  with  frequently  also  in  pernicious 
anemia,  acute  and  chronic  Bright's  disease,  amyloid  degeneration  of  the 
iiidney,  and  in  poisoning  by  phosphorus  and  certain  other  mineral  sub- 
stances. In  this  condition  the  kidney  is  flabby,  and  in  well-marked 
cases  paler  than  normal.  The  cortex  is  the  part  chiefly  affected.  It  is 
swollen  and  of  a  uniform  pale,  yellowish  color,  or,  again,  blotched  with 
yellow,  presenting  a  marked  contrast  to  the  darker  red  of  the  medulla. 
The  fpt  may  be  detected  microscopically  by  staining  the  tissue,  which  has 
previously  been  frozen  or  hardened  in  formalin,  with  Sudan  III,  or, 
apiin,  by  placing  it  in  Fleming's  solution.  By  the  first  method  the  fat 
appears  like  granules  or  droplets  of  a  golden-yellow  or  carmine-red 
color.  By  Fleming's  solution,  which  contains  osmic  acid,  the  fat  is 
stained  black  or  brown.  It  is  mainly  to  be  seen  in  the  secreting  cells  of 
the  contorted  tubules  and  the  lining  cells  of  Eowman's  capsules. 

Hyaline  Degenention. — Hyaline  degeneration  affects  chiefly  the  glomer- 
uli in  chronic  Bright's  disease.  The  globules  of  all>umin  and  the 
(les()uamated  cells  within  the  tubules  often  fuse  into  hyaline  masses, 
thus  forming  casts. 

Amyloid  Degeneration. — This  Ls  a  frequent  accompaniment  of  general 
amyloid  disease.  A  local  amyloid  transformation  is  occasionally 
met  with  in  chronic  Bright's  disease.  The  condition  is  invariably 
asscK'iated  with  fatty  changes  and  diffuse  nephritis.  The  structures 
first  involved  are  the  capillaries  of  the  glomerular  tufts,  the  afferent 
ariirioles,  the  interlobular  arteries,  and  the  vessels  of  the  medulla.  In 
advanced  cases  all  the  vessels  of  the  cortex,  and  even  the  basement 
mtinbriincs  of  the  tid)ules,  are  affected.  The  vessel  walls  are  thickened, 
presenting  a  homogeneous  translucent  appearance,  and  the  lumina  may 
iK-coine  impermeable.  In  advance*!  cases  a  whole  glomerulus  may  be 
(■(niverte<l  into  a  structureless  mass.  The  specific  secreting  cells  show 
(louily  swelling  and  fatty  degeneration,  while  there  is  frequently  an 
interstitial  round-celled  infiltration.  In  the  tubules  are  to  be  seen  cellular 
ileUris  and  hyaline-looking  casts.  It  is  doubtful  whether  the  amyloid 
easts,  so-called,  are  really  composed  of  amyloid  material. 

The  kidney  is  usually  enlarged,  very  firm,  and  of  a  consistency  sug- 
fiestiiifr  india-rubber.  When  the  cut  e<lge  is  held  up  to  the  light  it 
presents  a  grayish,  tmnshicent  appearance.  In  some  cases,  the  glomeruli 
are  sufficiently  enlarged  to  l»e  recognized  as  small,  grayish  dots.  \Miere 
there  is  nuich  fatty  change  the  kidney  may  Ije  pale  and  present  the 
ftrciss  a])pearance  of  the  large  white  kitlney,  or,  again,  it  may  resemble 
tlu'  (.'ranular  contracted  kidney.  The  conditioti  may  l)e  recognize*!  in 
the  iK)sttnorteni  room  by  the  application  of  a  watery  solution  of  iodine 
to  the  cut  surface  of  the  organ.  The  glomeruli  usimlly  then  appear 
as  Miiall,  gelatinous-l(K)king  points  of  a  mahogany  brown  color.  The 
tevt  may  fail,  however,  in  the  early  stages  of  the  disease.  In  niicro 
s(()|iic  sections  treated  with  anilin-gentian  violet  or  methylviolet,  the 
amyloid  appears  as  pinkish  masses  on  a  dull  bluish  or  greenish-blue 
liM.!  ;,'roun(!. 


762 


THE  KIDNEYS 


Necrosis. — Nccrasis  of  tlie  kidney  is  a  cotniTum  condition  due  to  the 
destructive  action  of  bacterial  or  mineral  toxins  or  the  products  of  disoni- 
ere<l  metabolism  circulatinj;  in  the  blood.  Among  the  infective  diseasfs 
which  bring  it  about  may  be  mentioneil  diphtheria,  scarlatina,  variola, 
septicemia,  typhoid,  and  tul)erculosis.  It  is  met  with  also  in  dialn-tcs, 
pout,  icterus,  carcinoma,  hemoglobinemia,  and  in  poisoning  with  siii)- 
liniate,  phosphorus,  arsenic,  caniharides,  pyrogallic  acid,  and  salts  of 
chromic  acid.  A  local  necrosis  is  also  observed  in  acute  or  relapsiii); 
nephritis.  The  cells  chiefly  affe<ted  are  those  of  the  contorted  tubules. 
The  cytoplasm  is  swollen,  the  nuclei  fail  to  stain,  the  lumina  are  irregular, 
and  the  whole  cell  has  a  diffuse,  opaque,  or  ground-glass  appearance. 
The  condition  closely  resembles  the  coagulation  necrosis  found  in  infarc- 
tion. In  cases  of  sublinia*-^  poisoning,  deposits  of  lime  salts  may  he 
found  replacing  the  cells  of  the  degenerated  tubules.  The  [larencliy- 
matoiis  degeneration  is  often  more  marked  than  in  the  case  of  nephritis, 
but  there  is  no  intiltralion  of  the  connective  tissue  with  inflamniatDry 
pro<lucts. 

I^naditi  and  Helms,  from  Khrlich's  laboratory,  have  describcil  a 
peculiar  form  of  renal  necrosis  limited  to  the  papillie,  brought  about  by 
vinylamin  and  tetrahydro<iuinoleinc.' 


HEMATOGENEOUS  INFILTRATIONS. 


These  are  of  the  nature  of  corpuscidar  elements,  pigments,  or  salts, 
brought  to  the  kidney  by  the  blood  and  deposited  either  within  the  inter- 
stitial .substance  or  within  die  imnina  of  the  .secreting  tubules.  Varimis 
soluble  salts,  the  result  of  pathological  prix-esses  within  the  kidney  or 
elsewhere  in  the  body,  may  through  hxal  chemical  change  be  converte*! 
into  insoluble  pnKlucts,  forming  the  so-<alled  "infarcts." 

Hemorrhage.  —Hemorrhage  into  the  substance  of  die  kiilney  is 
met  with  in  severe  passive  congestion,  embolism,  trauma,  certain  furms 
of  inflammation,  and  in  the  general  hemorrhagic  diathesis. 

The  effusion  takes  place  about  the  interlobular  vessels  or  into  tlie 
Howman's  capsules.  Very  freiiueiitly,  the  tubules  become  filled  uitii 
blood  so  that  blood  casts  are  prn<luced,  or  when  destruction  of  the  \<l>m\ 
takes  place,  pigincntation  of  the  se<-reting  cells  occurs. 

Ill  acute  nephritis  and  in  the  hemorrhagic  diathesis,  small  peie,  liial 
.spots  are  .seen  (listribute<l  over  the  cortex  or  throughout  the  ki  iiiey 
substance. 

Leukocytic  Infiltration.  LeukiM-ytic  infiltration,  apart  fnnn  in- 
flammation, is  met  witli  in  leukemia.  The  kidney  is  enlarged  an.:  pale, 
grayish-y«'llow  in  color,  due,  in  part,  to  the  leuko<"yti<"  accumulation  and 
in  part  to  the  associated  fatty  degeneration.  The  cortex  is  s-ojleti. 
Whitish  streaks,  leprcseiiling  (he  oveniistehded  straight  vessels,  .i;  mtII 
in  the  pyramidal  portion,  and  more  or  less  wedge-shaped  or  ;; mute, 

'  .\rcliives  Intcrnat.  ile  I'liariiiacnilyiiiunie  et  lieTWrapic,  8: 1901 :  45  an  '   '.I'X 


NEPHROLITHIASIS 


Fig.  203 


rounded  areas  are  to  be  made  out  in  the  cortex,  the  so-called  "  lympho- 
inatii. 

Microscopically,  the  vessels  of  the  interstitial  substance  are  every- 
where greatly  distended  with  leukocytes,  so  that  the  secreting  tubules 
lire  widely  dissociate<l,  and  there  may  l>e  extensive  leukocytic  infiltra- 
tion alK)Ut  the  gLmeruli. 

The  secreting  cells  are  found  in  all  stages  of  cloudy  swelling,  fatty 
(lcj;e!ieration,  and  atrophy,  owing  to  pressure  and  lack  of  nutrition. 

Pigments.— The  pigments  found  in  the  kidney  are  chiefly  those 
(loriveil  from  the  blootl,  as  hemoglobin,  methcmoglobin,  hematoidin, 
hemosiderin;  bile  pigment;  melanin;  and  extraneous  substances,  like 
(•arl)on  and  silver. 

Blood  Pigments. — The  blood  pigments  may  l>e  confined  to  the  vessels 
or  may  1)6  deposited  in  the  interstitial  substance  ami  within  the  secret- 
ing cells. 

Bib  Pigments. — ^Bile  pigments  lead  to  a  diffuse  or  streaky  staining 
of  t'  0  kidney  of  a  greenish  or  greenish-yellow  color.  Bile  pigment  can 
1)1'  recognize<l  in  the  secreting  cells, 
which  are  often  degenerated  and  cast 
otr,  so  that  a  form  of  cast  is  produced, 
("rystalline  deposits  are  seen. 

Argyriasis. — .\rgyriasis,  or  the  so- 
called  "silver  infarct,"  is  now  but 
rarely  seen.  The  kiclney  has  a  dark 
gray  or  blackish  tint,  and  the  silver 
is  (Icpositetl  in  the  interlobular  con- 
nective tissue.  It  may  lead  to  fibroid 
clianges. 

Uric  Acid.-  Uric  acid  or  urates  may 
1)0  precipitated  within  the  kidney 
tul)iiicsor  in  the  pelvis,  esjwcially  in 
cases  of  jrout  and  the  uric  acid  diath- 
esis, but  also  when  the  excretion  of  the 
urati  -  is  not  beyond  the  normal. 

I  i,ii](  infarcts,  composed  of  acid 
siMlium  urate,  are  sometimes  met 
with  in  casesof  gout  when  they  form 

liitish  streaks  in  the  dilated  urinary 
till  lilies.  Similar  tleposits  are  not 
iii(re(|iiently  found  in  the  kidneys 
i)f  iiilaiits  dying  U'twcen  the  .second 
and  foiirteenth  day  after  birtli. 
ll<re  the  salts  are  deposited  espe- 
<i:i!l.v  in  the  lumina  of  the  collecting 
I::'-  ::!is  of  the  papilliL'  in  tlie  form  of  doubly  rcfraclilc  spherolitlis. 

Nephrolithiasis. — \Mien  the  salts  are  dejiosited  in  the  pelvis  of  the  kidney 
■ire  found  in  the  form  of  uratic  gravel,  or  as  calculi,  varying  in  size 
fi'    !  that  of  a  pea  to  a  large  branclunl  mass,  the  so-called  "coral  calculus," 


A  cnral  calrulux  in  the  pehis  nf  the 
kidney.  (Fritiii  the  l*iith(>liiK>i'al  Mucieum 
of  Mctlill  I'niveMty  ) 


tl 


764 


THE  KIDSEYS 


wliitli  may  occupy  tlie  whoU-  })€>lvi.s  of  the  orpan.  The  smaller  calculi 
are  net  infrequently  fouiul  within  tlic  calices,  or  may  l)e  impactetl  in  tlic 
ureter. 

The  condition  often  leads  to  suppunitive  pyelitis  or  pyonephrosis, 
and  the  whole  or^an  may  l>e  destroyed,  lieing  finally  represented  only 
by  a  fibrous  sac  inclosing  the  stones. 

Depasits  of  carbomitc  or  phonphale  of  lime  are  met  with  occasionally 
in  old  i)eople  when  resorptive  prtx-esses  are  going  on  in  bone,  and  in 
cases  of  sublimate  poisoning  (see  vol.  i,  p.  853). 


PROGRESSIVE  METAMORPHOSES. 


The  kidney  substance  passesses  considerable  powers  of  regeneration. 
This  might  l)e  inferred  a  priori  from  tiie  fact  that  many  cases  of  acute 
inflammation  of  this  organ  heal  perfectly,  and  we  have  further  proof 
of  it  in  the  fact  that,  in  both  acute  and  chronic  nephritis  and  in  llie 
neighborluMHl  of  woun«ls  and  infarcts,  the  nuclei  of  the  secreting  cells  of 
the  tubules  are  to  l)e  found  in  different  stages  of  mitosis.  Whether  tlif 
reparative  jwwers  are  sufficient  to  reprcMluce  whole  tubules  and  gloincrim 
is  still  in  (luestion.  It  seems  probable,  however,  that  this  may  be  pos^ihlc 
in  young  developing  individuals  of  certain  of  the  lower  animals.  .Vs 
age  advances,  the  power  of  growth  inherent  in  the  cells  becomes  notice- 
ably weaker. 

Gompensatory  H3?pertrophy.  ('omjH'usatory  hyprtrophy  is  fouiul 
in  cases  where  one  kidney  is  congenitally  defective,  has  been  removed 
by  operation,  or  is  inefficient  from  disease.  The  remaining  kidney 
resembles  closely  the  normal  organ  save  that  it  is  :nuch  l^.ger  and  its 
cortex  is  somewhat  broa<ler.  It  rarely,  however,  attains  the  weiglii  of 
two  normal  kidneys  combined.  The  pyramids  are  not  increast'd  in 
number.  Such  an  organ  is  spwudly  liable  to  disease,  inasmuch  as  its 
reserve  power  is  small.  Whether  the  condition  is  a  true  hyiKTtropliy, 
or  not  rather  a  hyperplasia,  is  ;,till  unsettled. 

Tumors. — For  purposes  of  descri|>tion  it  is  convenient  to  cla^ifv 
tmnors  of  the  kidney  according  to  their  histological  ap|M'arancc.  On 
'his  basis  we  may  n'cogni/e  tumors  of  epithelial  type,  meatiing  l>y  tliis 
the  various  I'orms  of  adenoma  and  carcinoma,  and  those  of  conmnivc- 
tissue  type,  which  would  include  such  forms  as  the  fibroma,  myoma, 
lipoma,  myxoma,  angioma,  and  sarcoma.  It  should  l>e  remarked.  Ii<>\v- 
ever,  that  the  various  new-growths  of  the  kidney  have  nuich  nitHv  in 
common  than  have  epithelial  and  coiintHtive-tissue  neoplasms  (Hcuiiing 
elsewhere,  inasmuch  as  the  kidney,  both  in  its  se<Teting  mecli.misin 
and  supporting  framework,  is  derived  entirely  from  the  mesobla.sl  We 
nmst,  therefor*-,  give  the  term  carcinoma,  if  we  apply  it  to  the  k 
a  histological  sen.se,  ratiier  than  a  developinental  one.  In  luU 
not  a  few  of  the  kidney  tumors  are  of  mixed  tyj>e  and  may  propt 
classed  as  teratoid  in  natun-. 

The  conunonest  tumors  of  the  kidnev  are  the  sarcoma  and  can  ii'>iiia, 


liiey, 
lion, 
V  lie 


T,  f 


a_ 


TUMORS 


765 


the  former  being  somewhat  mor»-  fmiueiitly  found  than  the  latter.  The 
In-nign  growths  are  usually  small  and  iasigniheant,  though  large  lipomas 
have  been  descril)ed  by  \S'artliin  and  others. 

Adenonu.^ — The  adenoma,  a  l>enign  tumur  of  epithelial  type,  varies 
in  size  from  that  of  a  millet-seed  to  that  of  a  walnut,  or  even  larger, 
and  is  usually  found  in  the  cortex.  It  forms  single  or  multiple,  soft, 
weil-tlefined  notlules  of  whitish  color.  Histologically,  an  alveolar,  a 
tubular,  and  a  papillary  form  can  l)e  recognized.  The  cells  forming 
the  tumor  are  of  columnar  type.  Occasionally,  the  tubules  are  tlilated 
into  cysts — cystadeaoma.  S»)me  of  the  tmnors  formerly  cla.ssed  with 
cystadenomas  may  possibly  have  l)een  hypernephromas  (q.  v.). 


Fli;.  204 


l'i.i]i|p™»at<iry    hypennipliy:    R.    Kidney,  cnnKciiitnl 
liviuTtniphy   (leiiKth,  14. "i  cm.);    \nrnt.,  :i  rutnual  ailiilt    K. 
ni.iili'  1(1  soale  fri)m  aiieoimeii!!  in  Mri;ill  Mt'ilical  Muwuni.) 


.-Ill:    A.   Kidney,    rompern»atiiry 
.■  lU'iiKili,  ll.O  rm.).      (Outlines 


Fibromas. — Fibromas  are  rather  common  in  the  kidney  but  are  in  '  '- 
iiiluant  in  importance.  They  form  small  ma.s.ses,  from  a  microscopic 
ii'"liilc  to  one  the  size  of  a  jK-a,  rarely  larger. 

Leiomyomas  and  Fibroleiomyomas.  lA'iomyonias  and  fibroleiomyomas, 
ciiiiiiosed  of  un>itriped  mu.sclf.  or  an  admixture  of  muscleand  cdmiectivc- 
n-iic  fil)crs,  are  met  with,  but  ire  rare.  'I'hcy  may  be  found  both  in  the 
I '  !!<  x  and  in  the  pyramids. 

Rhabdomyomas  are  rare  also. 


760 


r//£  KIDXEYS 


UpomM. — Lip«inas  are  found  beneath  tl>e  capsule  and  in  the  corti-x 
of  the  kidney.  They  are  single  or  niuliiple,  and  usually  of  small  .size, 
although  exceptions  to  this  rule  (xrur.  Histologii-ally,  they  are  encajH 
sulated  and  consist  of  ordinary  adipase  cells. 

Certain  of  the  renal  fatty  tumors  are  considered  by  (irawitz  to  Im-  roii- 
(renital  and  referable  to  overgrowtlis  of  misplaced  suprarenal  tissin- 
(atrumcE  lipomatuden  al>errat<B  reiiis).  The  Gra^vitz  tumors  differ  from 
the  others,  however,  in  that  the  component  c<  >  -.-ontain  multiple  fat 
droplets  and  resemble  the  cells  of  the  suprarenal  cortex.  They  are  not 
true  fat  cells. 

Myxomas. — Myxomas  are  rare.  Most  of  the  growths  descri'jed  as 
myxomas  iire  more  probably  to  1m'  reganled  as  coimcctive-tissue  growths 
that  iidve  undergone  se<'ontlary  mucinous  degeneration.  Bezold  ami 
Hf.llen,  however,  have  each  report«'<l  a  case  of  true  myxoma. 

Ohondromas  and  osteonuus  have  Ix'en  met  with,  but  are  extremely 
rare. 

Angiomas,  more  correctly  teleangiectases,  are  occasionally  foiind. 
They  may  be  situated  in  tlu-  pyramids  ov  pelvis.  When  projecting  into 
the  cavity  of  the  kidney  they  -nay  give  rise  to  serious  hemorrhage. 

Sarcoma.— Sarcoma  is  the  most  connnon  tumor  found  in  the  kidney. 
It  is  met  with  both  in  childhood  and  in  adult  life.  New-growths,  often 
tennt'd  sarcomas,  are  comparatively  conmion  in  early  life  and  may 
even  be  congenital.  Car  Tul  study  of  these,  however,  will  show  that 
the  vast  maj()rity  of  them  are  of  mixed  type,  containing  strijXHl  nnisde, 
cartilage,  or  bone.  Tiiey  are,  therefore,  more  properly  included  undor 
the  teratoid  new-formations. 

Uoiiml-cilird  md  spindlr-cilU-d  sarcomas  are  descril>ed,  the  former 
being  often  highly  vascular.  Alnohir  uinjhKvircoma,  really  eitl-er  an 
endothelioma  or  peritiiclioma,  is  (Kcasionally  met  with.  Endotiicliomas 
may  arise  from  the  lining  cells  either  of  blcHxlvessels  or  lympliatics. 
(jiant  cells  are  at  times  found  in  renal  sarcomas. 

Carcinoma.  -Carciiioma  of  the  kidney  is  scmiewhat  more  coinmon 
on  the  rigiit  side  than  on  tlic  left,  and  is  more  fre(iu<'nt  in  men  tlian  in 
women.  It  may  arise  fnini  the  secreting  cells  of  tiie  tubules  or  from  the 
epithelium  lining  the  pelvis.  It  is  generally  held  that  the  adenoma 
has  a  distinct  teiulency  to  develop  iiUo  carcinoma.  Carcininiiii  uf 
distinctly  glandular  tyjK'  is  known  as  nilmocnrclnomtt. 

It  is  somewhat  difficult  to  draw  the  line  In'tween  the  simple  adcinMiia 
and  the  carcinoma.  Certain  authors,  notably  Pilliet,  Sottas,  and 
All)arriin.  hold  that  tumors  which  histologically  resemble  pure  ade- 
nomas In-liave  at  times  like  malignant  growths,  as  evidenced  liy  l.-al 
infiltration  and  the  formation  of  metastases.  The  same  jmidiarii  -  lias 
been  observeil  i.i  adenomas  elsewhere. 

Primary  carcinoma  may  l)e  nodular  or  diffuse, and  is  of  the  ,t(/V'  'o»,«, 

simpli-,  or  mffliillnry  type.      The  nodular  forms  are  well-<leK I   md 

are  provided  often  witii  a  more  or  less  jR-rftnt  capsule.  The  It  use 
forms  lead  to  a  generalized  enlargement  of  the  organ  without  mill 
deformity.     Carcinomas  frequently  attain  a  considerable  size.  I'  '  are 


TERATOIDS 


767 


not  usually  so  large  as  the  sjirroinas.  The  growth  may  extend  into  the 
jxivis  and  ureter.  Degenerative  <-hanges  not  infrequently  occur  in  the 
ctiitre  of  the  growths,  leading  to  hfinorrhagic  extravasation,  cyst-forma- 
tion, and  sometimes  cal  areous  deposit.  Ilemiituria  is,  therefore,  a  not 
uncommon  manifestation  of  the  disorder. 

Carcinoma  is  mucii  more  often  secondary  in  the  kidney  than  primary. 
It  may  follow  cancer  of  the  testicle,  liver,  sfoi.iach,  uteras,  mamma, 
pancreas,  or  of  the  other  kidney. 

Sarcomas  may  also  form  metastatic  deposits  in  the  kidneys.  'I'he 
iiulnnotir  sarcoma  is  always  secondary. 

Ter»toid«.-"The  teratoid  or  embryonal  mixed  tumors  of  the  kidney 
form  a  most  interesting  study.  They  inclu<le  the  large  majority  of  the 
s( walled  .sarcomas  and  carcinomas  found  in  childhood.  Ciireful  in- 
vcsiigations  have  shown,  however,  that  they  have  distinct  features  of 
tlicir  own  and  should  \te  placed  in  a  class  by  themselves.  Inasmuch  as 
tlicy  have  been  found  at  birth  or  shortly'after,  it  has  In-en  thought 
that  they  are  due  to  developmental  errors,  probably  k'ing  present  in  a 
latent  form  at  a  very  early  period  of  life,  and  l)eing  subse<|uently  excited 
into  activity  under  the  influence  of  some  stimulus,  notably' trauma. 
Wry  exceptionally,  they  are  met  with  in  adults.  The  left' kidney  is 
involved  more  often  than  the  right,  but  both  organs  may  be  primarily 
atlVcted.  These  tumors  often  attain  a  great  size,  one  being  on  record 
which  weighed  thirty-six  pounds.  The  general  slm{)e  of  the  kidney  is 
not  greatly  altered,  though  the  surface  may  Ik-  somewhat  nwlular.  I'lie 
kidney  substance  projH'r  usually  forms  a  more  or  less  comj)lete  shell 
alioiit  the  tmnor.  On  section,  the  gn)wth  may  be  homogeneous  and  of 
a  grayish-pink  color,  but  it  is  common  to  find  areas  of  degeneration, 
cysts,  and  hemorrhagic  extravasation  info  its  substance.  Extension 
nsiially  takes  place  into  the  veins  and  the  lungs  are  usually  secondarily 
involved. 

The  histological  structure  is  often  highly  complicated,  and  may  vary 
(onsidfrably  in  different  tumors,  and  in  different  parts  of  the  same  tumor. 
In  f;tncral,  it  may  be  said  that  there  are  to  be  seen  more  or  less  abundant 
cpiliiclial  ('ells,  arranged  in  masses  or  in  tubules,  and  of  glandular  tyjjc, 
tojicilicr  with  a  somewhat  cellular  stroma,  composed  of  round  or  spiiidle 
(ills.  This  peculiarity  of  structure  has  led  to  these  growths  being 
tcrnrcd  ndcmmmmas.  According  to  the  predominance  of  one  or  other 
tvpc  of  cell,  however,  these  mi.xed  tumors  may,  at  one  time,  closely  re- 
st  inhh-  the  adenomas  and  carcinomas,  with  wiiich  they  have  often  been 
(niifiiiiiulcd,  and,  at  another,  the  sarcomas.  In  addition  to  tiie  features 
nu  iiiiDiied,  tlie  majority  contain  fitn'rs  of  strijKMl  and  unstrijK-d  muscle 
(rh.ihihtmijoma,  rhubdomtjosarcomn,  myonarcoma),  islets  of  hyaline  carti- 
lap',  and  even,  it  is  said,  ganglion  cells,  thus  indicating  their  teratomatous 
iiatiirc.  Rarely,  epithelial  "pearLs"  surrounded  by  nniscle-fibers  have 
1h'(;i  (,l)served. 

<  nii,i(lerable  divergence  of  opinion  has  been  expressed  in  regard  to 
th.  nrlgiii  of  these  growths.  The  presence  of  striated  muscle-fibers  in 
niiii;\  „f  them  suggested  the  idea  that  they  were  due  to  the  development 


788 


THE  KIDXEYS 


of  inispliu-wl  embryonic  tissue,  notably  jjortions  of  the  Wolffian  ImkIv. 
It  is  possilde,  however,  Jis  Wihus  un«i  others  tliink,  that  the  HIkt^  in 
(juestion  are  derivatives  of  the  primitive  myotomes  of  tlie  embryo. 

In  the  eate>,'ory,  also,  of  tumors  deriveii  from  embryonic  "rests"  is 
the  form  conveniently  terme<l  by  Birih-Hirs<hfel<l  the  hypomaphroma. 
This  is  a  tumor  believe«l  by  many  comjH-tent  patholojjists  to  be  ihrivcd 
from  misplaceil  suprarenal  tissue  (drawitz,  Lubarsch.  (latti,  Kelly). 
Atressory  suprarenals  or  misplacetl  portions  of  suprarenal  tissue  have 
be«Mi  found  in  a  ffreat  variety  of  situations,  such  a.s  the  innn»diat.' 
nciKhlwrlKKHl  of  the  normal  .site  of  the  suprarenal,  in  or  Wneuth  the 
capsule  of  the  kidney,  about  the  renal  vessels,  in  the  .spermatic  cord, 
l)etweeu  the  testis  aiitl  epididymis,  in  the  inguinal  canal,  in  the  broail 
ligament,  in  the  solar  plexus,  the  cieliac  pinjjlion,  and  even  in  the  liver 
and  pancreas.  Tumors  may  originate,  conceivably,  therefore,  from  the 
proliferation  of  suprarenal  tissue  in  any  of  these  situations. 

The  most  conunon,  and  by  far  the  most  important,  of  such  new- 
growths  are  those  found  in  co'nnection  with  the  kidney.  They  are  met 
with  usually  at  the  upper  end  of  the  organ,  in  the  cortex  just  beneath 
the  capside.  The  growth  is  well  circumscril)etl,  and  usually  i)ouinle(l 
by  a  more  or  less  perfwt  connective-tissue  capsule.  It  is  maile  up  of  a 
series  of  notles,  varying  somewhat  in  size,  divi<led  one  from  the  other  hy 
comie<-tive-tissue  .septa,  anil  j-omposed,  in  turn,  of  a  series  of  sirialler 
n.Khiles,  which  contain,  as  a  rule,  but  little  connec-tive  tissue,  llvpr- 
nephromas  are  intMleratcly  firm,  of  a  yellowish,  ycllowish-wlnte.  or 
brownish-vellow  color,  'riiere  is  a  marked  tendency  to  retro;;raiic 
metamorphosis,  necrosis,  fatty  change,  hemorrhage,  and  cyst-formal  ion. 
Rarely,  there  is  calciHcation.'  As  they  grow  they  gradually  rephu  e  the 
kidnev  substance,  but  are  usually  bounded  by  a  zone  of  distorted  and 
compressed  renal  celN.  Tiie  coiinective-tissue  capsule  is  often  iiiva.led 
by  the  proliferating  cells,  l)Ut  the  remains  •)f  it  can  generally  be  deteeted 
oil  careful  examination.  This  constitutes  one  of  the  charm  terbtic 
features  of  the  hypernephroma.  The  larger  growtlis  tend  to  penetrate 
into  the  pelvis  of  the  kidney  and  invade  the  renal  veins.  M.t:i.la>is 
thus  takes  place  through  tlie  IiUkkI  circulation. 

Histologically,  the  structure  of  thf.se  tumors  is  highly  complicated,  and 
it  is  not  surprisii-g,  therefore,  that,  until  Grawitz  pointed  out  tlieir  true 
nature,  inanvof  them  had  l)een  <lescribed  variously  as  lipomas,  ad.  iioinxs, 
carcinomas,' .sarcomas,  adeno.sarcomas,  angiosarcomas,  endotli.  I  omas 
and  peritheliomas.  The  microscopic  examination  will,  as  a  nil' .  r-veal 
a  connective-tissue  capsule,  which  in  the  smaller  gnmths  is  often  loiii- 
pleteand  in  the  larger  ones,  although  more  or  less  infiltrated,  can  u^iidlv 
be  traced  here  and  there.  In  brief,  a  hypernephroma  may  be  .1 
as  a  tumor  composed  of  a  stroma  forminl  of  a  rather  close  in 
of  capillary  vessels,  and  of  cells  arranged  in  rows,  columns,  or 
closely  associated  with  these  capillaries.  The  character  and  arr.i 
of  the  cells  recalls  more  or  less  perfectly  the  appearance  of  the  . 
the  suprarenal  ami  of  tumors  arising  therefrom.  This  resemj 
most  striking  in  the  case  of  the  smaller  hypernephromas.    Tl 


I  TJbi'd 
-li.vurk 
■Insters 
■t'Mient 
nte.N  of 
iiiee  is 

larger 


i^iaAi 


HYPERffEPHROMA  759 

prowth-s  are  apt  to  be  alveolar  in  type,  the  component  nwJuIes  beinjr 
sepamted  one  from  the  other  by  a  small  amount  of  connective  tissue, 
in  the  form  of  tral)eculn!  contiinious  with  the  capsule.  The  endothelium 
lining  the  capillaries  is  usually  cpiite  distinct  and  mav  even  lie  proliferateil. 
Th.-  alveolar  appearance  may  cause  the  tumor  to  \te  mistaken  for  a 
:  rtnioma  or  a  sarcoma.  The  tumor-cells  pro|)er,  King  l)etween  the 
riipillary  vessels,  are  arranged  in  rows  or  double  rows',  like  the  cells  of 
till-  zona  fas<iculata  of  the  suprarenal  cortex,  and  are  directly  continuous 
with  the  cells  of  the  vascular  endothelium.  Thev  are  of  epithelial  tvpe, 
iisimlly  polygonal,  but  may  In*  rounded,  ciibicid.  'columnar,  or  irregi'ilari 
1111(1  frequently  contain  nniltiple  vacuoles,  spaces  which  originallv  con- 
taiiuHl  fat.  The  fatty  infiltration  of  the  cells  is  a  noteworthy  feat'ure  of 
the  hypernephroma.  (Jlycop-n  is  also  commonlv  present  in  relatively 
Crciu  amount.  A  black  pigment  is  also  to  Ih-  'found,  similar  to  that 
iiortnally  present  in  the  suprarenal  >;land. 


Km.  iin 


Km.  urn 


S.-.  ii.,ii  .,f  portion  <>i  a  liy|i<Tm'pilir..ina  of 
til'  kiinry.  A  ohururti'ri>tii'  aren  -liowiiiit 
niluiiui*  of  dpiir  iKilynonal  cfll.:  a.  lyinn  iti 
iniriir.lMiii-  ap.|,o.iiion  to  the  eiidotlieliiim  i</) 
"f  111.-  c;i|.illury  »inuses  (r).  At  b,  ureas  of 
iiiBltnoiiii  anil  itrKriii'ration. 


Seition  from  another  portion  of  the  same 
tuttior.  tnore  liitjhly  iiiaffnified,  phowinK 
tiiliular  arratiKeini'iit :  a,  swollen  tranitluoent 
tumor  cells  surrounilins  a  definite  lumen 
h.  eapillary  c  fat  dro|>lel9  in  tumor  cells. 
(Huday.) 


Htsiiit's  the  alveolar  form,  a  tubular  or  tral)ecular  arrau'ement  is 
•xra-ioimily  met  with;  or,  again,  the  type  may  vary  in  different  parts  of 
the  ^rrowth.    Tumors  of  great  complexity  may  thus  be  formed. 

Dermoid  Cysts.— Derincjid  cysts  have  been  found  in  the  kidnev,  but 
arc  \civ  rare. 

Parasites.— Among  the  animal  parasites  descrified  as  at  times  infesting 
thi"  khlripy  may  be  mentioned  the  Echhwcoccus,  the  Cifntlcercitti cilhdosw, 
thf  /»  ,s^)«ia  hematobiuiii,  the  Emtroiitfijlus  gigas,  the  Filari a  sanguinis, 
aiul  liir  Peuiastomum  denticulatum. 


770  TIIK  IKISAHY  P.\SSA<!h:S 

THB  PILVn  or  TBI  KIDMIT  AND  UUTIS8. 

OOXOBIIITAL  ANOMALIKI. 

These  have  iMfii  (listuss*-*!  u'.iove  (see  p.  72S). 


OIRCULATORT  DI8TUKBAN0I8. 

(Idema.-  (l-^h-iim  is  fouml  iissixiati-d  with  jmssive  c-onp-stiim  ami 

inHiiiniiiHtioii. 

Hyperemia.  Aetiva  Hyperemia.-  Active  liypremm  of  tlie  iniinms 
meinlirane  lining  the  |H-lves  and  ureters  is  in«'t  wUli  in  cases  i>f  iiitliiiii- 
inatioii  aiul  wliere  irritatinj;  siil>staM<es  have  In-eii  excn-teil  1a  ilic 
kidnevs.  ,  •      • 

Passive  Hyperemia.  Passive  li\|MTemia  is  ohserved  ni  the  ("iiiIiIhmi 
of  fieiierai  svstemic  |>assive  i-Dn^estion,  and  also  in  oNstructiori  lo  the 
outflow  of  liicMMl  from  the  renal  veins. 

Hemorrhage.  Meniorrha>;e  results  from  inflammation,  jiassive  roii- 
pestion,  ulceration,  traumatism,  the  liemorrhapc  diatheses,  parasiir..  aii<l 
tinnors.  In  certain  cases,  also,  of  acute  and  chronic  nephritis,  I.IixrI 
may  escajH"  into  the  urinary  passages. 

ALIBBATI0N8  I»  THE  LUMIKA  OP  THE  URINARY  PASSAGES. 

Harrowing  of  the  l\»neii  of  the  uri'ter  nmy  cxcur,  and  leads  to  a  inor.' 
or  less  consplete  ol.struciit)n  to  the  outflow  of  the  urine.  -V  \aii.tv  of 
<-auses  mav  l.riiig  it  ahout.  Chief  among  these  are,  inflanunaton  tlii(  k- 
ening  of  the  nnicosa.  the  presence  of  granulomata,  and  fibroid  iii.liiraiK.ii 
of  the  ureteral  wall.  Owing  to  inflanunatory  changes,  the  iiiii<<m> 
memhrane  lining  the  |M-lvis  may  encroach  upon  the  orifice  of  tli<'  iint.r 
after  the  fashion  of  a  valve,  aiid  lead  to  ohstruction.  Swelliiiir  '•<  ili<' 
nuicosa  of  the  hladiler  may  also  shut  off  the  opning  of  tli.  iiivtcr. 
Strictures  of  the  ureter  may,"  however,  Ik-  congenital  us  well  a>  a.iiMiriil. 
Possihlv  hoth  are  inflanunatory  in  their  origin. 

'I'he  "lumen  may  he  obsUucted  by  foreign  substances  IcMlginir  wiilim 
it.  (  alculi,  bhMHl  clots,  nccnttic  tissue,  portions  of  tumors,  and  ii;iraMif> 
are  to  be  mentioned  in  this  connection. 

Pressure  from  without  is  also  an  imiK>rtant  etiological  I'aii.r.  it 
maybe  due  to  tumors,  enlarged  glands,  a  retroflexed  uterus,  or  -n  ovtr- 

fillc'-d  rectum  or  bladder  iii  a  contriuted  pelvis,  inflammatoi  v   ' '- 

ligatures,  a  horseshoe  kidney,  an  anomalous  renal  artery,  or  an 
lation  of  extravasafed  urine. 

Traction   upon  the  ureter,  and  kinking  or  torsion   from  a   ' 
kidney,  sometimes,  also,  bring  about  obstruction. 


laliil 

I  IIMIU- 

Kivalile 


PYKUriS 


771 


'I'lu-  efteit  iif  Niuh  oliseruction  w  the  same  in  all  vnses.  The  urine 
is  .liininMNl  iMM-k.  iirxl  tliut  |M.rti«)n  of  (lit-  urifmrv  pa.sjwijje  proximul 
to  till"  |Kiint  <>f  ol),srru<»ii)ii  is  (|ilmi-«l.  When  the  pIvLs  of  the  kidney 
is  .iistendwl  with  .Iriir,  watery  tltii.j,  usually  a  tn<Nliti<-(|  urine,  the  «oncli. 
lion  •    '    own  as  hydronephrosii.     Hydmneiihrosis  is  more  likely  to 

»• "  ">«■  "Iwlrurtion  is  hrouKht  alMHit  slf)wlv  or  is  du"  to  iiiter- 

mil  'iitly  aetinjr  causes.     IJoth  kidni-ys,  hut  more  often  only  one,  inav 
lie  iiffec'te«l. 

In  n  mcxierately  advanced  ease,  the  jM-lvis  is  dilated  and  the  kidney 
siihstuiH-e  IS  somewhat  eonipressiil  and  atrophic,    'i'he  condition  will 
iiiMler  ordinary  cinunistaiues,  p,   „n    in.reasinj?    until    the   external' 
pressure  is  e<|ual  to  that  of  the  s«r«'ti..n.     In  time  the  kidnev  mav  l)e 
>.'r.iitly  enlantJ-d,  ln-inj;  •■oiivert«'<l  into  a  thin  sac  containinc'wrhaixs 
several  liters  of  fluid.     The  fluid  in  «|uestioii  is  low  in  s|)ecific'  imivitv 
(1(102  to  1012).  c..iitaii:,  little  or  no  alhiimiii.  and  is  <leficient  in  urea 
IK.ri.les.  an.l  phospiuites.     Microscopi.ally.  it  mav  contain  leuk<K-vtes' 
n-.l  IiIinnI  corpuscles,  aii<l  <holesf.,in.     .Should  iiif.rtioii  take  place  the' 
.ont.i.fs  JH-ome  uitermiii>;I.Hl  with  pus  (pyonephroili).    (S-e aisc) p  7.-)9  ) 

SolutiOM  of  continuity  of  th..  ureters  are  usiiallv  due  to  traumatism 
iilccnitioii,  or  iiew-jjrowfhs. 


INTLAMMATIOra. 

Inflatniiiafioii  of  tin-  jK-lvis  of  the  ki.lncv  is  called  pyelitia:  of  the  ureter 
ureteritis.  ' 

Pyelitis.-  Pyelitis  HHxst  conimonly  results  from  an  asceiidinK  infec- 
tioM.  luicnHirpiiiisms  remhiii^  the  jK-lvis  of  the  kidnev  from  the  lower 
nnnary  passages  l,y  way  of  the  urine.     The  ,)ossiI,ilif;-  of  this,  in  spite 
"    th.-  <i..wuwar.    current  <.f  the  urine,  has  l.e.-.i  ainpiv  <lemoiisfrate.l 
Any  ,„n,liti..n  which  interferes  with  the  fr.-c  outflow  of  the  urine  and 
hri.,;:s  al,<.uf  Its  (hyomiKxsition  u„„Id  nalurallv  aid  in  the  pr.Hluction 
-'I  Iiv.lilis.     Hetcntion  of  urine,  cystitis,  and  stri.tiire  of  the  urethra 
ar.'  III.,  .•on.lilions  of  most  iiMp..rtance  in  this  .„nne»tioii.      It  shouhl 
!»■  .M.i,li.,ne.l.  h.mever.  that  in  these  cases  the  inflammatorv  pnxess 
'K'.l  i„.(  |,r..^rress  by  conti>;uity.  f..r  pyelitis  mav  n-s.ilt  from  a  pretWistiiiL' 
|vsli(i;  wiih..ut   the  ureters  l.eiiij;  involve.l.      Morcver.  alfl,oui;h   the 
||it-"iii>;  ajients  may  have  d..velope.l  within  tlie  hhidder,  thev  mav  infect 
ni.|  |i.lvis  .)f  the  ki.lney  without  settiiij;  up  a  cvstitis 

•wli.is.  a^ain.  may  he  the  result  of  a  hemat.veneous  infection  .,r  of 

itl^  iiiiiii.l.,rv  pr.K-esses  mvolvin^r  die  ki.lnevs  themselves.     In  this  form 

i<;  ..n.Mis  inf«.ti..ns  and  intoxications  play  an  imp..rtant  role.     Lwal 

ri  an,,,,  within  tl:     pelvis  may  „Iso  brinj;  about  pveiitis.  such  as  mav 

Ih-  !in.,l„.-..,l  by  stones  and  parasites. 

In  ,„,,.  cases,  pyelitis  may  be  due  to  the  extension  of  inflammation 
troii   -nine  of  f|,e  parts  about  the  kidnev. 

h'..,,,.!,  in  many  instances  pyelitis  is  toxic  or  irritative  in  nature,  it 
"   ''liv  not  long  before  mfection  is  suin-radded.    The  microorganisms 


772 


THE  PELVES  ASD  URETERS 


moAt  often  at  fatilt  are  the  B.  coli.  the  varioiw  pyotjeiiic'  aitri,  (Ui.I  (li.- 
Gonoccxriix,  more  rarely  the  B.  pniteiin. 

Pvelitw  w  UHimllv  l.ihilenil.  Kveii  if  the  pr.i«esH  at  hrtt  \^  WiiW/M 
to  oiie  ki«lriey  pelvw.  as  in  the  «a.H«'  t.f  stime.  it  is  not  niHoniinon  for  iln- 
infective  aj;e'nt.s  to  make  their  way  into  the  i.lh.r  nnt.r  bimI  attmk  lli.- 
Qppmite  kiihiev.  A«conlin>;  to  the  anatontiiul  •liaiij.'i's  |)ri)«hn<-<l.  wr 
mav  reco>jni«e  a  dUithal.  a  surour»tiT«.  a  nwrnbrwioM,  un<l  a  gtBcranoui 
pytUtU.  The  form  proilue*-.!  «U|M'n.ls  larj^ly  n|Nin  tiie  nature  mii.I 
inteitf ity  of  the  infe«tion  ami  the  me<haiii<  a!  coiulitions  siihsistinj.'. 

In  eatarrhal  pyelitis,  the  mn«-ons  m<  inhrane  lininjr  tiie  Ih-Kis  is 
swollen,  eonKeste«l.  ami  may  pres«>nt  luiinite  hemorrha>{es.  'i'he  iirmr 
contains  mnens,  lenk<Mytes,'an«l  desqiiumated  epithelial  cells. 

In  the  purulent  form!  the  inflannnation  is  mon-  intense  ami  the  tiriiif  is 

distimtly  punilent.     In  some  eas.s,  us  aln.ve  mentiomil.  the  |mIvis,  aiMJ 

even  the  ki<lnev.  mav  Ik-  .listemlwl  with  pus  (pyoMphroiii).     In  .mm  s  „f 

stone,  in  which  pn'ssiire  is  exerteil  iijHin  the  iiiHametl  mucosa,  iilt.ra- 

tion  and  jfannrenc  may  result.  ,      •    ■        ■  , 

Membranous  pve'.itis  is  the  result  of  u  parliiularly  virulent  iiift-.  iioii. 

In  cas«>s  of  pvefitis  that  have  \iistvi\  some  lime,  the  mucosa  is  riil.lnifil 

ami  thickene«l,'aml  is  stiuhU-il  with  a  numlH-r  of  urayish  proiiiiii.iics 

These,  acconlinjt  to  some  oliservers.  an>  lymphadenoid  in  nuliirc  and 

are  due  either  to  hvperplasia  of  previously  existiun  lymph-mHJcs  or  m  a 

new-formati<m  of  Ivmphoid  tissue  as  a  result  of  the  iiiHammatioii.     In 

other  cases  small  i"vsts  an-  present  (pyeUtU  eyitic*).     In  ver.\  .  linmic 

pvelitis.and  es|m-iallv  in  the  tulH-niiloiis  variety,  the  lininj;  m.nil.rane 

l)J-comes  thi<-kened  aiid  horny,  and  of  a  pearly  white  color,  r.-*.nil.liiij; 

cholesteatoma.  , 

UreteritiB.-    I'reteritis  is,  in  most  resp. ■•(<      ■•nilar  to  py.liii^.  and 
its  characters  mav,  therefore,  Ik-  inferred  from  wi.at  lias  just  Ik-.ii  -ml. 

Tubercul08i8.--Miliary  tulierciilosis  .if  the  iM'lvis  of  tin-  ki.lii.v.  :i|>|Kir- 
cntlv  hematojienic  in  oripii,  has  Ik-ch  met  with,  hut  is  rare.  Tlir  iimwI 
typ^  is  chronic  an.l  cas.-iitiii>c  in  character.  This  form  iisiiall.v  inav  !«• 
tnu'ed  to  the  infliienc-e  of  a  tiilH-rciilous  kidney  but  is  soiiu'liin.-.  also, 
the  result  of  an  iisceiKiinn  infec-tion  from  tlu'  lower  urinary  pav^air.s  or 
Henitalia.  We  fiml  small,  elevated  tuliercles  in  the  mucosa  wliu  li  tfii. 
to  coalesce.  These  are  often  found  in  the  uppr  part  of  lli.'  in.  t.  r  and 
"ar  its  entrance  into  tiie  hla.liler.  In  time  they  lead  t..  i.i.k.  inii;;  of 
mucous  membrane  with  encr.iachment  upon  the  lumen  and  inorc  or 
.,.,s  obstruction  to  the  free  outflow  of  urine,  ritimately  the  wall  of  the 
ureter  licomes  jrreatlv  tliickene.1  an.l  ul.eration  takes  plac. .  In  an 
a.lvanc.-d  case,  we  have  .st-eii  the  whole  of  the  urinary  passaps,  l.oi.i  tliP 
point  of  the  jH-nis  to  the  ki.lney,  inHltrate.1  an.l  thickly  stnddrd  witli 
coarse  tubercles  teiidiu);  to  liecoine  coiifliieiit. 

Parasites.— The  more  imi>ortjnit  parasites  are  the  Filnnn     ••,(:<iim 
hominiit,  the  Dhtoma  hematohlnm,  the  Kustroiifj!ilii.i  (j'Kjd".    "id  the 

Asrarh  himlmvoiden.     Filaria  in  the  urinary  passa^'es  cause  I aHiriii. 

Chyluria  i.s  also  a  characteristic  symptom  of  filariasis. 


TUMORS 


rtz 


mmooBiafiYi  lOTAMOirBoui. 


I  luymly  .•c>iHJUi..ri  worthy  ..f  mW,  coining  utHler  i\m  tateK.»ry.  is 
nlemtion.  1  Iim  is  .s<)iii,-tiii,..s  th<-  rvsuh  „f  inHuiniimtion,  hut  u  per- 
l.»|.H  rnort.  often  dw  to  tli.-  prt-sfmi.  of  u  chIcuIus  (prvuure  necrotit) 


PKoouunri  mTAMowHotu. 

Tumon.  -'riie  nio.st  frit|iiently  ocrurriiijf  tumor  of  the  ix-lvis  of  the 
khln. y  IS  the  vi  Imis  ptpUlonu.'  It  iimy  give  ri.se  to  serioiw.  even  fatal 
iLMiorrhage  Malignant  |m|)illoiiiafou.s  tpithtUonM  have Ijeen  met  with 
l.nt  an-  rare.'  Primary  MrciaonM  'm.h  Urn  ohserv.Hl.  hut  Is  rare '  It  is 
•H . nsumully  foiiml  a.s,s,xiut«|  wit'  .e  pr...seiHe  of  stones,  sugg^stinif  an 
.n..l..gi(al  relutionsiiip.  Lymphot  jiu  of  the  pelvis  is  de.stril)e.l  'An 
tdanoiv  of  the  ur..ter  has  JHrn  met  with.  Inasmuch  as  this  structure 
•  onlanLs  no  kIhihIs.  it  has  Urn  .siii,,Kxse«l  that  the  tumor  originates  from 
nnmins  of  the  Woltfian  .luct.  Ilekto..,.'  has  recorded  an  instance  of 
|)riiiiiiry  carcinoma  of  tiic  iin-tcr. 

SMiu-tiines  the  mucous  men.hranc  lining  the  urinary  pa.s.sages  is 
il.c  Mtc  of  multiple  small  ,ysts.  a  condition  call«|,  ,K,s,sil.lv  eVrone.,usly, 
pyelit^i.  ureteritU,  cyititU,  urethritii  cyiUc.  as  the  .ase  may  he  These 
Imvc  l.,rn  ihought  hy  som.-  (o  originate  in  downgrowths  of  the  siiiH-rficial 
'I'l  I'lmm.  Others  think  that  they  arc  .liie  f.  proliferation  of  the  suIh 
••|»illi.liul  comitvtivc  tissue,  with  d.-vation  of  the  muc(wa.  The  cysts 
.LvHop  „,  thv  angle  thus  form.-.l  hy  the  prominence  and  the  general 
surface,    btill  others  would  attrihute  them  to  the  activity  of  parasites. 

'  >av(>rv  1111(1  SanU.  I.iiiicct,  l.uii.i  .n 
I'.Kil;  ll!». 

•  Kelly.  I'nic.  I'liUi.  Six-.  I'liih,,,  (N.  s.)  ,{;  I'.MH):  217. 
Hiktocii,  ./our.  .\iiiiT.  Med.  .\ks<io.,  2''«-  lN"fi:  111.5. 
*Wiitc,  Trans.  I'litli.  S.r.  I.oii.li.n,  Hi;  ls>.)H:  17S. 
•I"iir.  .Viiier.  Me<J.  .\nkoc.,  *(>:  IH'M:  1115. 


I'.KX:  KHill;  Hiissu,  Virchow'g  .Vtchiv,  164: 


CHAPTER  XXXVI. 

THK  BLADDER  AND  UUETHRA. 

THE  BLADDER. 

OONOENITAL  AN01IALIE8. 

The  development  of  tlie  l)la(l<ler  iiiiiy  In;  iiiterrupteil  at  any  sta^'.-  of 
its  progress.  Complete  delect  of  tlie  bla.lder  lias  been  reporte.l.  I  n  this 
case  the  ureters  discliarfte  into  the  urethra.  ( )eeasionally,  the  scptnm 
divuiine  the  re<tinn  from  the  bladder  is  wholly  or  partially  lackinj:,  so 
that  the  ureters  and  the  re<tum  empty  into  a  large  clo»c».  This  is  soiiit- 
times  a.sswiated  with  imjjerforate  anus. 

Bxtroversion.  "'i'he  most  coiniium  anomaly,  however,  is  extrover- 
sion Here  there  is  failure  of  union  l)etween  the  two  halves  of  the 
bodv  aloiiK  the  median  ventral  line.  'I'he  anterior  wall  of  the  hlad.ier 
and  the  corresponding  portion  of  the  alMloininal  wall  are  wanliiif;. 
The  pubic  bones  are  also  often  separate.1  by  a  considerabl.-  ii.t.rval. 
The  condition  is  much  nM)re  common  in  males  than  in  females,  hxtnv 
version  in  the  female  is  apt  to  be  ass.Kiate.1  with  prolapse  or  pr.MMl.Mitia 
of  the  uterus.  In  rarer  cases,  the  Idad.ler  is  complete  but  prolapstnl 
through  an  alMlomiiial  fissure  {ectopia  vesica;). 

Diverticula.  Diverticula  may  be  fotind  near  the  point  of  juiiction 
with  the  urachus. 

Small  cysts  of  the  urachus  are  common. 


DISLOCATIONS. 

The  bladder  mav  be  dispbced  upward,  downward,  or  to  .. 
The  pregnant  uterus  in  the  course  of  its  enlargement,  tumor 
pelvis  and  pelvic  organs,  and  intestinal  adhesions,  may  carry 
the  bladder  upward.  ,     ,  ,• 

Downward  disUKation  is  the  most  common  and  iini)ortant  l< 
is  due  to  muscular  relaxation,  sagging  of  the  pelvic  fl.M)r,  .1. 
of  the  iH-rineal  bodv,  and  malpositions  of  the  uterus,     f //v/.' 
downwar.1  pouching  of  the  H.K.r  of  the  bla.Mcr.     Kjrtronmu 
bladder  through  th.-  urethra  (female)  is  rare,  and  is  met  with  . 
young  <-hildren.     It  is  sometimes  caused  by  the  prolapse  ol 
of  the  trigone,  which  passes  into  and  through  the  urethra.  . 
dragging  the  biiidder  after  it.  .  ,      .   „  .        ■  , ,, 

Lateral  ilishKatioii  mav  Ik-  causwl  by  inflammatory  iiilil" 
adhesions,  tumors;  in  rare  instances,  the  bladder  has  formed  i'. 


IIIC     ■'lilt'. 

,  of  the 
or  ih'iii; 

inn.     it 
-niirliiiii 

■,h     i^  11 

,..  of  th.' 
hirHy  in 

,,    tllllll)!' 

.nitimlly 

ilioii  nf 
lit  of  the 


CYSTITIS 


775 


roiitcnts  of  the  sac  in  inpiinal  and  femor.i;  liernia.  It  is  hardly  net-essarv 
ti)  sav  that,  for  aiuitoniical  and  ph_v.sioh)j;i{'al  reasons,  dish'x-ations  of 
the  bladder  are  almost  confined  to  the  female  sex. 


OIBOUI^TORT  DISTURBANCES. 

'riipse  are  not  of  nn   I   [)ra(tie;il  Ii.ij>  .1  ance. 

Hyperemia.— Acti^ .  Hyperemia.  .V  ,ive  hyperemia  is  nearly  always 
an  inflannnatory  ma  .ift: Miion,  iuid  is  met  with  in  cases  where  the 
urine  contains  irritat.  -  s  U.fjii.e,  as.  for  instance,  canUiaridin,  or 
wlicre  there  is  extension  of  inflamin<ition  from  the  neighhorinf;  parts. 

Passive  Hyperemia.— I'assive  hyperemia  is  a  frerpient  accompaniment 
of  jreneral  systemic  con>;estion.  The  vessels,  particularly  those  of  the 
inline  and  neck  of  the  bladder,  are  tnri)id  or  even  varicose,  standing 
out  in  marked  contrast  with  the  otherwise  pale  mucosa.  This  apijear- 
iiiue  is  all  the  more  characteristic  since  the  normal  vesical  nmcosa  is 
strikingly  pale.  Passive  congestion  often  leads  to  (edema  of  the  bladder 
wall  and  finally  catarrh  of  the  nuicosa. 

Hemorrhages.  -  Hemorrhages,  either  in  the  fortn  of  petechia:  or 
tiKjiliUations,  are  met  with  in  cystitis,  ulceration,  tumors,  and  the  hemor- 
riiagic  diatheses. 

INFLABIMATI0N8. 

Cystitis.  Inflammation  of  the  bladder  -cystitis— is  of  frcciuent  (x-cur- 
rfiicc,  and  is  due,  in  the  vast  majority  of  cases,  to  the  extension  of 
iiiHainniation  from  other  parts  of  the  urinary  passages  (kidnev,  etc.), 
(ir  to  aiinormalities  in  the  contents  of  the  viscus.  ( Jonorrlucal  urethritis 
and  pyelitis  arc  examples  of  the  first  class.  Of  the  second,  dfromposing 
iiriiK",  calculi,  and  foreign  Ixnlies  may  be  cited.  The  irritation  set  up 
is  usually  aggravated  by  secondary  infection. 

()i(struction  to  the  outflow  of  urine,  as  in  stricture  of  the  urethra  or 
enlarged  prostate,  is  a  common  catise,  not  only  from  the  stagnation  of 
llic  urine,  but  on  account  of  infection  which"  invariablv  takes  place. 
A  distended  blachler  is  particularly  liable  to  bacterial  invasion,  since  its 
risMiiig  power  is  dimiiushed,  and  the  retained  urine,  undergoing  as  it 
(l(«  ■-  marked  chennVal  changes,  acts  as  a  dire<-t  irritant  to  the  inucous 
ni<  iiihrane.  Moreover,  certain  bacteria,  which  reach  the  bladder  from 
"iiiMile,  induce  various  forms  of  fermentation  and  chemical  decomposi- 
timi  so  th.it  the  original  disturbance  is  aggravated  and  jH'rjH-tuated. 
Ill''  microorganisms  in  rpiestion  reach  the  bladder  from  the  urethra,  or 
from  parts  adjacent  to  the  bladder.  They  an-  also  introduced  through 
ranli  ^s  instrumentation  or  the  use  of  a  dirty  catheter. 

Till'  urine  in  cystitis  is  often  alkaline  aiid  has  a  fictid  ammoin"acal 
"li'ii.  The  reaction  and  the  fermentative  pnK-esses  going  on  depend, 
l""irv.r,  on  the  nature  of  the  offending  microorganism.  The  ordinarv 
!iinm.,ma(al  dwomjwsition  of  the  urine  is  brought  about  bv  the  MicnJ- 
eon  lis  ureie.     When  the  B.  coli  is  present  alone,  according  to  Schmidt 


J      ■ 


776 


THE  URINARY  BLADDER 


V  1 


and  A.schoff,  the  urine  is  iicid.  If  the  urine  contain  staphyKxcci, 
either  alone  or  assoiiatetl  with  the  B.  eoli,  the  reaction  is  alkaline. 

In  a  few  instames,  cystitis  can  l)e  traced  to  hematogenic  infection  of 
the  action  of  a  circulating  toxin,  or  to  the  extension  of  an  inflaininalory 
process  in  adjacent  organs,  like  the  uterus  and  rectum. 

Cystitis  is  acute  or  chronic. 

ACQte  Cystitis. — Catanhal  Oystitii. — The  mildest  form  of  the  a<  ute 
affection  is  catarrhal  cystitis.  .\s  people  do  not  die  from  this  distase. 
the  con«lition  is  only  discoveretl  in  the  roufne  examination  of  tho.if  who 
have  died  'r  m  other  causes.  At  autopsy,  th  re  may  he  surprisiii);ly 
little  evidence  of  its  presence,  even  where  the  signs  were  clear  during 
life.  At  most,  there  is  sliglit  ntlness  and  swelling  of  the  mucosa,  ami 
any  urine  present  contains  a  little  mucus,  with  a  few  leukocytes  ami 
some  degenerated  epithelium.  Small  grayish  blebs  may  l)e  found  alumt 
the  neck  and  trigone  {herpes  vcsicw). 

Acute  Suppuntive  Cystitis. — A  more  serious  disturbance  is  acute 
suppurative  cystitis.  Here,  the  mucous  membrane  is  reddened  and 
swollen,  particularly  about  the  fundus  and  trigone,  and  on  the  surface 
of  the  rugie.  If  the  urine  has  been  alkaline,  a  macerating  prmrss  lias 
been  going  on  and  the  epithelium  is  swollen,  soft,  and  des(|uaniatiiif;  in 
large  flakes.  In  this  detritus  phasphates,  carbonates,  and  other  urinary 
salts  are  often  deposited,  giving  the  mucosa  a  dirty  whitish  or  wiiitisli- 
brown,  gritty  ap{>earancc,  not  unlike  mortar.  Pus  can  frequently  l)e 
scjueezed  out  of  tiie  lacuna-,  and  hemorrhagic  patches  may  be  seen  lure 
and  there. 

The  suppurative  prwess  may  extend  into  the  bladder  wall,  infiitratin); 
the  interstitial  tissue  ai,  I  undermining  the  muscle,  which  may  tlms  he 
«lissectetl  off  and  Hoat  free  in  the  vesical  cavity  in  the  form  of  >oft, 
friable  fags.  When  the  supi)uration  extends  diffusely  througliont  liie 
nuiscular  wall,  the  condition  may  l)e  spoken  of  as  phlegmonous  cystitis. 
The  prcxess  may,  however,  extend  still  deeper  to  the  surroiimlint: 
connective  tissue^-paracystitis,  or  even  to  the  peritoneum-  pericystitis. 
Abscesses  of  considerable  size  may  form  in  the  perivesical  cclluhir  ii>>ne. 
Provided  that  the  patient  survive,  they  may  l)ecoinc  circiunscrilMil  ami 
heal,  leading  to  fibrous  induration.  Perforation  of  the  abscess  into  tiie 
peritoneal  cavity,  intestine,  and  vagina  has  been  recorded. 

Membranous  Cystitis.— A  third  form  is  the  .so-calle<l  nuMnliranous 
cvstitis.  This,  in  man\  cases,  is  brought  about  by  chemical  (hanires  in 
the  urine,  particularly' by  the  action  of  anunoniuni  carbonatf,  which 
produces  swelling,  (les<]uaniation,  and  maceration  of  the  tissues  ilie 
condition,  however,  also  jKcurs  in  certain  of  the  infective  fevers,  lyjilioid, 
cholera,  the  exanthemata,  pyemia,  diphtheria,  dysentery,  and  in  Hroml- 
ary  carcinoma  derived  from  the  uterus.  The  bladder  is  inttii-  ly  rnn- 
gested  and  of  a  deep  n-d  hemorrhagic  ap|)earance,  while  upon  tin  -irfiur 
of  the  rugw.  particnlarly  in  the  jM)sterior  part,  there  is  a  whin-h-gray 
membrane,  more  or  less  finnly  adherent.  This  membrane  is  hail.'  to  l»e 
infiltratetl  with  urinary  .salts.  Microscopically,  the  mucosa  presents 
coagulation  necrosis. 


TUBERCULOSIS  j-^j 

Chronic  Cystitia.-Chrunic  cystitis  may  result  from  the  acute  form, 
or  muy  l«.  .  -ronic  fr«i„  the  start.  Depending  upon  the  cause,  the 
l.hi(l.ler  IS  di  i.n.led  and  thin-walltHl,  or  contracte<l  and  hypertrophic 
1  ■<•  mucous  membrane  is  usually  much  thickened,  and  lies  in  deep 
folds  or  polyj>oid  outgrowths  may  be  formed.  The  mucosa  is  sometim^ 
greatly  reddened  but  more  often  Ls  of  a  slaty  color,  showing  incrustation 
w,  ii  salts  and  slight  superficial  erosion.  The  lymph-follicles  may  be 
enlarged  or  increased  in  numbers,  so  that  they  become  visible  and 
give  the  surface  a  granular  appearance. 

Syphili8.--Syphilis  but  rarely  affecU  the  bladder;  little  or  nothing 
IS  known  of  luetic  ulceration  in  this  locality. 

Tubercul0Si8.-The  mucous  membrane  of  the  urinary  bladder  is  nor- 
nialiy  quite  resistant  to  tuberculous  infection.  Active  bacilli  may,  for 
a  long  tune,  l,e  brought  in  contact  with  it  without  inducing  lesions  A 
prtrxisting  cystitis  w  ill,  however,  lessen  this  relative  immunity  Vesical 
tuherculosis  is  rarely,  if  ever,  hematogenic,  but  the  infection  is  carried 
through  the  medium  of  the  urine  from  the  upper  urinary  passages,  or 
iniKh  less  often,  reaches  the  viscus  by  extension  from  the  g.^iitalia! 
lliat  tuberculosis  of  the  bladder  is  rarer  in  femal.s  than  in  males  is 
.xp ained  by  the  fact  that  genital  tuberculosis  is  not  so  often  met  with 
in  t  u-  former.  In  the  male,  tuberculosis  of  the  kidnev  or  of  the  prostate 
IS  tie  usual  cause.  Only  rarely  is  the  tulK-rculosis  primary,  and  in 
smh  cases  the  bacilli  are,  possibly,  derived  from  the  bl,KHl,"but  more 
probably  from  the  outside  through  the  urethra.  That  the  urethra 
IS  iininvoived  dws  m)t  exclu<le  this  possibility,  for  it  is  particularly 
rt'friutory  to  tuberculous  infection.  ' 

Aiiutomically,  there  are  two  forms,  niMple  miliu  and  the  rn.ieoiu,  ulcer. 

he  miharv  var-  '  •  ukes  the  form  of  minute  grayish  luxlules  situate<l 

jMst  beneath  the  .  I  layer  of  the  mii.osa.     In  descen.ling  inftrtio,. 

hcsc  are  usually  ckly  groupd  about  the  orifices  of  the  ureters 

n    lu-  ascending  I     .,  a.ey  are  found  at  the  trigone  and  neck  of  the 

I'la'l'lcr.     I  he  milia  are  surrounded  by  a  rcldish  zone,     'i'he  larcer 

oms  present  central  caseation   but  the  smaller  can  only  be  distinguished 

from  hy,HTplastic  lymph-follides  by  microscopi,-  examination. 

Ului,  tiie  mxlules  coalesce,  large  granuloma.s  are  pn^luced  which 
".Hlcrgo  necmsis  and  ulceration.  These  tend  to  be  restricte.1  to  the 
niiKosa,  and  spread  laterally  rather  than  into  the  muscular  wall.  It 
..a.v  ,e  difheult  at  first  to  recognize  them  as  tuberculous,  si.ice  the  bases 
[11.  \  he  (,uite  clean  ami  free  from  necrotic  an<l  caseous  material.  Only 
M  ll.c  more  extreme  cases  are  large  tuln^rc-ulous  masses  produced,  with 
n.pilar  and  fissured  surfaces,  which  may  undermine  the  mucosa.  As 
m  ti,..  ,,ise  of  other  ulcers,  the  surface  is  often  infiltrated  with  urinary 

■Svoiidary  tuberc-ulosis  of  the  blad.ler.  .leriunl  from  organs  not  in 
1  n.  t  contact  or  communication  with   the  viscus.  is  somewhat  rare 

Tuirrcolo'rT;."^'""''',/''™"*^''  "'"^  "'"liation  of  the  |H-ritoneum: 
tu  o.r„I^  small  mtestme,  cecum,  appendix,  or  Fallopian 
luiii  ^  plays  a  leading  role  here. 


778 


THE  URINARY  BLADDER 


Parasites  and  Abnormal  Contents.-  I'lie  urine  wliich  mvflies  tlic 
bladder  may  he  ahnoriiml  in  its  swretion,  or  may  hetome  contimii- 
nateil  by  contact  witli  the  urinary  passajjes,  or,  apiin,  may  underj;!) 
chemical  def.imposition  wlien  r»'tained  witlni;  the  bladder. 

Erythrocytes  or  their  derivat.ves  may  ire  found  in  the  urine  in  certain 
cases' of  nephritis;  in  <'onj;estion  of  the  urinary  organs  and  passages;  in 
acute  inflammation  or  ulceration  ^f  the  pelvis  of  the  kidney,  ureter. 
or  bladder-  in  certain  intoxications;  and  in  the  hemorrhagic  diatiicM  s. 
Tumors,  like  angiomas  or  carcinomas,  may  bleed  freely.  Blood  dots 
or  blood  casts  may  l)e  foun<l. 

leukocytes  result  from  ii-flanmiation  in  any  part  of  the  urinary  tract. 
Thev  mav  form  casts. 

Epithelium  from  the  jx-lvis  of  tiie  kidney  antl  bladder  is  often  met 
with,  and  is  of  considerable  importance  in  tliagtiosis. 

In  ulcerative  processes,  simjile  or  cancerous,  necrotic  tissue  and  dilritiis 
mav  lie  found. 

Urinary  casts  are  derived  from  the  tubules  of  the  kidneys  in  viirimis 

forms  of  nephritis.    Tiiey  may  \)e  hvii'Mie  and  colorless,  a.nyloid  (collnid), 

fatty,  granular,  epithelial,  leuk«H.\.    ,  fibrinous,  or  com{)osed  of  nd 

1'  .(k1  cells.     Casts  should  be  carefully  differentiated  from  cyliniiroids, 

.liich  are  of  no  practical  importance. 

Bacteria  of  various  kinds  are  of  frecpicnt  occurrence.  They  arc  de- 
rived either  from  the  urethra,  or  are  eliminated  through  the  kidiny. 
A  .mling  to  most  authorities  normal  u.'ine  is  a.septic.  Eiiri(|iiez' 
has  made  a  careful  study  of  this  point.  Whetiier  a  physiological  (•\(  rc- 
tion  of  microorganisms  through  the  kidney  is  possible,  in  the  alistiu c  of 
a  lesion  of  the se<retiiig epitiielium,  is  still  a  m(M)t (lucstion.  Tlic  iii:i jnrily 
of  observers,  following  Wvssokowitsch  and  Neumann  and  KoMJajtff, 
.seem  to  think  it  d(H-s  not  oJ'cur,  but  Sciiweitzer'  and  certain  otlitr-  UM 
that  bacteria  may  pass  tiie  renal  epithelium  in  the  absence  of  any  Iimoiis 
that  it  is  po;  ;ible  to  recognize  microscopically. 

Th.-  chief  pathogenic  bacteria  found  in  the  urine  in  diseased  coiidiliDiis 
are  the  H.  coli,  B.  typhi,  B.  tuberculosis,  stapliyhKCKcus,  strcptiH mriis, 
I)ipltK<K'cus  pnetnnonia',  (!on«H(Kcns,  and  B.  Kriedliinderi 

Yeasts  are  met  with  in  the  urine  of  diabetics. 

A  variety  of  foreign  bodies  have  In-en  found  in  the  urine.  In  II  "iloiis 
communications  with  the  rectum,  fiKCf!  and  gas  may  enter  tin-  hhi.l.itT. 
A  dermoid  cyst  may  open  into  the  orgi.n  and  hairs  may  be  p,i>M<l  in 
the  urine  (pilimlrlio). 

In  the  case  of  children  and  tl'.ose  addicted  to  masturbation,  niiii  in 
attempts  to  relieve  itching,  foreign  IxMlies  of  all  kiials  have  l)ccii  [la^-Hl 

into  the  iireth  a  and  may  slip  into  the  bladder.     Among  tlic>i   '" 

mentioned  catheters,  hairpins,  hatpins,  nwdles,  nuitches,  stra\v>. 
handles  of  parasols  or  toothbrtishes,  glass.     Foreign  bodies  may  I.  ■ 
nucleus  for  the  formation  of  concrements. 


ni:iy  l)e 
.iiidles 
nil  tiie 


'  HiThorchcs  hiiet.  siir  I'miiie  normale,  Scmaitic  luMicalc,  No.  .^)7:  l-^''!    <''>*■ 
•Vircliow's  .\reUiv,  110:  1,S87 : 2,-)5. 


;l  '.aaai    iti: 


.'ROGRESSIVE  METAMORPHOSES 


779 


Concrements  and  calculi  are  produce<l  in  the  pelvis  of  the  kidney  or 
in  the  bladder  (see  vol.  i,  p.  S«4).  Stones  in  the  kidney  are  usiially 
(■(impased  of  urates,  uric  acid,  oxalates,  or  combinations  of  these  with 
pliosphates.  Vesical  calculi  are  commonly  phosphatic.  It  is  obvious, 
liowcver,  that  stones  of  varying  character  may  reach  the  bladder  from 
tlif  renal  pelvis  an(!  form  a  nucleus  for  a  much  larjjer  phosphatic 
calculus.  Certain  rare  forms,  cystin,  .xanthin,  and  silicates,  may  just  be 
mentioned. 

'riu-  pansitos  found  are  the  Echiiiococcus,  Filaria,  Ohtoma,  and,  in 
cattle,  the  larvce  of  certain  flies. 

RETROGRESSIVE  METAMORPHOSES. 

Atrophy. — Atrophy  of  the  bladder  is  met  with  in  old  p^;^,  es»)eciallv 
in  women,  and  in  marantic  and  cachectic  states.  The  mucosa  is  thinned', 
l)iit  the  muscular  coat  is  the  portion  chiefly  involved,  i'he  bladder  wall 
is  sometimes  retluced  to  the  thickness  of  paper.  Long-continued  dis- 
tention, such  as  is  met  with  in  paralysis  of  the  muscle,  is  an  important 
cause  of  atrophy. 

Necrosis.-^ Necrosis  of  the  bladder  wall,  at  times  leading  to  perfora- 
tion, is  commonly  due  to  injuries  during  |»arturition,  either  from  instru- 
niiiilatioii  or  the  pressure  of  the  fcctal  head.  It  may  also  result  from  the 
pressure  of  a  large  calculus. 

Fatty  and  amyloid  changes  are  conunon. 


PROGRESSIVE  BIETAMORPHOSES. 

Hypertrophy.-  Hypertrophy  of  the  vesical  muscle  is  of  fre(]uent 
(xvurrcnce.  According  as  the  cavity  of  the  bladder  is  contracted  or 
liilaicd,  we  can  recognize  a  concentric  and  an  excentric  hypertrophy. 

'I'lic  most  common  cause  is  some  obstruction  to  the  free  outflow  of 
urine,  such  as  is  l)r(»ught  about  by  an  enlarged  prostate,  stricture  of  the 
urctlira,  the  pressure  of  a  prolapsed  uterus,  tumors  of  the  uterus  or 
liliiddtr,  or  an  impacted  calcidus.  A  second  form,  without  iirinarv 
iilisiriution,  is  found  in  cases  of  chronic  cysti(is,  vesical  calcidus,  anii 
tiiiiK.rs.  Here,  it  is  supposed  that  the  constant  irritation  leads  to  in- 
<n:is(.(l  activity  of  the  motor  nerves  and  functional  overwork  of  the 
iiHiM  Ic.  As  in  the  ciuse  of  the  heart,  hypertrophy  may  in  time  give 
pliKc  It)  dilatation,  notably  in  the  obstructive  cases.' 

dilatation  of  the  bladder  with  hyj>ertrophy  of  its  wall  is  fre(|Uently 
rim  wiili  in  certain  alfe<tions  of  the  spinal  cord,  hKomotor  ataxia,  mve- 
liti-,  iind  the  like.  In  such  cases  there  can  W  no  ([uestion  of  obstruc- 
tion <ir  of  reflex  irritation.  The  dilatation  might  l)e  accounted  for 
o!!  t!:.'  score  of  diminished  sensibility  ami  cunscijucnt  n-tcntion,  but  we 
ui;i .  ( (insider  also  that  the  hypertrophy  is  due  to  some  trophic  disturb- 
uiin  I'  the  sympathetic  U'-r vous  svstem  or  of  the  nenes  in  the  muscular 
wall. 


780 


THE  VniSARY  BLADDER 


In  pure  h}"pertrophy  the  bladder  wall  is  thickene<l  and  of  firm  con- 
sistence. The  niusciilar  i)an<ls  of  the  inner  surface  are  greatly  enlarp-d, 
recaUing  the  coluninH>  carneic  of  the  cardiac  ventricles.  When  ohstnic- 
tion  has  been  operative,  it  is  not  uncommon  to  find  smaller  or  Lir^ir 
sacculations  or  diverticida,  either  due  to  loi'al  weakening  of  the  olaildcr 
wall,  or  to  hernial  protrusions  of  the  mucosa  through  weak  spots  in  the 
muscular  coat.  Tlicsc  diverticula  are  most  freijuent  at  the  fundus  of 
the  bladder,  while  the  trigone  is  usually  free. 


Fio.  207 


llyperlmiihy  iiml  ililalntion  cif  tlii'  urinary  lihiililrr  ilin- 1"  an  p>ilarKr<l  pnislair.  lli.-  .;i  .ula- 
tiiin  "f  tin*  hlaiMcr  i-*  Wfll  ?.!uiwii  ami  aUo  dii"  fncrimi-hnH'iit  of  the  niiildii'  liilj*'  of  tlir  pi"^(ate 
on  the  uriMhra.     (Kpiin  tin-  I'alliolniiiial  Musfum  of  Mci;ill  l'iiiver»ity.) 


Tumors. — Primary  tumors  art;  not  common.  Benign  vesical  ;.'rii"tli.s 
are  rather  more  common  than  the  malignant.  In  (i-M)  cases  j;!  i n  hy 
Watson,'  00  per  cent,  were  non-malignant.  Males  are  more  frti|uiiitly 
attacked  than  females,  the  proportion  being  about  3  to  2.  An  a  rule, 
the  base,  the  posterior  wall,  or  both,  are  involved. 

Papilloma. — The  most  common  growth  is  the  papilloma,  wMili  is 
often  benign  but  has  a  distinct  ten<lency  toward  malignancy,  an  I  luiiee 
maf  develop  into  a  papillary  carcinoma.  It  appears  as  a  snfi  Mlitms 
mass  attachwl  to  the  mucosa  by  a  fibrous  pedicle  of  varying  tli    kiiess. 

'  Morrow's  System  of  (Jenito-uriiiary  Diseases,  1 :  1893 :  50.'). 


TUMORS 


781 


Wlien  flouted  out  in  water  the  tumor  has  a  slingRy,  tree-like  appearance. 
Tiie  growth  is  generally  re<l(lish,  hut  may  present  paler  areas,  due  to 
mrnxsis  or  superficial  erosion. 

.Microscopically,  the  tumor  consists  in  a  niu..i)er  of  connective-tissue 
cons,  rather  rich  in  hlcHxlvessels,  which  are  covered  with  simple  or 
stratified  jwlymorphoiis  or  cohnnnar  cells.  If  tl-  •  tumor  lie  malignant, 
the  wall  of  tlie  bladder  is  infiltrated  with  a  soft,  hrain-like  substance,  from 
which  a  milky  juice  can  l>e  obtained  on  scraping.  L'n<ler  the  micro- 
s(i)i)e,  the  mucosa  and  mn  -ularis  are  found  to  contain  masses  of  epi- 
thelial celb,  resembling  those  covering  the  pai>illic  of  the  original  growth. 

Fibroin*.— Fihromas  or  fibrous  polyps  are  rather  more  uncommon. 
Tlicy  often  show  my.\omatous  degeneration. 

Myoma  and  Fibroiu/oma. — Myomas  and  fibroniyomas  are  among  the 
rarest  of  bladder  tumors.  They  vary  in  size  froni  that  of  a  jn-a  to  that 
of  a  child's  head,  and  may  l)e  f)edunciilatcd  or  sessile. 

Adenoma.— Adenomas  are  quite  rare.  They  are  sessile  or  jH-diincu- 
laled,  and  have  a  smooth,  lobulalcd,  or  jpapillary  surface.  They 
probably  arise  from  the  mucous  crypts. 

Angiomas  and  teratomas  are  excessively  rare. 

Carcinoma.— Carcinoma  originates  from  the  epithelium  lining  the 
l)l'(l(ier  or  that  of  the  nnicous  crypts.  It  often  forms  a  rather  superficial, 
.litbise  growth,  projecting  only  slightly  into  the  cavity  of  the  bhuKier,  or 
presents  a  nodose,  somewhat  elevated  surface.  The'mucous  membrane 
is  sometimes  intact,  or  may  be  enxled  and  ulcerated.  Flattened  ulcers 
witli  indurated  edges  may  be  formed.  In  otiicr  cases,  as  before  men- 
tioned, carcinoma  takes  the  form  of  a  papillary  outgrowth,  or  cauliflower- 
like  mass.  Vesical  carcinomas  are,  as  a  rule,  somewhat  slow  growing, 
and  do  not  tend  to  invade  the  deein-r  structures.  Metastases,  when 
pri  sent,  are  usually  strictly  Icx-al. 

Sarcoina.— Sarcomas  are  commonly  multii)le,  sessile,  with  a  smooth 
snrfiice.  In  color  they  are  red,  purplish,  or  almost  black.  They  are 
exircmely  rare.  Myomrcoma,  chondrosarcoma,  and  osteoid  chondro- 
mrmma^  have  been  recorded. 

Secondary  tumors,  usually  carcinomatous,  are  more  frequent  than 
primary  ones.  In  the  male  they  originate  in  the  prostate;  in  the  female, 
111  llie  uterus  or  vagina.  In  both  sexes,  carcinoma  of  the  rectimi  may 
extcn,!  to  the  bladder. 


THE  URETHKA. 

OONOENITAL  ANOMALIES. 

Absence  of  the  urethra  is  met  with  associated  with  other  grave  defects. 
1 1"-  urethra  m.-iy  divide,  so  that  it  discharges  by  two  or  more  openings. 
In  thi'  male  the  passage  may  o|)en  at  the  ba.se  of  the  .scrotum  instead  of 

'  -ii.itti.ck.  Trans.  Path.  Soc.  .-JS:  1SS7:  1S.3;  also  Ueiicke,  Arch.  f.  path.  .\nat.  u. 
I'l'.       1.  I.  khn.  MeU.,  lUl:  1900;  70. 


782 


THE  VRKTHRA 


passing;  through  the  corpus  .spongiosum,  and  in  the  female  it  inay 
empty  into  the  vagina.  L(K-ai  obUtantion  of  tiie  urethra  may  Im-  met 
with  at  tiie  meatus  and  in  other  parts,  due  to  defective  developuieiu  of 
the  corpus  spongiosum.  Vilve-Uke  membnnei  also  lead  to  partiiil 
or  complete  obstruction  of  the  canal. 

OIKOTTLATORT  DUTUKBAHOES. 

What  has  already  l>een  stated  with  regard  to  the  Madder  applies  witli 
ecjual  force  to  the  urethra. 

In  females,  varieei,  or  urethral  hemorrhoids,  are  met  with,  fonnlii}; 
small  carunc'les  or  pt)ly|M>id  masses.  They  may  give  rise  to  sjtIous 
hemorrhage  or  to  suIiuuicoils  hematomas. 

INFLAMMATIONS. 


Urethritis.  Simple  Urethritis.  Simple  urethritis  is  coiiiniDiily 
brought  about  iiy  irritation  from  unclean  habits,  careless  iiisiriiincii- 
tatioii,  injections  of  fluids,  foreign  IxMlies,  calculi,  or  direct  violfiice. 
In  the  female,  inflammations  of  the  vulva  and  vagina  not  infre(|ii(iitly 
extend   to  the   urethra. 

A  simple  urethritis,  analogous  to  inflammation  of  other  iiiiicous 
membranes,  may  arise  in  the  course  of  the  various  infective  fevers. 
It  is  also  In-lieved  to  be  prcKliiced  by  coitus  with  a  woman  sufferini;  from 
a  leucorrhd'al  discharge,  or  who  is  menstruating. 

GonorrhoBal  Urethritis.-  The  most  im|M)rtant  affection  is  six'cilic 
urethritis  or  gonorrluea,  which  is  due  to  a  particular  microorptiiisin, 
the  (ion(X'(K-cns  of  Neis.ser.  (lonorrlxeal  urethritis,  as  a  ]>i'iiiiary 
disca.se,  is  more  fre(|uent  in  males  than  in  females.  In  the  latliT  it  is 
more  liable  to  spread  by  extension  from  a  previous  infe<'tion  of  tlit-  \\\\\-\\ 
or  vagina.  The  condition  is  br  'ight  about  by  contact  with  iiifi'itivc 
.se<'retion  from  a  mucous  membrane,  usually  by  coitus,  although  iii-tiiiHrs 
of  mediate  contagion  are  not  uncommon.  Thus  the  infecting  aj;riits 
may  Ik-  carried  by  the  Hngers,  towels,  sj)onges,  or  bed-linen. 

The  sjKM'ific  microorganism  is  a  nii<'nM'(Krus,  usually  lying  in  pnirs, 
the  opposed  surfaces  of  which  are  slightly  concave.  Single  ctHri  ami 
tetrads  are  also  met  witli.  'V\\v\  are  often  intracelhilar,  but  an  also 
foiniil  lying  free.  They  stiiin  readily  with  aniline  dyes  and  are  decolor- 
ized by  (Jram's  metluxl.  Owing  to  the  fact  that  certain  other  miiro- 
organisnis,  namely,  the  Trichomonas  vaginalis  and  .some  alH'rrani  forms 
of  the  H.  coli,  resemble  (ioncM-cK'ci  rather  closely,  diagnosis  slioiiM  not 
l)e  made  from  stained  films  only,  indess  the  history  and  cliiiici 
arc  clear.  In  doubtful  and  es|Kcially  in  medicolegal  cases, 
metluxis  .should  also  be  resorted  to. 

Gonorrhcea  usually  .starts  near  the  meatus  and  rapidly  spread 
rest  of  the  anterior  urethra.  After  the  first  week  the  inflanunai^ 
spread  to  the  posterior  urethra  and  the  prostate. 


-ijriis 
illiire 

to  the 
!  iiiav 


PLATE  IX 


Gonococci  in  pus. 


!  I 


i 

i 


GOS'ORRIKE.M.  VRKTIlltlTIS 


788 


Tin-  disfnse  is  a  m'\*'Tv  niiriil«>rit  ciiturrli,  It'iuliii);  at  first  to  intense  ron- 
jffstioii  <»f  the  iirftliru,  fiillowc<l  l>y  the  |mNliicti(iii  of  u  profuse  vellowi.s:: 
or  >;rtt'iiisli-_vt'llow  (lisc-harj;e,  iM'cusioimlly  inixe<l  witii  l)i<HNi.  The  pn-- 
|)iirt>  uiid  ^laiis  an-  often  influined  (l)nlano}>oHtliili.s),  aixi  there  inuv  lie 
|iarapiiiiiiosis.  In  severe  cas^-s  mild  eoiistitiitioiml  syrnptoins  arise, 
tii^'ttlicr  with  painful  en-eti  s  of  the  jK-nis  (rhnnln).  The  seeretion 
(oii>ists  of  pus,  lilood,  and  deH(|uaniate<l  epithelial  cells,  ami  contains 
till'  s|M*ciKe  inicroorgani  .nis. 

IMicroscopically,  the  .su|M-rK<ial  epithelium  is  des«|uamatin);,  and 
leukocytes  can  In-  seen  passing  In-tween  the  cells  to  the  surface,  or  infil- 
Iraliii);  the  jn'riurethral  conia-itive  tissue.  'I'lie  various  lacun<e  and 
|H'riiirethnd  glands  are  usually  distended  with  pus. 

.\fler  a  few  we«'ks  the  intensity  subsides,  as  a  nde,  and  the  proi-ess  may 
tiKJ,  even  in  the  al>sen<e  of  treatment,  in  healing.  Tiii  is,  I  iwever, 
nut  often  the  case,  since  the  alTection  tends  to  In-come  t-hronic.  a  i  certain 
(oinplications  may  set  in.  If  the  in  '  Mnmatir<n  extend  to  the  prostatic 
jrliiiid,  the  diseiise  Iw-fomes  very  ohsti'iate.  riceration  or  al>sces.s«-s 
in  the  jH-riurcthral  comie<-tive  tissue  iK'cur,  and  the  various  glands — 
liriistiitic,  ("o\v|H'r's,  Tyson's,  and.  in  the  female,  Martholin'.s  j;lands  - 
Miay  retain  inft-ctive  j)us  lonj;  after  the  urethra  is  free.  This  lin-al  sujipu- 
raiinn  may  Ik-  due  to  the  ( ioucx-ck'cus  alinie,  or  to  other  j;erms  ass(x-iated 
with  it.  More  rarely,  acute  orchitis  or  ej)idi<lymitis  results.  In  the 
female,  the  vagina, particularly  about  the  cervi.x  uteri,  is  apt  to  Ik*  involved. 
(iiinnrrhical  endometritis  is  met  with,  hut  more  often  the  uterus  escaj)es, 
\vliil<'  tl  ■  Fallopian  tulw-s  ixH-ome  diseased.  A  few  cases  of  ^onorrlueal 
[Mritiiiiitis,  due  to  extension  of  infection  from  the  tuhes,  have  l)een 
ri|)()rte(l.  In  both  sexes  the  Madder  is  not  infr»M|uently  attackeil, 
altlii>n>,'h  the  kid.a'vs  are  hut  rarely  involved,     .\nionf;  the  most  serious 

< plications    are    conjunctivitis,    adenitis    and    |Mriadenitis    (huho), 

ariliritis  and  tenosynovitis.  entltK-arditis,  an<l  septicemia. 

(icmorrlKcal  arthritis  and  tenosynovitis  usually  manifest  themselves 
weeks  or  months  after  the  first  iiifecfion,  and  are  most  obstinate  condi- 
tions, ."suppuration  in  the  joints  and  fibrous  ankylosis  are  not  un- 
eiiininiiii, 

(  lironic  fionorrluea  is  usually  the  continuation  of  an  acute  attack  in 
a  1(>^  llorid  form.     It  may  be  catarrhal,  hyperplastic,  or  indurative. 

Tlie  catarrhal  form  resenibles  the  acute.     The  exudation,  however, 
is  less,  in  parts  there  are  sujHTficiai  erosions  of  die  epitlielimn,  and  the 
iliical  cells  may  Ik*  converted  into  sijuamous  ones.     The  various 


dii 


(Tyjiis  and  glands  may  contain  pus  or  desipiamatetl  cells,  and  show 
iviilenrcs  of  deeply  seateil  inflammation.  Occasionally,  in  addition  to 
eaiiinli.  the  nmc<.>.  is  thickenwl  and  studded  with  warty  or  polypoid 
cxi  TeMciices. 

.Vn  miijortaiit  type  practically  is  the  indurative,  in  which  dense  fibroiw 
lis-ne  IS  prcHluced,  leadiiif;  fre«|ue!itiy  by  its  <-ontraclion  to  stricture  of 
tlie  nivijira. 

Sini  lures  may  be  sinj;le  or  multiple,  and  are  usually  found  in  the 
iiie'iii.iaiious  urethra,  although  the  penile  portion  may,  at  times,  be 


784 


THK  VHETHHA 


'l:!i 


affwfwi.  The  cotHiition  is  u  .slowly  tlfvclopiii);  oiii-  uthl  U  ini|(<irt;iiit 
on  nctoiint  of  tlu-  .s4.-riou.<t  clUlurliuturs  to  wliirh  it  givt's  rist-,  <)lMtru<  ihui 
to  the  free  iluchur^  of  urine,  hy|iertro|>hy  of  th«'  hludiler  with  (liliilaiion, 
hy(lmne|>hrosi.s,  pyonephrmiit,  rupture  of  the  urethru,  luul  extnivusaiiim 
of  urine.  R«>hinil  the  .stricture  the  urethru  is  p'nerullv  in  ii  stiiir  of 
chronic  i-nturrh.  In  chronic  urethritis  tliere  is  usimlly  ii  .sli>;ht  disdinrdc, 
generully  in  the  morning;.  It  i.s  not  nt-cessiiriiy  piiriMent,  i>ut  is  nmrc  i.f 
11  mucous  nature  (glret).  In  this  form,  the  urine  nmy  ((itilain  i\  f»w 
f{(K¥ulent  shrills,  u|Min  wiiich  muy  Im-  <letecte<l  iH-citsionui  leukjx ytts  arMJ 
p>n(K-iN-ci. 

Mambnuunu  UrathritU.     Memhraiums  un>thritis  is  rure. 

Of  liK-aM/,e<l  inHummatory  lesions  muy  Ih'  uu-nliontij  the  loft  cbancrt 
anil  liu>  primary  syphilitic  ton.  They  are  foun<l,  not  rarely,  just  uitliin 
the  meatus,  to  which  they  give  a  jK-i-uliar  sfiuure  ..p|M-urunce  in  iraiisvtrsf 
.section.  Tlie.sc  infections  may  Ih>  inoculated  ut  the  .sjime  time  a-^  a 
gonorrluea. 

▼ariolotu  putalat  have  lieen  met  with  in  the  urethra. 

Among  thechroni<'  inf!anunution.s  may  Im*  mentioned  polypoid  or  vvartr 
excrescences  (eondylomai),  due  to  dirt  or  irritating  discharges.  'l']\v\ 
are  (isually  found  at  the  meatus. 

Tuberculosis. TulK-rculosis  of  the  urethra  is  not  common,  i.ual 
fiK'i  of  caseous  nivrosis  are  sometimes  juet  with  in  the  prostatic  pcprticm, 
due  to  extension  from  the  i>ladder  and  prostata',  and  in  women,  ai  ihr 
anterior  portion,  in  cases  of  lupus  of  the  vulva.  We  have  sci  n  ila' 
urethra  studded  with  coarse  granular  tulM-nit's  along  its  wlinlc  li  ni.'tli, 
when-  the  kidneys  ami  urinary  tract  were  extensively  involvexl. 

Foreign  Bodies  and  Puasites.-  What  has  already  Iwen  ivmarkid 
when  dealing  with  the  hladih-r  applies  idso  to  the  urethru  Tin'  luo^t 
itn]>ortant  foreign  bodies  are  ralruli,  colloid  mu.inen,  and  jxirtrms  uf  lumr 
all  of  which  may  lea<l  to  ohstrucfion. 

( )f  the  parasites  may  In-  mentioned,  hy  way  of  curiosity,  the  I'l  nirillium 
ijlaticum,  the  Kii.slriiii(jylii.i  ijiija.i.  and  the  laria-  of  ccrlain  tlir~.  In 
females,  especially  in  young  children,  tliriad  irorinn  may  ri'ai  li  the 
urethra  from  the  anus,  and  .set  up  pruritus  and  marked  irritation. 


RETROGRESSIVE  METAMORPHOSES. 


Ulceration  may  take  place  from  the  action  of  cau.stics  or  fro 
inflictetl  during  parturition  or  instrumentation. 


;lllrl^■^ 


I      ': 


PROGRESSIVE  METAMORPHOSES. 

Ttimors.-  I'rimary  tumors  are  rare.  They  are  more  conitm 
than  in  women. 

In  females,  .small  excrescences  or  caruncles  are  sometimes  foiin 
hy  thickening  or  hyjjertrophy  of  the  normal  foldj  of  the  mm  i>-. 


Ill  IMI'll 


rall.siHl 


ISJVRIKS 


'Hf> 


Simple  ntratloa  ojtta,  iirisin)}  fh,iii  tli«-  |).tmrfJliral  Rlunds,  art'  <kih- 
sioiiiilly  met  with.  They  iimy  iil.so  sturt  from  (he  (owner's  i{lnnds. 
( >rth  hiiH  n-conh-tl  ii  cystadmoBU. 

nbnmt  palriM  huve  In-en  dtHM-riUMl. 

Carcinoma  is  riire.  It  may  orijfinate  in  the  CowiH-r's  >;hiinN.  or  from 
|H  riiinlhral  fistiihe,  wliich  have  Utome  lineii  with  squamous  epithelium. 

larcoma  is  still  rarf>r. 

As  a  rule,  um|iKiuint  >,  -vtlis  arise  hy  extension  from  the  wnitalia 
miiiMs  |>enis,  vagina,  vulva). 


nrJURiis. 

The  urethra  may  Ik-  injure.1  in  various  (lejrr«H-s  through  instrumenta- 
tion, or  parturition.     Falls  u|Hin  the  iH-riiu-um  nuiv  priMJuj-e  laearation 
Wh.ii  rupture  of  the  urethra  takes  pla<»"  ami  the  iiriue  eannot  escatn- 
.Atravasatioii  of  I'le  urine  .Kcurs  into  the  layers  of  the  iH-rineum  ami 


iiiHiiiriiiniil 
Mild  I  It'll  til 


iiliiiK  to  inflammalion,  anil.'ofien.  wiih-sprea.l  necro.si.s 


.-m 

■it 

i 

^^^Hil. 

■ 

M 

f 

a 

-1 

SECTION   VII. 
THE  REPKODIICTIVE  SYSTEM. 


CHAPTER    XXXVII. 

THE  MALE  SEXUAL  OUGAXS. 

THE  PENIS. 
OONOENITAL  ANOBIALIES. 


1  iiKsK  are  very  rare.     Complete  absence  of  the  penis,  doubling  of  tlie 
orjr,,,,,  an.l  partial  defecta  in  ti.e  <.,rpora  .avernosa  mav  Ik.  ,„enti,.ned 

A  ......^.enital  fiatuU  has  l,een  .le.s,rilKMl,  in  wl.i.l,  ^^dmt  ,„nn«-ted 

wi^,  the  pros  ate  opene,!  iijM.n  the  .iorsum  of  the  penis  or  at  tiie  .r|ans 

C ruvejlhier'  hRures  a  ease  in  whi<h  the  eja.uh.torv  duct  took  a  course 
MKl.IHMHienfiy  of  the  urethra  and  opened  on  the  jjlans 

S..inew-hat  more  common  than  absence  of  the  ,)enis  is  total  defect  or 
ul.n..r.nal  shortness  of  the  prepuce.  Hypoplasia  of  the  external  L-enitaha 
>s  rare  n.  men  otherwise  well  developetl,  but  is  more  frequent  h,  cr>-pt- 
onhi.is,  cretins,  idiots,  and  epileptics.  •* 

Hyperplasia  has  been  observe.!.  Bifurcation  of  the  penis  mav  simulate 
a  iUmUv  orjran.  A  curious  malformation  is  one  in  which  'the  organ 
reM-„,l,|...s  the  toiiRue  of  a  bell.  Atresia  and  phimosis  of  t!,e  prepuce 
an'  not  uncommon.    Plates  of  bone  have  also  In^n  note<l  in  (he  ^eiiis. 

OIROULATORT  DISTT7RBAN0ES. 

Passive  0onge8tion.-Passive  congestion  is  met  with  in  those  suffer- 

21\T  'vu"'  ''*''|!"'.  '"'*'*-'^  °'"  ""^^"-^  obstruction  in  the  systemic 
mtilation.  Ihe  condition  leads  to  enlargement  of  the  corpora  caver- 
:;' ,  -^  ''•"''"'  ^"^^  '-^  produce*!  by  the  rela.xation  of  the  supporting 
•n,.„.re  of  the  corpora  in  those  addicte,!  to  sexual  exc-ess.  'EssivS 
'Hi|:.-non  is  sorretimes  also  due  to  paraphimosis  or  other  causes  that 
e     ,,,  constriction  of  the  organ,  such  as  strings  tie,!  around  it  or  rings 

i    V  "„;,rb«j;"    Vh   '•"'-;"^"''""«^  conditions  are  oc-casionally  met  with 
.^""M,«  boys.     1  he  result  is  often  serious,  as  gangrene  may  ^t  in. 

'  Atlas,  Lfg.  39:  Taf.  2:  Fig.  .•}. 


II  si 


!      :| 


!1^ 


i  i . 


788 


THE  PENIS 


Kio.  208 


ill 


Gangrene.-  C^.anRreiie  may  also  be  due  to  embolism  of  the  dorsal 
arterv  »)r  to  thrombasis  in  the  corpora. 

Varicosity.— Varicositv  of  the  dorsal  veins  is  not  uncommon. 

Hemorrhage.-Owinn'to  the  loose  structure  of  the  corpora  an.  skin 
of  the  prepuce  and  penis,  effusions  of  blo«.i  readily  take  place.  1  lu.se 
mav  l.e  due  to  rupture  of  the  corpora  or  the  blo«ives.sels.  an.  ...ay 
attain  considerable  size  (hematoma).  This  acrident  may  occur  .luring 
coitus.     Dilatation  of  the  larger  lymph-channels  is  rare. 

nmJAOIATIONS. 

Inflammatory  processes  of  various  tj-pes  affect  the  penis,  llu-  ,Kn-ts 
attacked  ai.  the  skin,  prepuce,  glans,  and  -n^,j;-- ^Va^' 

tia,  and  ctvemitis.  As  a  rule, 
both  prepuce  ami  (jlans  are  af- 
fected together  (balanoposthitii). 
The  preputial  sac  is  parti,  i.larly 
liable  to  intliuniiiati.tii.  --iiice 
there  is  a  teiulency  to  a.iuimi- 
hition  of  smegma,  pus,  .ii.l,  and 
urinary  salts,  which  form  a 
suitable  culture  n.c.li.iii.  for 
many  germs.  Chemical  and 
mechanical  irritation,  iiowcver, 
also  play  a  part.  If  tl.c  swell- 
ing of  the  parts  Ik-  g.<at,  it 
mav  1h'  impossible  for  the  patifiit 
to  draw  the  prepu.v  forward 
(p<ir(iph!mo.iis).  I'assiv.-  con- 
gestion, ulceration,  ami  even 
gangn-ne  may  the  be  tin  result. 
Oatarrhal  Balanopostbitis,  — 
Simple  catarrh,  whi.li  leads 
merely  to  slight  riMld.niii);  of 
the  mucosa,. swelling  of  iln'  P"^ 
puce,  secretion,  an.l  il.  -<|iiiiina- 
tion  of  cells  is  a  trifliii-;  allVction. 
SuppuratiTe  Balanopoathitis.-More  important  is  supp.irati\c  l.aiano- 
posthitis,  such  as  often  .Kcurs  .luring  the  course  of  >!'>""•■•■  "-'"'i; 
phimosis.  Here  there  is  an  abu.ulant  purulent  sec-retion,  gn  .,t  r..Jnes 
Lnd  swelling,  together  with  shalL.w  erosions  due  t,.  ma.rnnon  and 
des.,uamation  of  the  epithelium.  The  pr.K-e.ss  s.....etMnc.  l.a.  s  » 
induration  of  the  affecte«l  parts  with  fibrosis,  ..n.  to  un.o,,  ,1  tl  t«o 
layers  of  mucous  membrane.     H..ti.  acute  an.l  cl.r..,i.c  tor::;    -.m^ 

the  cause  of  phimasis.  ,i  ,;    ..sner- 

BalanoposthitiB  Aapergillina.- A  mycotic  form-balanop..sii,  '<-  a^F 
gillina— has  been  met  with  in  diabetics. 


Paraphimo!*! 


:  penis  curved  nearly  at  a  riglit 
angle.     (Taylor) 


ai 


,IML 


SYPHILIS 


780 


tlic 


Membnnons  Balsnopoathitis. —  Membranous  inflaniination  is  due  to 
tlio  irritation  of  retainetl  setretion  or  to  wound  infection,  and  occurs 
also  in  the  infective  fevers,  diphtheria,  typhoid,  variola,  scarlatina,  and 
measles. 

Herpes  ProgeniUll».— Herpes  pro);enitalis  \mg\m  with  the  formation 
of  one  or  more  groups  of  small  vesicles  that  rupture  and  form  superficial 
erosions,  surrounded  hy  a  scanty,  whitish  border  of  epithelium.  From 
infection  larger  ulcers  may  result.  The  condition  is  possibly  neuro- 
tropiiic,  since  in  one  case  at  least  fibrosis  of  the  nerves  of  the  penis  was 
discovered. 

Cavernitis. — Cavernitis  is  either  acute  suppurative  or  chronic  productive 
in  liiaracter.  It  affects  the  corpora  in  whole  or  in  part.  Local  abscesses 
may  be  formed  which  perforate  into  the  urethra  or  a  diffuse  affection 
results,  with  fibrous  induration. 

Syphilis.— The  primary  lesion  of  syphilis  {"hard"  chancre)  is  by  far 

e  most  important  affe<;tion.  The  initial  sore  makes  its  appearance 
on  an  average  from  three  to  four  weeks  after  infection,  usually  upon  the 
prejjuce  near  the  raph«?  or  on  the  corona,  sometimes  within  the  urethra 
or  on  the  skin.  It  l>egins  as  a  minute  vesicle,  which  in  time  ruptures, 
leaving  a  su|)erficial  erosion  surrounded  by  a  reddish  border.  In  a 
short  time  the  ulcer  Ixvomes  indurated  and  hard,  s  that  when  pinched 
iK'tween  the  finger  and  thumb  it  feels  as  if  a  small  bit  of  parchment 
were  inserted  in  the  base.  The  amount  of  ulceration  and  inflammatorv 
reaction  is  often  trifling  and  the  lesion  is  frequently  overlooketl.  The 
sore  s  infi'ttive,  but  indolent  and  not  auto-inoculable. 

Microscopically,  the  part  is  infiltrated  for  the  most  part  with  small, 
round  cells,  but  occasional  epithelioid  elements  and  giant  cells  are  seen. 
The  round  cells  are  chiefly  aggregated  about  the  smaller  vessels,  the 
walls  of  'vhich  are  also  thickened  and  infiltrated.  The  endothelium  of 
the  capillaries  is  proliferated.  In  the  periphery  numerous  "Mast-zellen" 
may  lie  made  out.  The  connec-five  tissue  shows  a  progressing  fibrosis. 
The  su|H"rficial  epithelium  presents  a  loss  of  substance  that  extends 
more  or  less  deeply  into  the  underlying  strata. 

The  S|)ir<Klia'ta  pallida  has  now  been  repeatedly  found  in  the  syphilitic 
ehaii.re  (S<liaudinn,  Levaditi,  Buschke  and  Fischer,  Hurlat  a'nd  Vin- 
eeiiti,   usually   in    the   lymphatic  spaces  and   between    the  epithelial 

Sooner  or  later  the  infection  l>ecomes  systemic,  an  early  sign  of  which 
IS  hyptrplasia  of  the  inguinal  lymphatic  glands,  forming  what  is  known 
lusihe  "indolnit  bulm." 

In  the  se<'ond  stage  of  syphilis  small,  reddish,  moist  nodules  form  on 
the  iiuicosa  which  may  fuse  togt>ther,  and  from  the  effect  of  warmth  and 
iiioMure  form  the  broad  condyloma.  As  in  the  case  of  the  primary 
•   these  mav  ulcerate. 


ell 


\u  t.Ttiary  s^-philis.  small  ijtimmas  (syphilomata)  mav  lie  formed  in 
aii>  part  of  the  penis.  They  are  usually  deeplv  situated'and  mav  cause 
exti  ii-iv,.  ulceration.     When  they  heal,  dense  and  deforming  scars  may 


I 


res  1 1 


m 


790 


THE  PENIS 


I  i  «li: 


K! 


!  ; 


Ohuicroid. — As  contradistinjjuislicd  from  the  primary  syphilitic  sore 
or  "hanl"  chancre  we  liave  to  recognize  a  non-specific  sore  or  "mifl" 
chancre  (chancroid). 

This  develops  in  from  one  to  five  days  after  exposure,  in  the  form  of 
a  small  vesicle  or  pustule  which  rapidly  breaks  down  into  an  ulcer, 
having  a  sharply  define«l  or  undermined  e<lge  ami  an  angry  rcddisli- 
yellow  base  secreting  pus.  A  necrotic  membrane  Ls  often  forme<l  on  the 
surface. 

The  ulcer  is  usually  found  on  the  inner  surface  of  the  prepuce, 
especially  about  the  frenum,  and  on  the  glans.  It  differs  from  tin-  true 
syphilitic  sore  in  the  shorter  incubation  period,  the  more  rapid  ami 
severe  erosion,  to  a  certain  extent  in  its  ]M)sition,  and  on  the  fact  that 
it  is  auto-inoculable,  so  that  multiple  ulcers  are  frequently  observed. 
Secomlary  syphilidcs  do  not,  of  course,  <levelop.  A  certain  amount  of 
inflammatory  induration  may  he  prmluced,  but  this  is  rarely  to  Ik-  con- 
fused with  the  parchment-like  feel  «)f  the  syphilitic  sore,  which  may 
persist  long  after  the  ulcer  has  tlisappeared. 

Microscopically,  the  vessels  arc  dilated,  the  papillie  in  the  iieij.'lil)or- 
IiochI  are  proliferating,  an<l  the  base  and  edge  of  the  sore  are  niarkedlv 
infiltrated  with  inflammatory  pnKlucts.  The  exact  cause  of  the  soft 
chancre  is  not  certainly  known,  whether  it  is  due  to  the  ordinary  ])iis 
germs  or  to  a  sj)ecific  microorganism  acting  with  the  pus  germs.  It 
should  not  be  forgotten  that  a  mixe<l  infection  with  .syphilis  ami  soft 
chancre  (K-casionally  occurs.  Here  what  appears  to  be  an  ordinary  soft 
chancre,  eventually  becomes  indurated  and  is  followwl  by  the  ordinary 
secondary  manifestations  of  syphilis.  Soft  chancre  often  leads  to  swell- 
ing of  the  prepuce,  lym])hangitis  in  the  penis,  and  to  suppurative  intlam- 
mation  of  the  inguinal  glands  (rintlnit  bubo)  and  the  neighboring  tissues. 
In  |)ersons  of  low  vitality  it  may  become  phagedenic. 

Tuberculosis.-  Tulwrcidosis  is  rare  in  adults,  although  .hmous 
idceration  of  the  glans  is  recorded.  Micro.scopically,  it  dm's  not  ilitfer 
from  tuberculasis  elsewhere. 

Tiil)ercidous  infiltration  of  the  prepuce  is  commoner  and  is  mil  with 
in  children  as  a  result  of  the  ritual  practice  of  circumcision,  in  cases 
where  the  saliva  of  the  ojxTator  contained  tul)ercle  bacilli. 

Foreign  Bodies  and  Parasites.  -  Retained  smegma  and  diit  may 
iH'come  inspissjited  an.  infiltrated  with  lime  .salts,  .so  that  ii  concre- 
ment  is  formed.  I'himosis  (tight  prepuce)  is  a  strong  pniii^jiosiii)! 
cause  of  this  condition.  I'rinary  calculi  may  also  be  arresttd  l>y  .1 
tight  foreskin  atid  form  a  nidus  for  further  accretion  (pn'putial  •  :ili  ulus). 
Of  j)arasites  may  be  mentioned  bacttria,  ijea.its,  .tporrx  of  ftiinii.  ami 
myrrlidi  ihrviuh.  'I'he  most  important  form  is  the  smegma  lacilhi<, 
inasmuch  as,  morphologically  and  tinctorially,  it  re.sembles  c  1..  .ly  the 
tubercle  ha<  illus.  As  it  is  contained  in  most  urines,  it  will  be  -t .  11  how 
important  it  is  to  differentiate  l)etween  the  two  microorgam-i-  (viiie 
p.  757). 


liii 


CONDYLOMA 


791 


RITKOOSAI)!  ICITAMORPHOUS. 

Senile  ttroiihy  of  the  corpora  is  common.  As  the  prepuce  is  less 
affected,  it  appears  to  be  relatively  long.  Heeroiii  and  nlcention  may 
lead  to  deformity  of  the  organ.  In  some  cases,  supposed  to  be  due  to 
a  lack  of  resisting  power  on  the  part  of  the  individual,  ulceration  may  be 
rapid  and  destructive  (phacedena).  This  Ls  apt  to  occur  in  alcoholics, 
syphilitics,  diabetics,  and  in  tuberculoas  persons. 


PROOEI88IVI  MXTAMORPH08E8. 

Condyloma  Acuminata. — Papillomatous  outgrowths,  due,  for  the 
most  part,  to  inflammation  or  chronic  irritation,  are  not  uncommon  on 
the  glans  and  prepuce.  The  most  frequent  form  is  the  condyloma 
acuminata,  which  develops  characteristically  on  an  inflammatory  basis, 
r  ul  is  generally  due  to  an  irritating  discharge  (gonorrhoea)  or  retained 
st't  retion.  Phimasis  is  a  potent  predisposing  cause.  Condylomas  take 
(he  form  of  larger  or  smaller  multiple  papillary  excrescences  on  the 
plans  and  prepuce  not  unlike  a  cock's  comb.  From  the  pressure  of  a 
contracted  prepuce  the  growths  are  often  somewhat  flattened.  In 
aggravated  cases,  large  masses,  the  size  of  a  fist,  having  a  cauliflower 
appearance,  may  be  produced. 

Micrascopically,  the  outgrowths  consist  of  a  fibrous  vascular  core 
covered  with  stratified  squamous  epithelium.  The  fibrous  tissue  is 
richly  branchetl,  so  that  papillomas  are  produced,  although  this  arrange- 
ment is  somewhat  masked  by  the  proliferation  of  the  epithelial  covering. 
1  riflammatory  infiltration  is  generally  also  to  be  observed.  The  diagnosis 
between  condyloma  and  carcinoma  is  not  always  easy.  Condylomas 
are  usually  soft  and  freely  movable  upon  the  subjacent  tissues,  unless 
ulceration  has  taken  place.  In  this  case,  inflammatorv  induration  is 
apt  (o  impair  the  mobility.    Carcinoma  is  usually  hard  "and  infiltrated. 

Keratosis.— Another  form  of  hypertrophy  is  seen  in  the  heaping  up 
of  the  suj)erficial  epithelium  known  as  keratasis. 

Tumors.— OMcinoma.— Carcinoma  of  the  penis,  usually  epithelioma, 
forms,  according  to  Orth,  2.8  per  cent,  of  all  cancers,  and  is  met  with 
penerally  l)etween  the  ages  of  fif»y  and  seventy.  Phimosis,  as  it  con- 
duces to  the  retention  of  decomposing  secretion,  appears  to  he  an 
»u|X)rtant  predisposing  cause.  Epithelioma  mav  also  arise  in  the 
condylomas  just  described  and  in  keratosis.  The  growth  may  begin 
in  any  part,  but  usually  at  the  edge  of  the  prepuce,  the  sulcus,  and  the 
inn.'r  surface  of  the  prepuce.  It  begins  ordinarily  as  a  small  wart  that 
gradually  extends  over  the  surface  of  the  organ,  forming  a  papillomatous 
mas^  I  hat  may  erode  through  the  prepuce.  The  surface  is  miist,  the 
folds  ( (,ntam  a  foul,  whitish,  greasv  secretion.  Ulceration  occurs  in 
advanced  cases. 

Ml.  roscopically,  processes  of  squamous  epithelium  are  seen  to  extend 


1 11^ 


792 


THE  PENIS 


deeply  into  the  underlying  structures  from  the  superficial  strata,  often 
forming  branching  masses.  "Cell-nests"  of  keratohyaline  material  are 
often  present.  \\'hen  ulceration  takes  place  the  growth  becomes  very 
granular,  owing  to  infiltration  with  inflammatory  products.  E.xtension 
takes  place  through  the  lymphatic  system,  and  the  inguinal  glands  are 
first  and  most  strikingly  involvetl.  Much  rarer  is  medullary  carcinoma 
of  the  adenomatous  type.    Still  rarer  are  melanotic  forms. 

Melaootie  sarcoma  occurs  and  is  liable  to  be  confounded  with  carcinoma. 
Unpigmented  sarcoma  has  been  found  originating  in  the  corpora,  and  also 
intravascular  ondotheUoma.  Secondary  growths, carcinoma,  and  .sarcoma, 
usually  are  metastatic  or  arise  by  extension  from  neighboring  parts. 

nbroma,  lipoma,  and  neoroma  have  also  lieen  described.  Oysts  due 
to  obstruction  of  the  sebaceous  glands  are  fairly  common. 

Ilophaatiasif. — Somewhat  allied  to  tumor-formation  is  elephantiasis, 
which  chiefly  affects  the  prepuce,  either  alone  or  together  with  the  whole 
penis,  and  .sometimes  the  .scrotum.  The  extent  of  the  di.sea.se  may  \\e 
trifling  or  a  large  tumor  may  lie  produced.  One  is  described  that  w»%'Iuh1 
more  than  20  kilos.  The  growth  is  easily  distinguished  from  elepiiaiitiasi.s 
of  the  scrotum  in  that  the  opening  of  the  urethra  is  at  the  base  of  the 
tumor. 

Micro.scopically,  the  ma.ss  consists  chiefly  of  fibrous  ti.ssue,  containing 
in  the  superficial  layers  many  "Mast-zellen."  In  the  preputial  j)ortion 
buiulles  of  unstriped  mu.scle  have  l)een  noted.  There  may  he  diapcdesis 
of  leukocytes  al)<>ut  the  vessels.  The  superficial  pupilhc  of  the  skin  are 
often  unulteretl,  but  may  show  signs  of  overijrowth,  and  even  may  form 
papillomatous  warts. 


I  ; 


i  ! 


INJURIES. 

The  most  striking  injury  is  the  so-called  luxation  of  the  jienis,  in  wliich 
the  main  substance  of  the  organ  is  .separate«l  from  the  prepmc  and 
overlying  .skin  and  is  found  l)eneath  the  skin  of  the  trunk,  the  oriirinal 
covering  hanging  like  an  empty  .sausage  skin.  Fracture  of  the  ihmiIs, 
usually  of  the  corpora  cavernosa,  occurs  from  striking  the  or<;aii  when 
in  an  erect  condition  against  some  hard  sukstance.  It  is  soinctimes 
cau.sed  by  intentional  violence,  as  in  the  dangerous  practicr  auioii)! 
the  lower  orders  of  "breaking  the  cord"  in  chordee.  Injuries  al-n  'MCiir 
during  attempts  at  coitus,  from  falls,  tying  strings  around  the  oi;;;in,  itr 
inserting  foreign  substances  (catheters,  etc.). 


THE  PROSTATE. 


Ji 


MALTORMATIOira. 

These  are  not  common.     Complete abiance  of  the  prostate  i~    I't  with 
in  association  with  other  grave  defects  of  the  genito-urinary  nMuaratus. 


TVBERCVWSIS 


793 


Unilateral  apluift  and  hypoplMia  is  ext-eptionally  observed  in  unilateral 
hv|Mipla.sia  of  the  sexual  organs.  Abamnt  protUtei  have  been  found. 
I'liiluteral  or  complete  defect  of  the  eoUicnhu  leinintUi,  and  dilatatUm 
of  the  imtatie  linus  have  been  desc-ril)ed.  Oytti  are  sometimes  found 
along  the  course  of  the  Miillerian  duct,  due  to  imperfect  closure  of  the 


same. 


OIROTJLATORT  DUTURBANOBS. 


H]rp6reinia  is  a  common  but  comparatively  unimportant  condition. 
Ue|)eatetl  or  continued  congestion  has  been  by  .some  regarded  as  a  cause 
of  hypertrophy  of  the  organ.  The  prastatic  plexus  is  o'ten  found  dilated, 
and  thrmnbotia  and  phlebolith  formation  are  comparatively  common. 

XNTLAMMATIOire. 


Prostatitis. — Oaturhal  Prostatitii. — Simple  catarrhal  prostatitis  is 
(lt'S(Til>e<l,  in  which  there  is  an  accumulation  of  inflammatory  products 
and  (lesquamate<l  cells  within  the  tubules,  together  with  hyperemia  and 
(iilema  of  the  supporting  structure.  I^ittle  is  known,  however,  almut 
tliis  iitfection. 

Sappontive  Prostatitis. —  More  important  is  suppurative  prostatitis, 
in  which  the  glands  are  filled  with  pus  and  abscesses  are  pro<luced. 
This  is  not  an  infrequent  sequel  of  goiiorrhiMi,  but  is  also  a  result  of 
sfvtTt'  cystitis  a  ■■  injuries  to  the  urethra.  The  pnx'ess  in  the  first 
instance  begins  in  the  gland-tul)es  but  s(M)n  spreads  to  the  iieighlwring 
tissues  where  several  foci  may  coalesce  to  form  abscesses.  The  abs<'esses 
are  inultipie  and  are  scatteretl  irregularly  through  the  gland,  which  may 
!«■  almost  entirely  destroye<l.  They  may  perforate  into  the  bladder, 
iirfllin,  scrotum,  j)erineuni,  rectum,  or  through  the  alKlominal  wall.  A 
par'.prottatitis  may  lead  to  general  peritonitis.  Should  the  abscesses 
Ix'al.  fibroid  scars  are  the  result  or  {H'rluips  calcification.  Suppurative 
I)r()^talitis  is,  rarely,  metastatic  in  septicemia. 

Chronic  Prostatitis. — In  chronic  prostatitis,  prostatorrha'a  may  be  a 
cliiff  symptom,  and  Uokitansky  has  <les(Til)etl  a  condition  in  which  the 
sfcrciion  was  (|uite  milky  from  the  presence  of  lecithin.  The  condi- 
tion may  l>e  simple  or  suppurative.  The  organ  is  swollen  and  of  a  dirty 
lirciwnisli  color.  The  gland-tubules  are  dilated  and  may  coalesce, 
forming;  <'ysts. 

Tuberculosis. — Tul)enulasis  takes  the  form  of  multiple  caseous 
nciiliilcs  ill  one  or,  more  fre(|i»"iitly,  in  both  lobes,  which  may  lead  to 
(■i'M--i(lcral)le  enlargement  of  tbe  gland.  In  advanced  cases  the  whole 
pio-iatf  may  be  destroyed.  The  caseous  foci  sometimes  soften,  leading 
to  the  formation  of  abscesses  which  may  burst  into  the  urinary  passages 
oi'  into  the  rectum.  As  with  suppurative  inflammation,  the  process 
l>i  i;iii>  ill  the  gland-tubules,  both  in  tuberculasis  of  urogenital  and  hema- 
tof.'!  iiic  origin.  As  a  rule,  tulierculosis  is  part  of  an  extensive  urogenital 
inl' '  tion.     I'rimary  tuberculosis  of  the  organ  is  decidedly  rare. 


m 


The  prostate 


Toraign  Bodies.    Oonerationi,  cdrpora  amvlnrea,  are  found  cominonly 
ill  the  prostate,  es[M><-iully  of  old  [N-ople.     On  ciittiitg  into  the  ^luiid 


Kio.  :0B 


i.       ■  I 


I  ! 
I  i 

i  i 


..^ 


Cll(*<iUft  luberrul't!*i-i  uf  the  prontalp.     I,eit»  nbj.  \t>.  3.  witlxnil  nctilar.     The  npi-rotif  arp.i  i-  -If  wn 
to  tlieriitlit.  with  Kiant-cellH  ttiwunl  theiiiaricin      (Fnini  the  culln'ti  in  uf  Dr.  A.  (;.  NirtiMtN.t 


;|jf^!^*V 


Klii.  -MO 


.■X, 


Corpcirft  amylacea  in  theprofltate.    Leiti  ubj.  No,  3.     (From  the  eoUectiun  uf  L)r  A         >:-hoUft.) 


UYPKRTROPllY 


705 


till  V  iippear  like  gruins  i)f  l)luck  popper,  but  may  l>e  larjje  and  p"''*y. 
resciiililiiij;  jjrape-seeils.  The  latter  peculiarity  is  ilue  to  infiltration  with 
salt>.  'I'lie  corpora  are  found  ( hicfly  in  the  nei^hlmrhood  of  the  colliculus 
SMiiiiniilis,  hut  also  throuf^hout  the  gland. 

Mi(Tus<opi<'ally,  the  smaller  one>  are  oval  or  rounded,  more  rarely 
tri.iii>riilar,  showinj;  c<)nccntric  laminati(m,);iving  them  a  general  resemb- 
laiiK'  to  starch  granules,  wlifne  their  name.  In  many  cases  two  or 
tlircf  cells  in  pnx-css  of  fusion  and  disintegration  may  often  l)e  -seen 
wiili  Iwginning  hyaline  transfornuition,  showing  that  the  j)rocess  ha.s  its 
orij;iii  in  catiirrh  and  degern'ration  of  the  lining  epithelium.  The  larger 
>;ratMilcs  show  hut  little  lamination,  and  are  merely  amorphous  masses 
of  lirownish  mineral  matter.  Fosner  has  suggeste*]  that  two  bodies  are 
present  in  the  corjKmi,  a  hyaline,  albuminous  substance  and  lecithin. 
The  condition  is  of  little  pathological  significance. 

Parasites. — Echinocnrcm  ry»tii  have  l)een  found  in  the  prostate. 


RETROGRADE  METAMORPHOSES. 

g-mple  atrophy  of  the  gland  <x-curs  in  from  20  to  .30  per  cent,  of  old 
men.  It  is,  however,  (Hcasionally  met  with  in  young  people,  as  a  result 
of  wasting  disease,  cachexia,  castration,  the  impotence  of  the  tuliercu- 
loiis,  tlic  pressure  of  retaine<l  urine,  pent-up  secretion,  and  concretions. 
Ill  the  form  due  to  constitutional  causes,  the  glandular  portion  is  the 
one  eiiiefly  affected,  while  in  that  <lue  t()  concrements  the  stroma 
suffers  most.  In  the  latter  case,  however,  the  epithelial  cells  may  lie 
tiaiteiied  and  fattily  degenerated  from  pressure. 

Pigmentation  of  the  epithelial  cells  is  found  in  advanced  age  and  in 
tlie  cachexias. 

Hyaline  degeneration  of  the  muscle  bundles  and  the  glandular  epithe- 
liiiin  is  met  witii.  Patty  degeneration  is  also  met  with.  The  so-called 
amyloid  bodies,  abf.ve-mentioned,  have  nothing  to  do  with  amyloid 
(iisease. 


PROGRESSIVE  BIETAMORPHOSES. 

Hypertrophy.— HyjMTtrophy  of  the  prostate  takes  two  forms,  the 
nio^t  ( oimnon  In-ing  perhaps  a  condition  of  multiple  fibromyoma,  analo- 
C'liiN  lo  the  fibroids  of  the  uterus,  and  a  more  diffii.se  glandular  or  adeno- 
iiiaioiis  overgrowth.  In  both  varieties  the  gland  is  enlarged,  either  as 
a  whcili-  or  ill  part,  and  may  attain  the  size  of  the  fi.st.  The  outer  surface 
i--  iiMially  sni(M)th,  but  may  he  rough  aixl  warty.  On  section,  in  the 
fiKroMi\oiiiatous  form,  the  gland  is  studdeti  with  "nmlules  varying  in  size 
from  that  of  a  pin-head  tc  a  large  l>ean.  which  are  firm,  projecting,  and 
iiion  or  less  fasciculateil.  The.s<'  nodules  are  of  a  grayish  or  grayish- 
while  (oior.  In  adenomatous  enlargement  the  tissue  is  softer  and  some- 
what ^[»>ngy,  of  a  yellowish-red  color.  There  may  be  cvstic  condition 
of  iIh  iriands. 


TBS 


THE  PROSTATE 


i-; 


'mi 


The  enliirgrnient  mnyniTfct  one  or  iMitli  Miiles,  hut  of  mo  it  iin|Mirnin(f 
is  t>nlar(^tiient  of  dii*  .stMnllftI  "iijiililU*"  loU',  wliii-h  may  form  u  hmail 
se!4.sile  mass  or.n^iiii.a  |M'(liiii<iilat«>il  growth  projfctiii);  intitlie  iintlini 
ami  evrn  the  hliuliler.  This  roiiililioii  is  of  great  pnicticul  inoiiicnt  in 
that  it  leads  to  olisl ruction  to  the  tnt'  discharge  of  urine  with  nil  lis 
effe<'ts  on  tlie  lilatlth'r,  ureters,  and  kidneys.  Kxeeptionally,  oKstnn  lion 
•hies  not  «¥fur  in  the  prostatic  urethra,  which,  on  the  contrary,  is  nifher 
<liluted,  presumaltly  from  the  effects  of  the  pressun*  of  the  rcliiiiu'd 
urine.  In  cases  of  hxijj  standing,  cystitis  is  usually  present  with  liy|HT- 
tmphy  and  dilatation  of  the  bhulder.  Hydronepiirosis  ami  .septic  iivi'iv 
nephritis  are  not  infrei|uent  complications.  Where  catheterizatitur  has 
l)een  praetiseil,  false  imssages  and  al»scess«'s  may  Ih'  formed  in  the 
prostate, or,  again,  ci«alrices.  The  ejaoulatory  <luct  is  fretjuently  found 
olistriK'ted. 

Fiu.  211 


HB^^NT 

k 

iH 

\^* 

M%. 

nm 

■Il3-1^ 

^^4 

wj 

mm 

bh^ 

*p^ 

r                    ■* 

MyoiiiiiliiUH  p)ilarK«>ni**»t  <tf  tin-  |in>sl.-itc,  oli^tnictitm  to  the  *nitft" .  •  nf  urine  f  ".  t  liv  ilrf 
ovPrKPiwth  (if  tlip  (*n-calle<i  nii<Mt»*  lt»l»p;  coiii^tM-utive  liyjiertniphy  of  the  walU  i>l  ''  ■  '■i;iililfr, 
'Frnm  the  Pattiolniiiral  MtHeuiii  "f  ^leiJill  rni\or^ity.) 

HyjH'rtrophy  of  the  prostate  is  nilhercoiiinioii  incdd  men.  'I'l  reason 
for  this  is  not  (juile  clear.  As  an  expression  of  a  senile  chanp'  <■•■'■  would 
expect  atrophy  rather  than  liyjMTtrophy.  We  know,  howcvi  r.  iliat  the 
process  begins  in  the  neighhorluMMl  of  the  glandular  elcnu  .its,  and 
eonse<)Ueiitly  .some  observers  have  insisted  upon  the  action  <>f  p  ■  ixistmg 
irritation,  such  as  passive  congestion  and  chronic  inflamumtic  i,  us  the 


C  ARC  I  SOMA 


797 


ex(  itinjj  causes.  (■oi)orrli<ru  is  inciitioiKHl  in  this  connection.  Prob- 
alilv  tile  myonintous  form,  if  not  the  luienoinatous  enlHr^tne'.t,  is 
u  true  tumor,  und  us  such  (le|M-n<ls  u|Min  the  same  factors  that  are  at 
work  in  the  priMluction  of  tumors  elsewhere,  whatever  t\\vy  mav  lie. 

Micro.>M'o|)i<'allv,  in  the  first  variety,  the  iKNhilcs  are  com|M>.se<i  larf^ly 
iif  tnus<uhir  tissue  or  mi.\e«l  fihrous  tissne  ami  nuiM-je  ari-anKe<l  in  inter- 
im iri);  hiuuiies,  exactly  as  in  uterine  fiKroiils.  In  the  adenomatous 
t\j«'  the  ({lands  an-  apparently  inin-ased  in  nntnU-r,  dilated  and  .saccu- 
lalttl,  while  the  filirouuiM-ular  stroma  is  corrcs|NindinKly  diminished. 
'I'lif  s^retinj; cells  are  often  Huttenetl  or  dcsi|uanialed,  and  may  undergo 
various  forms  of  disintegration  and  hyaline  <hanp>. 


•C«*t*.<e»' 


^...laiird  "  ikIp 


ii™..nm      i.f  the  i>r..i.lute  kIuihI      a,,   iimyl.iid  l.,,.Iv  run  lie  „;■„  al   the  ui r 

hkI,!  I^in.l  fiUe  I.f  the  m-ti  .11.      Wirirkel  i.l.j.  N...  3.  willi..nl  ■,.ul,ir      (fr 
llr    A    (i    Nicli.ilN.) 


Krc.m  llif  ci>lli'cti.>n  iif 


Tumors.— Of  malipnant  growths  carcinoma  and  sarcoma  should  be 

iniMiiioned. 

Carcinoma.  Primary  carcinoma  is  not  uncommon,  and  orijjinates, 
in  iiimiy  cases  at  least,  in  a  pn-viously  existing;  adenonijitiMis  enlarge^ 
intiit.  One  case  has  come  under  our  ohscrvatitin  in  whicli  there  were 
sviiiptciins  of  urinary  olistruction  due  to  enlarjred  prostate  for  eleven 
vear>  iK'fore  the  development  of  adeniKiircinoma.  <'arciiH)ma  of  the 
pro.tiiie  takes  the  form  of  a  rather  soft,  mwhihir  tiitnor  in  one  or  hutlt 
lolx-  n!  the  prostate,  which  rapidly  infiltrates  the  capsnle  of  the  ^land, 
the  Miiic.,,a  at  the  neck  of  the  hiad.ler,  ami  the  prostatij-  urethra.  It 
may  in.loed,  extend  to  the  [K-nis  and  rectum.  Occasionallv  it  assumes 
a  pajiillumatous  appearance. 


7«^ 


THE  PROSTATE 


MKT«»«'opi«-ally,  lh«'  growth  is  <-«>in|MiH«s|  of  ( yliiuiriial  or  (Hilyli.ilml 
(«lli,  arraiiKi^  morf  or  \vsh  in  ^lumiiiliir  fashion  «ir  in  mA'u\  IihikIs  or 
masses.    The  stniiim  is  iioniml  or  infiltniliil  with  roiiiHi  tflU.    ('«<« 

KTiir  in  which  thi'  gniwth  reseinhK-s  snnoiim  «losrl_v  until  inorj- 1 mfiil 
study  how.i  it  to  In*  ctminoinatous  (Ailumi).  M«-tastusfs  an-  iiiManili- 
car     ;  .  a  nile,  and  iKfiir  lali-.     'Hm-  n-tro|N-ril<>nfal  l\m|»h-);laiMls  utMl, 

vni/.i  iially,  th»>  inguinal  glands  a  tie  I  |M'riloni-inn  an'  tht-  purls  allaiktNl. 
(  anitu,  na  is  found  at  all  ajc^s,  hut  naturally  nnich  mori-  cwnninnlv  in 
■    I  piopie. 


i    J 


Cufx-inofiia  c'  th- pnintitte.     Z«*i-N  Dbj,  III>,  ••ciiliir  No.  1.     (t'niiu   tli< 

ijf  McCill  riLi\>-r>ity.) 


i'»tii..i.H,i,  ,1  r.iii.M 


Sareoma.-  Sanoinas  are  usually  r((H»</-<r//(Y/ or  .vy)/;/<//(-(  lul.  \i  iiit 
10  per  cent.  J)f  all  nialii;iiaiit  tuniors  of  the  pru^iatc,  aci-oi  iiiii;  i"  '  'rili, 
tK-cur  in  ehihlluxMl.     'Hie  lar;;t'  tnajiirity  of  these  n  ^-  sarconia^. 

Secondary  tumors  of  metastatic  ori>;in  are  ran-,  ^iore  fn.i mit  art- 
those  due  to  exteiuion  from  tiie  bladder  or  nt'ttiin 


THE  TESTES  AND  EPIOIDTMSS. 


OONOEMITAL  ANOMALIES 


These  con.sist  in  de^-ct^  (»f  development  and    irrejjiiiarii        u  tlie 
priK-ess  jjf  des«'ent.     An  increase  in   tlie  nuriilM-r  nf  tiie  ii  po^f- 

orcbidifm — is  (K-casio!iallv  mt-t  with.     I'suallv  two  on  one  side        icmiihI. 


ORCHITIS  AND  EPIDIDYMITIS  f^ 

Oiw  riwe  in  on  m'i»r«l'  wb»Tp  U><h  Ifstes  wiir  fiiswl  into  oni>^  -lyiMnUd- 
iia;  ••oinpk't*'  aWnrt-  of  the  tMteH  anonUiUsm— i^  nior*  utual.  The 
al>s<'iu-e  may  l>r  unilateral.  In  sm-h  i-ases,  as  a  rule,  there  is  (iefert  of 
the  epuiidyniis  ami  va.s  (lefereii.<*  on  the  jtaine  nide.  Incomplete  develop- 
ment—liypopta«l»- Is  not  unoocnnion.  The  condition  is  hilutenil  or 
unilateral,  ami  is  due  usually  to  retardation  in  tlw  descrnt  of  the  orpin. 
Mi(n«eopi<-ally,  a  retained  testi<l"  shows  a  n-lative  increa.se  in  the 
amount  of  the  stroma,  while  the  jfland-tiil)es  an'  atrophi<-  «ir  Iwdly  de- 
viloped.  Hypoplasia  is  exceptionally  met  with  in  children  and  at  the 
ap"  <if  pul)erty.  In  such  cas«'s  the  testes  may  have  descended  pn>perly 
but  have  lafg(e<l  liehin<l  in  the  ({emeral  jfrow  th  of  the  sexual  orj^aas. 

Ai)nonnaI  p«>sition  of  the  testis  Mtopia)  is  not  uncommon.  The 
testis  is  cither  nftaine<l  at  some  jwint  in  the  canal  or  >,  actually  dishx-ated 
out  of  its  natural  pa.ssa«e.  The  testis  may  lie  retainetl  in  the  al.domen 
opiHwite  the  lumUr  vertehra-,  i:i  the  injjuinal  canal,  or  at  the  fold  lie- 
tween  the  scrotum  ami  lhi>;h.  In  cli.slocation,  djntopia,  the  testis  is 
luilside  its  normal  surrcmimlin^'s,  and  is  found  in   the  idMloniinal  wall 

1  11  fHHich  leacliuK  from  rhc  in|;uinal  canal,  at  ihe  fei    >r. -^rotal  fold. 

he  testis  may  also,  as  in  u    use  once  >  i.Mnwl  l>y  us,  l»-  found  in  an 
ariilicittl  sac  on  the  .iiner       c  of  the  thijih  (hainla  crort^  ii  taitieulatii ) 
A  ::n-at  rarity  is  the  presen.  ■•  of  IkK!    testes  in  the  same  half  of  the 

'..turn.     I)   -itopia    is    usually  unilal<     I,  but   nmy    \w    liiliiteral.     .\ 
■  i    I.Kated  testis  is  particularly  liable  to  disease,  and  generally  shews 
;iir..|>liy,  fatty  degeiierution  of  the  s«'cr€'tiim  «fll"<.  "'"1  fihroi  !  imiiiriitioi  . 
l!      ly  ids«)  \w  infarcted  ami  iiiHam«Ml.     Dystopia  is  not  always  congenit 
1)111  iim\  lie  due  to  trainna,  as  sometimes "liap|H'ns  in  pninasts. 

All  inlerestinj;  anomaly  is  the  presence  of  abeirmnt  lupnreMl  tiarae 
lMiw»t'n  the  testis  and  the  head  of  the  epididymis. 


OIRCULATORT  DU"  URBANOES. 

Anemit  of  the  testis  is  usually  due  to  pressure,  -  in  liydroc«  ml  hcma- 
tiKclt.  Ant'inii  and  heiiiorrhajric  infarcts  an  als<l^  m-ca  lallv  met 
witli.  Necroiu  is  apt  to  siiixrvcnc  ;n  such  ,iis»-.  an  whei  hichitis  or 
tlir.imiM.sis  of  tl;  i>ampiiiif..rni  plexus  is  prt-seni  hemorrh..ge  into  the 
t<'.Mi>  isgeneralK  .i  n-siili  ,  ,•  traiinmti  mi,  but  i    i'      met  w  th  h,  leukemia. 


mil, 
A 


UrrLAMMATTON 

Orcmtii  anu  Epididymitis.- Intlai     u,   ..n  of  the  testis    orchitis— 

'he  epididymis-  epididymitis     ii.,,v  .Kmr  indepciuleiitlv  ot  each 

.lit  are  usually  a.ssociat.  I'he  t  .ui<ii  vaginalis,  va.s "defen«n.s. 

^lH•l•lnaiic  cord  are  freiiuenn     !■!    .iv«.i  as  well. 

11  rule,  rhe  ccmdition  is  i.nnijfit  a  mhu  by  ii,ff<'tion  through  flip 


'  Cruveilhier,  'liiiitc      anu 


i    301. 


Nl 


800 


THE  TESTES  AXD  EPIDIDYMES 


spermatic  ducts  (gonorrhoeal)  or  from  continuity  with  the  tunica  and 
spermatic  vessels.  Trauma  is  the  next  most  important  cause.  Heinuto- 
penic  infection  is  not  so  vommon.  In  cases  where  the  infection  has 
spread  from  the  spermatic  ducts,  the  epiditlymis  is  usually  first  involved. 
The  character  of  the  inflammation  varies  somewhat  in  the  case  of  the 
two  organs.  In  the  testicle  the  inflammation  is  at  first  interstitial,  while 
in  the  epididymis  it  is  more  likely  to  be  catarrhal  and  desquamative. 
Orchitis  is  often  met  with  in  ponorrhiea,  less  frequently  in  typlioid, 
mumps,  and  variola.  It  has  also  l»een  observed  after  abdoniiiial 
operations.  The  gonorrhceal  form  licgins  usually  as  a  catarrhal  uiid 
in*!?Tstitial  epididymitis  which  fretjuently  extends  to  the  testis.  The 
affection,  as  a  rule,  arises  from  the  .second  to  the  sixth  week  of  the 
urethritis. 

Macroscopically,  the  epidi<lymis  is  enlarged  and  its  coasistciicy 
increasetl.  On  .section  it  is  reddened,  the  tubules  are  frequently  <lilat«i 
and  filled  with  grayish-yellow  material,  composed  of  pus,  mucus,  and 
desquamated  epithelium'.  The  testis  may  show  merely  re<ldeniiii;  and 
cederaa,  but  may  l)e  actually  inflamed.  Here  the  inflammation  tends 
to  l)e  interstitial,  and  abscess-formation  is  more  common  than  in  the 
epididymis. 

Microscopically,  in  the  epididymis,  the  vessels  are  congested,  and 
the  epithelial  lining  of  the  tubules  is,  in  part,  convertetl  into  gobltt-cells 
secreting  mucus.  The  connective  tissue,  the  walls  of  the  tubules,  and 
the  epithelium  are  all  infiltrated  with  inflammatory  pHxlucts.  Tiie 
looser  portions  are  a-dematous.  If  the  pnx-ess  last  for  a  sufficiently 
long  time,  fibroid  induration  sets  in,  which  may  lead  to  obstnution  and 
cystic  dilatation  of  the  tubules. 

'  In  suppurative  oix-hitis  the  organ  is  switUcn  and  its  capstde  tense. 
On  section,  it  is  of  a  yellow  color,  pulpy,  and  ^edematous,  the  liilmies 
showing  as  yellowish-white  streaks.  Large  or  snuiUer  abscesse,  are 
oficn  found.'  Microscopically,  the  tubules  are  distended  with  pus  cells 
and  the  interstitial  stroma  is  either  diffusely  infiltratetl  or  preseni-  foci 
of  suppuration.     In  chronic  cases  fibrosis  may  result. 

Chronic  Fibroid  Orchitis. — Chronic  fibroid  orchitis  may,  as  Ii:h  jnst 
been  remarketl,  terminate  a  simple  or  suppurative  inflannnatii)ii.  Imt  is 
most  strikingly  found  in  syphilis. 

Tubercnlo^. — ^Tul)erculous  orchitis  and  epididymitis  are  fairly 
frequent.  The  affe<-tion  is  rarely  primary,  but  is  usuallv  a-^K  iated 
with  tul)erculosis  of  the  seminal  vesicles,  vasa  deferentia,  initiate, 
bladder,  and  ureters.  In  adults  the  pro<'ess  generally  begin-  in  llie 
epididymis  and  involves  the  testis  secondarily.  In  chihln-n  iiclnic  the 
age  of'pul)erty  the  reverse  is  the  case.  The  infet-tion  is  cither  h mato- 
genic  or  frot'n  extension  along  the  viw  deferens.  Infe<fi<)ii  h'W  ilie 
urethra  is  rare.  Nakaiai'  has  shown  recently  that  tul«'nle  lia.  Hi  may 
be  foun«l  in  the  normal  testicle  and  epididymis  of  a  tulienuloi^    .isDn. 

It  is  the  rule  for  one  or  more  large,  ca.seous  foci  to  l)c  fmn 


with 


■  Zicgler'a  Deitriige,  24: 1808:327. 


^l;l 


Mi-I 


SYPHILIS 


801 


siihsidiary  smaller  tul)ercles,  but  occasionally  there  are  numerous  foci 
of  alxiut  equal  size.  When  the  epididymis  is  involved  it  is  converted 
into  a  caseous  mass,  often  Iwunded  by  fibrous  tissue.  Here  the  process 
l)e>;iiis  in  the  walls  of  the  tubules  in  the  globus  major.  Next  to  the  epi- 
di<lynii.s,  the  corpus  Highmori  is  the  most  seriously  affected,  being 
either  filled  with  small,  caseous  nodules  or  totally  destroyed.  In  time 
tlif  infec-tion  spreads  to  the  testicle,  which  contains  a  few  small,  gray 
or  yellowish  white  tuliercles.  These  start  in  the  tubules  or,  occasion- 
ally, in  the  interstitial  tissue.  Inflammatory  infiltration  takes  place 
with  catarrh  and  proliferation  of  the  tubular  ejpithelium,  and  the  process 

Fio.  214 


Tuhcrrul"!-!"  iif  the  eiiiilidymi*.     Zeiss  i>bj.  DI),  ncular  Ni>.  I. 
Lalxiratiiry  of  McUill  Iniversiiy.) 


(From  the  Pathulocical 


Cra.liially  spreads  along  the  lymphatics  and  tubules.  Caseation  rapidiv 
.sii|Hr\ ('Ill's  and  giant  cells  are  numerous.  Later,  the  testis  is  filled  with 
larjrc  cascDus  or  caseofibroid  masses  tending  to  coalesce.  The  disease 
mav  trraduully  extend  to  the  tunica  propria  and  tunica  comnnmis,  and 
hiially  to  the  skin.  \Mien  softening  txrurs  fistulte  mav  be  formed. 
biinyi.i,!  graimlations  may  appear  externally.  Fibrosis  i*s  never  suffi- 
ciciii  to  overbalance  the  destructive  process. 

Syphilis.— Syphilis  is  not  uncommonly  found  in  the  testicle  in  the 
later  Maf;es  of  the  disease.  As  a  rule,  the  process  l)egins  in  the  testis 
an.l  priads  thence  tt)  the  epididymis.  Two  forms  are  met  with,  a 
diffiis,  lihroid  induration  jiJid  gumma. 

In  tin-  first  type  the  testis  t)n  section  presents  delicate,  pearly  white 
iwii.i  of  connective  tissue,  not  infreipiently  extending  from  the  rete  to 
thf  !.  !  ica  albuginea.    These  are  pathognomonic  of  syphilis.    Micro- 


802 


THE  TESTES 


scopic'iiUy,  the  pnK-e.ss  is  .-i-en  to  Ik*  priiimrily  uii  iiiterstitiul  dim-.  Ilic 
intertiihiilar  .stniina  f«)iituiniiijj  ii  few  leukcK-ytes  uiul  lieiiij;  >;rriiily 
thickene<l,  while  tlie  tiihules  iiri-  iilniphie  and  hyaline.  The  arteries  are 
also  thickened.  Federniaini'  has  |M)inted  out  as  a  further  diajrnnstic 
{>oint  that  in  syphilis  the  elastic  tissue  of  the  testis  is  pn-served,  wliile 
in  tulHTculosis  it  disap|)ears  even  l)efore  caseati<»n  ha.s  set  in. 


f  [ 


i   '1 

■              ■       ; 

• 

■     1 
1 

Hrulril  T..v|>liili«  "f  llif  Irsli".  I.eili  i>l>i.  No.  ■\.  »ilhiiiil  ciiiilar.  Tlii'rc  i-  :i  muk.  I  "ipr- 
Krnwth  «»f  roniierlive  ti-ifup.  Miuiy  i»f  llif  tiilmle'.  Iium-  tli^tnpiieiirt^l  eiilirely.  S.^mc  :tr.'  reiT*^ 
r>4>hipi)  iinTpIy  hy  rinR!-  nf  nurlpi,  Thoi^p  !.till  Pxi^titiK  iire  (■4»miirp»!M'il  anil  atTupinr  1  i.uii  ^Ut 
cille-tinii  iif  l>r    A.  C.  Ni.ti..ll-..> 

In  the  uninniatous  form  the  testicle  contains  firm  M<xlulfs  cuilnM'd  in 
Hhrous  tissue.  .\s  a  rule,  only  one  orjjaii  is  affwted.  In  iiimii\  la^cs 
the  tmiica  albuninea  lu'«'omes  involved  so  that  a  serous  or  scrcililiiiiiiiii< 
exudation  is  jmxlucjHl,  which  may  leail  to  thickening  and  inllii^iim  "f 
the  memhrancs.  ( )c<-a  ionally,  the  skin  is  involvi-d  iiiui  jriiiniiiy  fi»i 
muv  discharp'  externa. i.-.  Funj;oi(l  excrescences  about  llu  -iiiii-t- 
(K'cur,  as  in  tuhen'idosis,  l>iU  an-  rare. 

Lepra.  I/cprosv  o«-<'iirs  in  tin-  testis  and  cpididyniis  in  tin-  '"nii  of 
pninulomas,  leailinj;  to  necrosis.  ShouM  healinj;  take  place  li  r  lirpiii 
r«'mains  permanently  atrophic. 

Glanders.  In  the  Imman  subject  j;landers  ran'ly  affecl>  li  > 
In  >;uinea-pi>:s,  however,  thai  have  Ikhmi  inject»^l  intra|»critiini 
the  H.  mallei,  the  testes  and  scroluin  In-c-ome  acutely  aiin  ' 
intillrated  with  infiuinmatory  prmiucts  (.Strauss'  piicuonicn" 
fact  is  taken  advantage  of  in  the  laboratory  dia>;nosis  of  liu  . 

'  Inuiii;.  DiKK.,  (lottiiigi'ii,  IIKHI. 


Ir^tulf. 
,ll\  with 
•  i.irkttllv 

•rase. 


man 


CYSTS 


«)3 


RBTROORE88IVE  MSTAMORPHOSBS. 

Atrophy.  -The  (•(HidUidn  of  atrophy,  so-ciilh-il,  is  found  as  a  senile 
cliiiiifrfiirHl  in  wasHnj; diseases.  I'n-ssurt-  may  Ur'tua  •<  iilM)Ut,  as  in  hydro- 
cilf.  heniufiK-ele,  varic(K-«'h',  hernias,  and  tuinors.  A  similar  eondition 
is  met  with  in  injuries  to  the  cerelM-llum,  concussion  of  the  lirain,  and 
|iar:i|>lepa. 

'i'he  most  common  retn));rade  clian>,'»-  is  a  diminution  in  the  size  of 
llic  testis,  in  wlii<h  there  is  a  more  or  less  complete  destruction  of  the 
spcrelinf;  cells.  It  is  not  to  Ik-  re>{ard«-d  entirely  as  an  atrophic  priKcss, 
however,  inasnnich  as  there  is  in  many  cases,  although  not  in  all,  a 
projiressive  Hhrosis  of  the  stroma  with  "thickeninj;  of  the  walls  of  the 
sfiiiifiiferous  tuhules.  Not  infre(|uently,  the  walls  apj)ear  swollen,  trans- 
|Kir.Mit,  and  hyaline,  so  that  folds  |)roj«-t  into  the  linnen  of  the  tuhules. 
wliiih  in  advance*!  «ases  may  1m-  oliliteratetl.  The  se«retin>r  cells  show" 
fatty  dej.'cneration,  and,  with  the  cells  of  the  interstitial  siihstance,  are 
|)i;;riiciited. 

CalciftcAtion  (xcurs  in  luinors,  al)s<esses,  and  fibrous  scars. 

Oangrene  of  the  testis  (M-curs  after  trauma. 


PROORB88IVE  METAMORPHOSES. 

Hypertrophy.  ('om|M'nsatory  hyf>ertropliy  of  one  testis  when  the 
other  i>  deficient,  proh  iMy  exists,  althoujfh.  contrary  to  what  one  would 
i\|H-(t,  it  is  very  rare.  .\  fortn  of  enlarfreinent  due  to  over>;rowth  of 
the  coiiiiective  tissue  has  lieen  nu-t  with  in  the  Tropics,  asscniated  with 
elephiiiitiasis  of  the  scrotiun. 

Tumors.  The  i  .mors  (K-currinjr  in  the  testis  are  strikiiij;  for  their 
;:rtai  variety  and  for  certain  sjxHial  forms  of  a  heterotopic  nature. 

Cysts.  .Simple  retention  cysts  an-  not  infre(|uent.  Thev  develop 
alioiM  [.iilM-rty  and  are  attriliutahle  to  defects  in  dcveh-pm.-nt.  Tlie 
sctiiiiiitVroiis  >r|ands  and  their  discharjrini;  ducts  are  deveh.iH"l  iiuh-- 
|«-ii.l.iiily;  c(.iise(|uently,  should  they  not  unite  in  the  normal  maimer, 
tlif;rlaiids  f(,rm  a  chist-d  cavity  which  will,  in  time,  liecomc  eiionnouslv 
<Im.i,(I.<|  with  fluid.  A  similar  condition  may  Ik-  l)rou>;hf  alxnit  l>v 
<>li>tnirt|.,:i  ,,(•  tiu-  ducts  from  fihrous  induration  or  tumors.  The  cvsfs 
of  til.' .pididymis  are  due  in  part  to  se<retion  with  retention,  s|M-rmat(>- 
<«-lf.  an.l  I..  aJK-rrant  j^rowth  of  cert:.in  eml.rvonic  "rests,"  h.dati<ls, 
uMomalM-,  of  the  Miillerian  duct  and  panididyniis. 

In.  iiM.si  interesting'  forms  of  cyst  of  the"  testis  are.  however,  to  In- 
"■tfifl'l  as  examples  of  true  tumor-formation.  Of  these  shouKl  l)e 
iiifiiihi,  ,1  ill,,  cyitonu  (  r),  in  which  numerous  cysts  are  present  without 
any  iii.  ,„  ,|;,r  sirucfurc,  the  cyttadtnnma,  nm\  epidwmoid  cysis.  .Some 
iif  III.  M  ,  vsts  are  of  mixed  type  aici  may  contain  carfilane  aiid  nmscular 
li>>ii.  teratomu.  The  epithelium  lining'  them  varies  considerahlv. 
'x'lii-      ;:tted,  cylindrical,  or  .stratified  pavement.    The  contents  of  the 


Mil 


I 


804 


THE  TESTES 


cysts  may  l>e  mucinous  (cystoma  miirogum),  porridjjy  (c.  uthmtmn- 
to9um),  or  cholesteatoraatous.  The  simplest  of  the  teratomas  iire  thr 
dermoids,  hut  many  are  extremely  complicated,  containing  hone,  carti- 
lape,  epithelia,  ulamls,  and  nencs.  The  higher  types  approach  closely 
twin  malformations,  or  the  so-<'alle<l /ff/iw  in  fatu. 

A  point  of  nnich  interest  and  importance  in  ref^rd  to  teratomas  is 
that  certain  malignant  forms  have  l>een  ohservetl  by  Breus  and  Slilaneii- 
haufer'  which  contain  syncytial  masses  and  cells  corresjxindin);  with 
those  of  the  Lnnghans'  laye:-.  The  resemblance  to  deciduoma  muii'jimra 
and  the  hydati<liform  mole  is  close,  and  opens  up  much  room  for  siMHula- 
tion.  Such  cases,  at  all  events,  support  the  view  that  deciduoma  is  a 
growth  of  fo'tal  and  not  of  uterine  origin. 

Chondroma. — A  gwxl  example  of  heterotopic  tumor-formation  is 
afforde<l  hy  the  chondroma  of  the  testis.  It  forms  nodular  growtiis  or 
abundant  cylindrical  bran<hing  masses.  In  the  last  t\-i)e  there  is  a 
developm«'nt  of  cartilage  within  the  lymphatic  vessels. 

They  may  reach  a  considerable  size  and  form  hard,  warty  growths. 
On  .scition,  softening,  cystic  degeneration,  and  calcification  arc  fre- 
(juently  to  be  seen.  The  new-growth  usually  l)egins  in  the  neighl>orh(Hxl 
of  the  rcM». 

Microscopically,  it  c(»nsists  of  hyaline  or  fibrocartilagc.  .\  tilirous 
perichondrium  is  common. 

These  tumors  are  met  with  in  children,  anil  are  therefore  prtsiiiiiai)]y 
due  to  congenital  defects,  probably  cell-inclusion.  .\  strikiiij:  jkhii- 
liarity  is  a  temlency  to  form  metastases,  so  that  the  tmnor  is  lo  lie 
regarded  as  relatively  malignant. 

Myomu. — Mycmias,  conijx)sed  of  smooth  or  striated  niiisdi'  are 
occasionally  obser^•e<l.  They  arise  from  preexisting  muscle,  a-  from  the 
siMalled  " inner"  cremaster,  an*l  from  remains  of  the  gulH-niai  iilimi. 

Fibroma,  osteoma,  und  angioma  are  rare. 

Carcinoma. — By  far  the  most  ini}M>rtant  malignant  growth  is  i;ti<  iiioina. 
It  is  most  conunori  l>etween  the  ages  of  thirty  and  forty,  but  i^  met  with 
in  chiUlh<HHl.  There  is  some  <liffereiice  of  opinion  as  to  wIm  tlier  it 
originates  in  the  tubules  or  iti  epithelial  cell  "rests."  The  ;.'ro\vth  is 
usually  riicfphaloid,  but  acirrliowi  forms  t)ccur.  Colloid  caii  inmna  Ls 
excessively  rare. 

Kncephaloid  can-inoma  l)egins  alwHit  the  centre  of  the  or;:an  a;iii 
infiltrates  cither  as  a  diffuse  growth  or  in  the  form  ()f  miillipli'  no<iiiles. 
The  whole  testis  may  l)e  destroyed,  but,  while  enlarged,  nia;  for  loiijr 
preserve  a  smooth  surface,  owing  to  the  fiiet  that  the  tiniica  iHnipiiea 
is  very  resisting.  On  section,  the  growth  is  soft  and  braiii-lilt  ami  "f 
a  grayish  or  yellowish-gray  coh)r.  Fatty  degeneration,  ii<- mtic  and 
hemorrhagic  areas  are  often  seen. 

Micro.scopically,  the  cells  arc  large,  |K>lyhe<lnd,  having  a  p  t!i .  .lelicate 

ottiplasin.     Ae««)itling   to   Laiighans,   glycogen   is   abiuui:!.     iIk" 


prot 

'  tVritrnlhl,  f.  (iyn.,  27:82:11103;  sfo,  also,  Curey,  Johns  ll()|ikin-    'I  -p 
|3:1'J02:27,'). 


Hull., 


PERIORCHITIS 


SOS 


vessels  of  the  stroma  are  often  numerous  and  dilatetl  (car.  teleangiec- 
iuticum).    Cysts  are  also  sometimes  found. 

SireoiM.— Sareoma  is  much  less  common  than  carcinoma,  but  also 
forms  a  rapidly-growing  soft  tumor.  It  is  most  frequently  bilateral. 
On  section,  it  is  more  homogeneous,  smooth,  and  grayish-red  in  color, 
somewhat  like  bacon  in  apj)earance.  It  is  often '  lobulated.  The 
growth  does  not  tend  to  infiltrate  to  the  same  extent  as  oaninoma  and 
in  the  course  of  growth  pushe;  lie  testis  to  one  side.  Microscopically, 
sarcoma  is  usually  romd-celled,  but  spindle-celled  forms  are  seen.' 
Plejti/orm  angiosarcoma  has  l)een  desc-riljed. 

A  peculiar  tumor,  somewhat  suggesting  the  intracanalicular  fibroma 
of  the  breast,  is  the  intracanalicular  cystosarcoma,  in  which  the  inter- 
stitial tissue,  in  a  state  of  sarcomatous  proliferation,  grows  into  the 
dilated  tubules. 

C'hondrosarcotna  and  myxosarcoma  as  well  as  nuligiuuit  glioma  are 
met  with. 
Sarcoma  is  most  frecjuent  in  childhood  and  in  eurly  manhood. 


The  Membranes  of  the  Testes. 

The  membranes  surrounding  the  testes  and  spermatic  cords  are  formed 
hy  the  evagination  of  the  peritoneal  sac  (prcxessus  vaginalis  peritonei). 
Ociiisionally,  from  defective  evolution,  the  |M)rtion  about  the  testis  does 
not  iKxome  separated  as  it  should,  so  that  there  persists  a  more  or  less 
[)erfe<t  communication  with  the  peritoneal  cavity.  This  has  an  im- 
portant l)earing  on  the  subject  of  hernia.  In  some  cases  fluid  collec-ts 
111  the  scrotum  about  the  testicle,  forming  one  varietv  of  hydrocele. 

Hemorrhagfe,  usually  l>etweeii  the  tunica  vaginalis  and  the  tunica 
loiiimunis,  may  ,Kcur,  forming  a  hematcmia.  It  is  usuallv  due  to  external 
violence,  heavy  nmscular  work,  or  coughing,  or  to  the  heniorrhairic 
diatheses.  " 

Hydrops.— Simple  hydrops  may  Ik>  found  in  general  anasarea. 
In  tlic  Tropics,  in  association  with  filarial  disease,  a  milkv  fluid  is  trans- 
ude.! into  the  cavity,  the  so-called  '' gulnctocek ,"  or,  more  correc-tiv, 

ehijUtciii'. 

Periorchitis.— By  far  the  most  important  affection  of  the  membranes 
IS  uiHainmation.  periorchitis  or  vaginitis  testis.  This  mav  Ik-  acute  or 
Phronic,  and  is  usually  secondary  to  lesioas  of  the  testis  cJr  epididvmis. 
OrcasK.nally,  it  is  primary  aii<l  due  to  trauma,  and  inav  cxciir  apparentlv 
spontaneously.  As  might  \w  siipposwl,  i)eriorchitis"is  more  c-ommon 
diirnijc  the  earlier  period  of  sexual  activity.  It  is  frequent  in  the  Tropics. 
t^onpnital  malformations  predispose  to  the  condition.  According  to 
the  iialtire  of  the  process  we  can  recognize  an  exudative  and  a  prcKluctive 

Serous  Periorchitis.— Serous  or  serofibrinous  periorehitis  is  characterized 
ov  thi'  exudation  of  a  serous  or  serofibrinous  fluid  that  often  collects 
in  ounMilerable  quantity,  and  leads  to  great  distension  of  the  sac.    The 


II 


(i 


ii 


^.1. 


800 


THE  MEMBRAXES  OF  THE  TESTES 


Fin.  2la 


process  may  Ix-  acute  or,  again,  iasidioas  in  its  onset.  The  flni<l  is  doar 
or  slijjhtlv  tnrl)i«l  from  the  presence  «>f  leuk<x'ytes  and  epitheliiil  cHls 
(arutc  hydroerlr),  or  may  contain  UUhhI  (ltfmat<trele).    The  filirin  iliat 

is  formed  tetxls  to  l)e  deixisiitd  on 
the  walls  of  the  sa<'.  Holli  the 
epithelium  and  the  superficial  In  vers 
of  the  sac  may  underp>  tihrimml 
transformation.  The  subserous  cdn- 
nective  tissue  is  usually  (edematous. 
As  the  prtK-ess  jjoes  on,  fihroiis 
adhesions  nmy  Ik"  fomieii,  Imuliii); 
together  more  or  less  firmly  the  two 
layersof  the  s>iv{adheiilir  periorchilix] 
In  long-standing  ca.ses  the  e.xuijati'  is 
usually  clear  or  tinged  wilii  iilootl. 
Not  infre<|uently,  it  contains  uiiiiier- 
ous  crystals  of  cholesterin.  nivinj;  it 
a  milky  gli.stening  ap|N-aran<  c  The 
more  fluid  portions  are  in  some 
ca-ses  ahsorlied,  leaving  Ix-liimi  a 
whiti.sh  or  pigmented,  nuisiiy-liMikiii); 
mass,  containing  cholesterin. 

Among  the  chief  causes  may  lie 
menti<>ne<l,  gonorrh<ra,  Iraiiitialisin, 
and  the  infectious  fevers,  such  a.s 
scarlatina.  Occasionally  in  iliihireii 
it  ap|)ears  inde|)endently  of  any  of 
these  cau.ses. 

A  s|>ecial  form  of  fii>^in<lll^  peri- 
on-hitis  is  the  pcriorrliilin  rlllimi  or 
I'vrritrma,  in  which  ]M)ly|)(»iil  excres- 
cences spring  up,  usually  ii|mjii  the 
epididymis.  The.sc  may  l>c  inni  off 
and  form  free  Ixxlies. 

Snppuntive   Periorchitis.     Siip|Hi- 

rative    j)eriorchitis    is    cliannicrizefl 

l>y  a  purulent  or  fibrinopunilrMi  tvii- 

dation  with  much  <'(>nj;(--iii'ii  nt' ilie 

membranes.     In   sonic  caM-   |Miiri(l 

decomposition    of   the    Huiil   'M<'urs. 

The  inflammation  may  cMii!  up  the 

s|>ermatic   conl    to   the   |iiiiiiMieuiii, 

or    may   involve    the    sciniMni.    In 

.some  <'a.ses  healing  takes  j 

atliu-siun  of  the  two  layer-  • 

The  pnKcss  may  \ie  metastatic,  but  nuich  more  comnioiil; 

a  preexisting  inflanunation,  to  injuries,  gonorrh(ea,  or  to  -' 

orchitis  or  epidi<lymitis. 


UytlnH-^-lp  of  the  ttiiiicu  vAviiialiM.  The 
lewtii-le  i«  !*erlt  lit  the  hiwer  |M,rli(in  iif  the 
Hiic,  (Knim  tlip  Pttthi))i«iral  ,\lii.'«euni  r,f 
M.tlill  I'liiver^ily  ) 


i.r  with 

due  to 
iiirative 


iiJ. 


PERIORCHITIS 


807 


Ohronie  Sarou  PerioreUtii. — ('lin»iiii'  serous  periorchitis  iisuallv 
oriciimtes  in  an  acute  uife<-tioii,  but  may  l)ej,'in  insi<liou.sly.  It  leads  to 
a  ( orisiderahle  out|HiurinK  of  fluid,  as  much  as  three  liters  in  some  cases, 
which  jontains  alMXit  o  \wr  lent.  of  alhumin  and  tends  to  clot  on  standing. 
It  may  contain  1)1«mm1  and  cholesterin.  In  some  cases,  where  there  is 
s|MTinat<)cele  or  an  al)errant  vas  deferens,  spermatozcui  may  l)e  found  in 
the  Huid  ( Hoth).  The  walls  of  the  sac  are  often  thickened  and  pigmented 
(pmluiilve  pfr'mrrhltiii).     There  may  also  Ik-  adhesions. 

In  all  effusions  into  the  tunica  the  testicle  is  usually  situated  in  the 
IMwtfrior  |M>rtion  of  the  dilated  sac,  and  while  for  some  time  it  mav 
retain  fairly  well  its  normal  condition,  it  later  l>ecomes  indurated  and 
(•()iiipres.se<l,  so  as  to  Ik*  with  difficulty  recogni/iihle.  The  testis  and 
epididymis  are  fre(|uenfly  atrophii-,  not  only  from  pressure,  hut  often 
from  pret'.xistinn  di.sease,  the  cause  of  the  original  hydriK-ele.  When  old 
adiu'sions  are  present  a  hx-ulated  collection  of  fluid  results. 

Tuberculous.  This  is  l>y  no  means  conunon,  except  when  secondary 
to  tuberculosis  of  the  testis  an<l  epididymis.  As  a  primary  atfectioii  it 
takes  the  form  of  disseminatetl  fcxi  or  large  gniinilomas. 

S]rphilis.  Syphilis  is,  as  a  rule,  met  with  as  an  adhesive  |M'riorchiti.s 
exttnding  from  the  testicle.  It  may  be  coi)!plicate<l  with  hydrmele. 
(iiimnias  are  rare. 

Tumors.  -Primary  tumors  of  the  timica  vaginalis  testis  are  rare. 
.Virioiig  them  may  lie  mentioned  fibroma,  leiomyoma,  rhabdomyoma, 
lipoma,  myxoma,  chondroma,  dermoid  cysti,  and  sarcoma. 

Parasites.     Kf7////<x(xrM*  dimme  is  fomiil  in  the  membraties. 


THE  SCROTUM. 

'V\w  scrotum  is  comp()si><l  of  a  UKNliKtHl  skin,  and  the  diseases  affecting 
it,  for  the  most  part,  resemble  those  of  the  skin.  <  )idy  a  few  of  the  more 
iiii|K>rtaiit  conditions,  therefore,  will  1k'  referred  to  here. 

Tlif  structuH"  is  very  elastic  and  contractile,  owing  to  the  presem-e  of 
iiiistripc<l  muscle  filnTs  com|M)sing  the  tunica  dartos.  SulKUtaneous  fat 
is  iiiiMiit.  but  blocMlvessels  and  lymphati<-s  arc  abinidaiit. 

Tlic  most  important  maUormationi  are  the  fission  that  <K'curs  in  liypo- 
s|)iiili^is  and  liertnaphnHlitisin,  and  hypoplasia. 

Owing  to  the  elastic-  texture  of  the  scrotmn  and  its  great  vascularity, 
hemorrhage  and  osdema  tKciir  readily  and  me  often  of  extreme  degree. 
(VAvwM  is  frefpiently  present  in  cases  of  ciironic  valvular  disease  of  the 
lifiirt  .\  JiH'al  form  is  also  described,  which  is  |Missiblv  due  to  nenro- 
piiiliii-  influences. 

INFLAMMATIONS. 

I  III  mflammations  are  usually  due  to  external  irritation,  Kn-al  infection, 
pani-iiis,  or  extension  from  the  testicle  or  epididymis. 


l^'' 


i 


'■  t 


J 


806 


THE  SPERMATIC  CORD 


UTX0ORU8IVI  MITAMOKPB08I8. 


ChtDgrana. — Among  retnif^ssive  changes,  gangrene  is  of  fre<|iient 
occurrence.  It  follows  cptiema,  extravasation  of  urine,  ery.ii|j«'las, 
phagedena,  and,  rarely,  infectious  diseases. 


PBOORItSIVK  1BTAM0RPH08U. 

Hypertrophy. — The  most  important  progressive  disorder  is  h\-pe^ 
trophy  or  elephantiasis.  Frequently  the  penis  and  scrotum  are  involved 
together.  Two  forms  exist,  the  one  a  diffuse  fibrosis,  and  the  ixher 
in  which  the  more  or  less  indurated  tissue  contains  numerous  diluted 
lymphatics,  sometimes  forming  on  the  surface  nodular  tumors  or  vefiicies 
{Itfmph  scrotum;  pachydermia  lymphangiectatica).  The  disease  is  most 
common  in  the  Tropics,  and  some  of  the  cases,  at  least,  are  due  to  filiiriasis. 

Tumors. — Of  the  tumors  may  he  mentioned  fltwoma,  lipoma,  fibro- 
mjontt,  angioina,  teratoma,  lareoma,  carcinoma,  and  various  forms  of  cysti. 

The  most  important  new-growth  is  careinoma,  interesting  chicHy  on 
account  of  its  peculiar  etiology.  It  is  due  apparently  to  irritation,  and 
is  found  in  chimney-sweeps  and  those  working  in  tar  and  paraffin. 
Melanotic  carcinoma  is  descril)ed,  but  is  excessively  rare. 

Kocher'  has  descrilied  a  remarkable  giant-celled  sarconui. 

Paruites. — The  animal  parasites  found  are  the  Filnria  mmjuhth 
hominis  and  the  Ekhinncoccus. 


TBI  SPERMATIC  OORO,  VAS  DEFERENS,  AND  VESICULJE 

SEMIKALES. 

(Edema.— (Edema  may  leml  to  swelling  of  the  cord  or  dilTiise 
hydrocele. 

Varicocele. — A  common  affection  is  dilatation  of  the  \v\r.<.  or 
varicocele.  The  disease  is  commonest  in  early  adult  life.  It  is  (H'("!--i<)n- 
ally  due  to  the  obstruction  to  the  free  outflow  of  blood  by  tuiiurs  or 
hernia,  but  frequently  appears  without  obvious  cause.  It  may  Iw  that 
there  IS  some  congenita!  weakness  of  the  vessels  that  predisposes.  The 
veins  in  question  are  poor  in  valves,  and  thus  a  long  column  of  l)li>'  d  has 
to  be  supporte<l.  Among  the  causes  to  which  the  condition  is  attribuied 
are  prolonged  standing,  violent  muscular  exertio  :exual  excess,  ironor- 
rhoea,  and  traumatism.  The  affection  is  asualh  .  and  on  the  Icl't  side, 
owing  to  the  fact  that  the  left  spermatic  vein  df  not  empty  ilirectly 
into  the  vena  cava  inferior  but  into  the  left  renai  vein,  and  a! ->  lio« 
behind  the  rectum. 

»  Eteutsche  Chir.,  506:  1887. 


aPEBMA  TOCYSTITIS 


809 


TaoicnUtil.— Inflammation  of  the  conl— funiculitis— is  due  to  the 
extension  of  a  posterior  urethritis  or  to  traumatism. 

Tnmon.— Of  primary  tumors  shoukl  be  mentioned  lipoma,  ibnina, 
myzona,  myxoflbroma,  and  MroDina.  They  are  rare.  Metastatic  deposits 
may  ocfur  in  sarcoma  or  carcinoma  of  the  testis. 

dyiti  are  due  to  localized  hydrcx-eles  of  the  cord,  or  develop  from 
remains  of  the  Wolffian  body  (?),  iluct. 

Deferanitif.— The  most  important  affection  of  the  vas  deferens  is 
inflammation,  deferenitis  or  spermatitis.  This  is  <lue  to  the  extension 
of  inflammation  from  the  urethra,  bladder,  prastate,  or  epididymis. 
Rarely  it  is  idiopathic  or  due  to  trauma.  The  usual  cause  is  gonorrhoea. 
Obliteration  of  the  vas  and,  if  the  condition  be  bilateral,  sterility  is  the 
result. 

Tub«rcnloiit.— Tuberculous  deferenitis  arises  by  extension  from 
the  associated  oq^aiis. 

Syphilis. — Gummas  Iiave  l>een  occasionally  obser\'ed. 

The  seminal  vesicles  may  be  abMnt  on  one  or  Iwth  sides,  or  may  be 
futd.  The  first  condition  is  usually  associated  with  unilateral  defect 
of  the  kidney,  vos,  and  epididymis. 

Hjrpoplaaia  occurs  in  anorchidism. 

Spernutocyititis.— Inflammation  of  the  seminal  vesicles,  sperma- 
tcxystitLs.  is  usually  an  extension  from  the  vas.  Rarely,  it  occurs  from 
trauma,  or  even  without  obvious  cau.se.  It  is  usually  due  to  gonorrhoea. 
The  inflammation  may  be  simple,  mucoid,  mucopurulent,  purulent, 
lieinorrhagic,  or  caseous.  The  walls  of  the  vesicles  are  infiltrated  with 
inflammatory  protlucts,  and  the  cavities  are  filled  with  leukocytes, 
ihiefly  mononuclear,  desquamated  epithelium,  debris,  and,  if  the  duct 
he  not  (Kx-luded,  with  spermatozoa. 

In  tnberealosif  there  is  a  caseous  detritus  and  the  walls  show  tuber- 
culous infiltration. 

In  advanced  ca.ses  of  spermatocystitis  the  walls  are  thickened  and  the 
cavities  may  be  contracted.  In  old  men  w  ho  have  suffere«l  from  chronic 
(tonorrlKva,  hypertrophy  of  the  prostate,  vesical  calculus,  or  stricture, 
diverticula  are  sometimes  found,  owing  to  irregular  proliferation  of 
fil)rous  tissue.  Occasionally  cystic  dilatation  is  the  result.  The  contents 
of  the  vesicles  may  in  some  ca.ses  become  inspissoted  and  infiltrated  with 
saUs,  so  tlmt  concretions  are  produced. 


Hi 


'^¥ 


y 


i^  iir 


r 


CHAPTKU    XXXVIII. 

THK  KKMAI.K  SKXIAI.  OIMJAXS. 

TllK  female  orgiiiis  of  generation  incliiile  the  viilvii  (external  neiiiialia), 
the  vu^inu,  the  uterus,  Fnllopiun  tulies,  ovuries,  unit  lironil  liptincnts 
(internal  nenitaliu).  Inasuuifh,  however,  as  the  mamnur  an-  <'l(i>iek 
fonnecte<i  with  the  function  of  repriMluction  and  attain  their  full  ilivclop- 
ment  onlv  in  the  female,  it  is  <-onvenietit  to  tli.s<"U.s.s  diteases  of  tin-  lirciist 
also  under  this  (■atep)ry.  Aifeclions  of  the  placenta  atMl  firtiil  iiicni- 
branes  will  also  In*  treated  here. 

A  jtreat  variety  «>f  nmlformatioiis  atfectin^  the  );enital  tract  in  whole 
or  in  {Nirt  are  descrilied.  Harmaphroditiim  is  <li.s<-u.ssed  in  another  placf 
(s«>e  vol.  i,  p.  257).  DonbUng  of  the  );enital  or);ans  as  a  whole,  iix  liuliii;; 
also  the  l>lad«ler  and  urethra,  is  nH-onleil  in  one  case.' 

A  more  common  animialy  is  hypopluis,  either  where  the  asual  cliati^fs 
incident  t«i  pulierty  are  refanU-tl,  or  where  the  or);ans  remain  small  or 
imperfect  thn>uj?h«»nt  life. 


TBI  IZTEKNAL  OKNITALIA. 

These  are  the  vulva,  inclndin^  the  clitr>ris,  labia  majora,  laliia  iiiiiiord, 
the  hymen,  and  certain  assiKiated  glands  -the  Cowper's  or  Hartliolini's 
glands. 

OOHOBNITAL  AH0B8ALIE8. 

Complete  defect  of  the  vulva  is  foimd  in  acephalic  monsters  ami  siren 
deformities.  More  conuiion  are  dcfwts  of  certain  parts,  eitliir  lilatcral 
or  unilateral.  Such  are  absence  of  the  labia  minora,  the  lal>ia  m.ijora, 
the  clitoris,  or  the  labia  minora  and  clitoris  together.  Hesido  ii|il,isia. 
hypopUiU  exists,  generally  assfxiatctl  with  retarde<l  developnicni  "f  ilif 
internal  organs.  The  vulva  in  the  a<lult  may  present  the  cliarin  it  risliis 
of  infancy  (ntlca  hifiiuiHix). 

Fiition Of  the  clitoris  simulating  reduplication  has  been  nici     iili.    It 
is  usually  ass<H"iate<l  with  epispadias.     Hypertrothy  of  the  cliion- 
the  prepuce  alone  or  the  organ  as  a  whole.      The  atftNtioii  i 
common  in  tropi<al   countries.     It  is  found  ix-casionally  in  i'" 
races,  in  |).scudolieruiaphr»Miiii.-.m,  and,  rarely,  in  prostitutes,     i 
cases,  hypertrophy  of  the  clitoris  iscombinetl  with  hyperpluu  < it' '' ' 

'  V.  Kng»-1.  Areli.  f.  Gyiiak.,  2<J:  18H7:  VA. 


llf«1S 

more 
l>la('k 
t-rtain 
laliia. 


m 


VI'LVITIS 


811 


III  certain  r.  r-s,  ns  niishnifii  ami  ilnttentots,  thr  labia,  particularly 
(Ik-  liiliiu  iiiinoru,  uri-  cxcrHsivcly  eiihtr)^!,  .siiii)t>tiine?«  uIiikmI  reiichiii^ 
the  kiircN  {lUHrtiM  apron).  Hiilur^inriit  of  the  lahia  iiiujuni  is  .<*aid 
|)V  some  to  Ih"  4liie  always  to  iiew-f{n»wtli. 

An  inaMM  in  the  numbtr  of  the  iaitia  is  rare,  lexs  .so  in  the  case  of 
iiviii|>hH'.  Con^-nilal  adhatloiii  of  the  ial)iu,e.s|iecially  the  luliiu  minora, 
exist  un«l  may  l<wl  to  interference  with  the  function  of  urination. 

Htmit  into  the  laltinni  niujus  thniu^h  the  iiiKuinai  cnnal  may  iK-cur 
[hrnilii  iiigu'niiiUs  liihialin},  or  nuty  extend  from  iM-nealh  the  rainu.s  of 
the  |)uIk>.s  into  the  !«»wer  part  of  the  lahium  (hfriiln  lahinlin  iiifrrlor). 

The  uni^nitul  sinu-  may  fail  to  develop  nalundly,  and  thus  per- 
nisteiH-e  of  un  emhryonic  condition  may  iKcur,  such  us  •piipadiM, 
bypoipMliM,  uihI  anni  pretamatonlii  TMtibnluii. 

The  li*  men  presents  jjreat  variation  in  its  form.  It  may  lie  com- 
|)lct('ly  occtadad  or  may  |M>s.se.ss  merely  a  imAll  optniag.  Or,  uf;uin,  the 
ii|>eiiin^  may  Im-  doiihle  (fii/mni  nrfituH),  sieve-like  {hijmrii  cr.'hrt/ormlii), 
i»r  sernite*]    hi/mcii  )iml>riii!iiJi). 


OntOULATORT  DUTTTRBAHOU. 

Hyperemia.  Active  Ufpntmin.—  .\clive  liy))ereinia  is  iltie  to  influni- 
niuiidii,  or  to  mechanical  irritation,  as  in  the  .s«*xnal  act. 

PuiiT*  Hyperemia.  ~  Passive  hy|K-rcmia  is  connnonly  due  to  pregnancy, 
or  til  fjfeneial  1>Io<kI  stasis,  as,  for  instance,  in  valvular  «lisease  of  the 
lu'iirl. 

If  tlic condition  jiersist,  the  vessels,  es|)ecially  those  of  the  luhia  majora, 
Ik^oiiic  dilated  aiut  vari«'ose.  Thromlnms  then  may  (K'cur  with  jM)ssil»ly 
plilfliiilitii  foriuulion,  or  a  veiuile  may  hurst.  Icuding  to  larj;e  exlrav- 
viisiitioiis  of  IiIihnI  {hemiiUim(i\  Rupture  of  the  veins  may  also  take 
place  from  external  traumatism  or  from  partiu'ition. 

Hemorrhage.  Hemorrhage  from  tearing  of  the  hymen  at  the  first 
coiliis  is  rarely  dangerous.  It  is  most  likely  to  !«■  severe  when  the 
orifirc  is  small  or  the  hymen  thick  and  fleshy. 

(Edema.  (I'vtleina  is  cotninon  and  may  lie  assiK-ialed  with  iiiHani- 
iiiiitory  hy|HTemia,  passive  congestion,  or  vas<-ular  changes.  It  is  ftiuial 
fsiM'cially  in  valvular  heart  atftH-tioiis  and  in  nephritis. 


INFLAMMATIONS. 


Till-  inflammatory  affections  of  the  vulva  are  practically  those  f<iund 
on  ^iiiy  skin  surface,  .\mong  them  may  lie  iuentione<l  erythema,  ecsema, 
herpe:;,  acne,  fnruncnlosig,  hard  and  soft  chancre,  condylomas,  impetigo, 
phlei^mon,  erysipelas,  diphtheritis,  gangrene,  and  lupus. 

Vulvitis.  Acute  Vulvitis.  Acute  vulvitis  or  vulvovaginitis  is  coni- 
moiii    due  to  gonorrhcra  and  ix-curs  chiefly  in  chiKlren  fmm  mediate 


812 


THE  VULVA 


infiH-tiun.  h  it,  howevi-r,  hIso  nipt  with  in  wiiilti.  CasM  btp  s<>tn«>- 
tiiiM'M  due  to  iiiK-lcanliiirss  or  iIm-  irritation  of  thmtd-wormH.  Tin-  liilii« 
cml  rlitorii«  are  re<l«leiie<l,  iwlfiii  >iw,  atwl  Uitiieii  in  pus.  'ITie  follicles 
may  also  l>e  invoive«i.     Kvorini  .n.  is  coinmon. 

OMurkal  VUvltii.  Simple  i-a.  \  Thai  vulvitis  may  l)e  due  to  tiirt, 
merhaniral  irritation,  or  irritating  dischar^^s. 

PhlsfmoiiMU  VnlTitii.  I'lilepnorHHis  vulvitis  lias  Imwh  known  to 
follow  injuries  in  lalMtr. 

MtmbniMUB  VnlTitU.  Menilininotis  vulvitis  may  l»e  due  to  diplillicria, 
or  may  lie  merely  diplitiiinml.  The  latter  form  oivurs  in  many  of  the 
infertiotts,  as  piier{)eriil  M-p-^is,  measles,  t'phoid,  scarlatina,  and  clKilfra. 
It  may  also  originate  in  the  exter  i  of  inflammation  from  the  lM>wel 
or  vagina  aiul  may  terminate  in  ff  :  i   'le. 


t' 


I'! 


riiliJylcimiu  (if  the  vulvii      .  Fniiii  llip  <iyiirciil<iici<'ill  Clmio  iif  the  Moiitreul  Oneral   II.  -lilal 


Inflamnmtionof  the  Bartholini's^larxls  is  commonly  due  to  j;oii(>rrli<ra. 
but  may  Ix"  an  extension  from  vulvitis  of  other  forms.  It  j;ivf^  ri^c  to 
catarrh  of  the  dint,  witii  retention  of  the  si-cretion.  Abscess  fr(i|iitiitly 
result.s.  Inflanmiation,  when  of  some  stHiiditi);,  leails  to  pniiluctive 
chanf^es  and  often  adhesion  of  the  nymplne.  Induration  of  tli<-  H:irtlio- 
lini's  ((lands  also  (x-ciirs. 

Oondylonu. — C'omMomas  are  inflammatory  outgrowths  on  ''ic  niucoiis 
membrane  t;f  t!ie  vulva  an<l  v:tj;itia  or  the  skin  near  by.  1;;;.  are 
either  acuminate  or  iiixliilur,  and  tend  to  lie  produced  wherever  linre  is 
heat  and  moisture.  They  are  cotnmon  in  syphilis,  but  niii_\  Uo  be 
due  to  irritating  discharges,  gonorrha-a,  etc. 


KU'HOSi^i 


LV'M 


ta 


Obucrvtd. — Chiiiicniul  or  jkw  imU*  f<Min<i  upon  tl  <■  laliM  mHj<tni 
■n<l  riiKira,  th«*  f-iun-hetlp,  «n(l  incntu  irinariii-*,  Tlw  uk^rs  teiid  to 
be  midtiple,  as  tlw  v  un*  iiiiJo-i     k  iiial)!*-.     I'lif  v  take  (lie  furiii  (if  piiiichni- 

Dlll  f\'  H\lltiori.S  MHTftillft  pMS. 

Sypkilif-  riip  lesioat  of  svpliilv'  are  pnrteHn 
primary  sort",  swoiidarv  eruptiims.  hhmihi.s  |MtC«li> 
ran'.y,  jfummas. 

T   Strcolosit.   -TiilK-miltwis   4.s.siiinr!4  the   f«»nn 

rii.f,  .,„*  uletrrltlon. 


We  may  have  the 

o,  (ofNiylomaM,  ami, 

I  if  lupus  or   rapid 


It  shtHild  Iw  in«"ritiorn-'l  thnf  thert-  hits  \>rr\\  «Ies«-rili«l  a  forni  of  chronic 
ukrrntiori,  \'  r\  r»'frHrti»n  tn  i>-fiit merit,  leadin;;  to  iiiHMiiimaiory  hyper- 
pliuia,  that  fias  l>een  r»"tr:iiiltii  l>y  -.oiim'  us  iiil>en-iilinis,  i»y  others  as 
sviifiilitu-.  Kc«-li  liehevrx  ihat  it  i**  «liw  to  lyrnpli  stasis  folhmin^  destruc- 
1111  of  the  iiipiiiiul  >;h»iM!-i.  Microscopical!  .  the  a|>}M'Hranccs  are  those 
uf  simple  inflainiiuilion. 

Actbiomjcont.     Actinoinycosis  of  the  vulva  is  very  rare,  only  two 
eases  iM'iiig  on  rt-t'onl.' 


KETROORfBSITE  '»?TAMOP.PH08B8. 


Atrophy. — After  tlic  clim;i't(Tic  'i!i<    !:ii)ia  maj«>n»  undergo  atrophy, 
owiinr  to  the  nhsorption  of  tin'  !  it.  and  licioinc  Hinall  niid  relaxed.  leiMJinf; 
I  t'XiMisr  till   vulvar  orifice.     Atr()|)ii .  ni  the  nyni|>hii'  also  iKciirs. 

Krftoroais  VhItb.— .\  curious  .nul  rare  t'onu  of  atntpliy  and  citiitntction 
of  tiie  vulva,  first  ilescrilK'<l  l>y  Hreisky.-  is  tlif  so-i-athnl  kr&nrotit  vulva. 
Tlu-  etiolo^ry  of  the  condition  is  still  d'Hililful  i>ut  it  nmy  Im-  inflauimator\' 
III  ori>;iii  The  disj-ji  '*  involves  tlu-  vestihule,  viipna,  labia  niajora, 
clitnris.and  the  inner  pjirf  of  the  iidtia  minora,  ''.'he  iiuicous  ineiiil)raii>' 
is  stretched,  smooth,  glistening;,  dry,  inelastic,  and  pale  re<ldi.sh-j;niy  ii 
color.  The  surfac-e  is  often  fissured  ;i  nd  enlarged  l>l(MHlve.s.sels  can  he  «-■ 

Microscopically,  aec-oniiiig  to  I'eter,'  there  is  at  first  <'hronic  int^u?: 
Illation  with  round-celleil  infiltration  and  iiiHainmatory  (edema  of  tie 
loriiiiii  and  epidermis,  and  later  atrophy  of  the  upjMT  layers  of  the  corinin , 
(■s(HK  ially  the  papilla?.  With  this  there  is  a  inarke«l  tendency  to  coii- 
tr.Ktioii  with  hypeipiasia  of  the  connective  tissue.  Very  little  can  lie 
sfiii  of  the  seliac'-ous  and  sudori|>arous  glands,  and  there  is  loss  of  the 
elastic  tissue. 

Gangrene. — Gangrene  of  the  vulva  results  from  simple  or  inflam- 
iniitoiv  •edema,  hemorrhage,   throinlH>sis,  and   from   traumatism.     It 


foiii  ,1  in  certain  infectious  diseases,  as  typhoid,  mea.sles,  s<'arlatina, 
anil  variola. 

< Viiaiii  spe<ial  forms  deserve  mention.  These  are  phngednm  from 
rli:iiii  riiiil   and   noma.      Nom.i   v-K-.s-  («'ciirs   um'  t  the  .sjime  circsnn- 


'  Uonftartj!,  Mur.a'H-irli.  ■    (i«li.  ii.  (Jyn.,  :i:  iMtti:  4. 

'Zcif.  f.  Hcilk     ti:  ls,s.5:  (><). 

'  ,Monat88chr.  1.  (i«b.  ii,     yiiak.,  3.1Si»t):2<.»;, 


S14 


THE  YVLVA 


stances  a.s  noma  of  the  cheek.     It  is  found  in  anemic  and  del)ilittitc<| 
'-.■hildren. 

Concretions. Concretions  may  form  Itehintt  the  prepuce  of  tin- 
clitt)ris. 

SOLUTIONS  or  OONTINTJITT. 

These  «K-cur  (hiring  coitus  and  parturition.  Small  fi.ssun's  nmy  !«■ 
pnMluced,  or,  again,  extensive  lacerations.  The  most  ini|Mirtanl  form 
IS  laceration  of  the  |K>rineum  <luring  la>M>r. 


M  lis 


PROORESSIVE  METAMORPHOSES. 

Hypertrophy.  Cutaneous  boma  due  to  hy|N-rtn>phy  of  the  t>|iiilit- 
lium  hav  Ikh-u  met  with  on  the  clitoris. 

ElephantiHii.  The  most  imjiortant  and  interesting  of  the  Iiv|kt- 
trophi.'s  is  elephantiasis.  The  etiology  is  l>y  no  means  perf»>ctly  uiiilcr- 
sttHxl  and  undoulitedly  varies  in  ditTerent  cases.  .Some  cases  iirc  con- 
genital, in  the  sense,  al  least,  that  at  liirth  then-  is  a  hypcriilaslic 
enlargement  of  the  |)arts  that  siiltsj-tiuently  Ikh-oiucs  excessive,  or  rliiit 
there  is  an  inherited   predis|Misitioii  to  the  ilisease  (iMiflii/drriiiiiliDrlc, 

rlrph.  niollLi).     Otiier  cas«'-i  are  undoulitedly  due  to  chronic  iiitl iiia- 

tion  or  to  some  alfe«'tion  of  the  lymph-glands  an<l  vessels.  Tlic  laller 
is  genendly  <'aused  hy  ol>stru<-tion  to  the  outflow  of  the  lym|)li  ami  iiiii. 
he  causttl  liy  tilaria*  and  infianunatory  filirosis.  The  condition  lia^  iHrti 
known  to  follow  suppuration  of  the  inguinal  glands.  The  iliseaM'  riiav 
Im-  unilateral  or  liilalcnd,  and  atf^'ts  the  laliia  majora,  less  frtiiiimtly 
the  nym|ilia*  and  clitoris.  The  surfa<'c  is  either  siniMtth  iilrpli.  ijlnhm] 
or  iKMlular  irlrpli.  lulMTimn).  The  anatomical  forms  vary.  In  one  [\\w 
the  |mrls,  as  a  whole,  an-  enlarged  and  the  n<>r,nal  contour  of  the  li^^iics 
is  destroyed  by  a  sulK-utaneous  M'd<'ma  or  conni-clive-tissui"  li\pi'r|(la»ia. 
In  whatever  way  the  pr<K-  -ss  starts  it  is  lialile  to  Ik-  complicatcil  liy  in- 
Hannnalory  changes,  such  as  induration,  ulceration,  and  gangn-iic 

Tumors.  Fibromu.  Kihromas  have  Ixvu  found  in  the  lal>ia  uLijora. 
less  connnonly  in  the  laliia  minora  and  clitoris,  'i'liey  are  ciliicr  lll:l^^ivt' 
or  (HHlunculated,  and  may  weigh  several  pounils.  They  oritrin  iir  in 
the  suliculaneou.s  connec-tive  tissue,  in  the  fascia,  or  in  the  |>ciMi.ii'iim 
of  the  jM'lvis  (  Kiwiscii).  .Structurally,  tilinimas  art-  composed  cd'  a  \imm\ 
often  (edematous  connt-f-tive  tissue,  or  iH-casionally  are  in  jiiiri  iniirdiii 
(myxoflbroiTA).  Owing  to  hemorrhage  or  degeneration  llicy  nia\  Ixiniiit' 
cystic.  Myoma  and  flbromjonui  have  also  lieen  descrilH-<l.  I(ai<  l^ .  iluy 
arise  from  the  end  of  the  roimd  ligament.  Lipoma!  are  r;ii'.<r  nil- 
connnon,  an<l  develop  in  the  mons  veneris  and  greater  laliia.  T'k  \  may 
he  comliinetl  with  angioma.  Hemangioma  and  lympbangioma  ■»■  aNn 
met  willi.  .\mong  tiie  greatest  rarities  is  chondroma  of  lli<  lltori^, 
iM-casionally  assiN'iat(sl  with  softening,  ('alciti<'alion,  or  true  Imh  nnvtli. 
I'igmentetl  inri  are  met  with  in  children  on  the  laliiu.  Adenoi:  i  of  the 
Hurtholini's  glands  is  rare. 


COXGKNITA  L  A  NOMA  UKS 


815 


Oueinoiu. — CairiiKiina  i)f  the  vulva  is  relatively  c-otnmoii.  It  arises 
iisimliv  from  the  lahia,  rlitciris,  coininissun's,  or  urethra.  It  «KX'urs  as 
a  i>:i|>iilarv  or  iiiMluiar  out^niwth  or  as  a  diffuse  infiltration.  Extensive 
iilccnition  may  oreur.  The  j;n»wth  is,  as  a  rule,  i;f  the  type  of  horny 
epltliillomii  or  cancroid,  hut  sclrrfutiui  and  .loft  forms  are  also  met  with. 
Can'iiKima  is  connrxmest  in  the  later  years  of  life,  and  appears  to  \ye  re- 
lattnl  to  chnmic  thi<'keninn  of  the  epithelium,  such  as  ix-curs  in  pruritus. 
Can'inoma  may  also  arise  from  the  ISartholini's  glands. 

SueomA.  ^Iuch  rarer  than  carcinoma  is  san-oma,  which  usually  takes 
till'  form  of  meldHniKirromti.  Rounil-  and  uphv.Ue-cvlled  f«)rms  as  well  as 
mii.w.iiirroma  have  l)e«'n  descrilx  .1. 

\  .s«-condary  maUnotie  hypernephroma  of  the  laliium  minus  has  i>een 
tie.s<Tii)ed.' 

Oyit*  are  of  various  kinds,  either  daji'iirrutivf,  retention,  or  detvlop- 
mnildl.  Some  arise  from  a  l(N-al  c<illc<-tion  of  fluid  in  the  canal  of 
NiK'k,  or  from  remains  of  (liirtner'.s  duel;  others  from  ohstruction 
to  ilic  duct  of  a  Hartholini's  ^iand.  They  may  \te  found  on  the  laliia 
mid  hymen. 

THE  VAODTA. 

Till-  vapna  in  adults  is  a  |M>teiitial  tulK',  the  widl>  of  whi<'h  are  normally 
in  coiilact,  com|M>sed  of  <-(inne<'live  tissue  'u  whi<  h  are  numerous  hands 
of  iitistri|>ed  nuiscle.  It  is  lined  with  a  niir.ous  membrane,  consisting 
of  siraliKed  pavement  epithelium,  the  cells  in  the  lower  layers  of  which, 
however,  tend  to  l>e  cylin<lrical.  The  mucous  memhrane  is  not  sni(H>th 
l)iit  thrown  up  into  papilheand  transverse  ridj^-s  or  ruga'.  Asa  rule,  it 
I'oiitiiiiis  no  glands,  hut  then*  arc  certain  lacuna-  or  crypt-i  o|M>ning  i>e- 
twccn  the  iNipiIhe  and  foltls.  In  a  few  cases  glands  lined  with  ciliated 
t'|)itlii'lium  have  l)een  oltservt-d  (v.  l*reu.s<-luMr').  In  the  sultmucous 
coniicf'tive  tissue  small  clumps  of  lympl'  lid  cells  arc  to  Ih-  found. 

Ik  rc|>eale«l  coitus  or  the  act  of  partunron  flu-  ruga-  In-come  gradually 
nlilii<'riit«'<l,  and  as  ol<l  age  comes  on  invohiliou  lakes  place.  The 
iiiiH'oMi  Ih-couh's  atrophic  aial  the  hniien  more  or  less  contracted. 


OONOBMITAL  ANOMALIES. 

Tlic  vagina  may  he  completely  kbaent  or  rc|)r«'sciited  only  hy  a  fibrous 
•onl.  Ill  other  cases  it  is  more  or  less  riidimeiilary  and  contracted  for 
ii>  In!!  Icngih  (total  atreeim).  Partial  atresia  also  iM-curs  in  the  lower 
|Miriin,,  i,r  ihe  vagina.  It  may  consist  in  a  nienibranoiis  <M'clusion 
(ttresia  vaginalis)  or  in  an  impcrforaic  hymen  (atresia  hymenalis). 
Wlirii  ihc  vagina  is  completely  absent,  there  is  defect  of  the  uterus 
aiiil  iirinTallv  <»f  the  adiiexa.     I'l'.rtial  atresia  after  the  establishment  of 


'  (ir;ifetil)iTK.  X'irrli.  Arcliiv,  l!ll: 
Mirch.  An-hiv,  7<t;lS77:  111. 


11KI.S:  17. 


1 


1  i 


I?  X 


816 


THE  VAGINA 


piil)erty  lewis  to  retention  of  the  menstrual  discharge,  which  may  loliwt 
in  the  vagina  (hematokolpoi),  and  may  eventally  lead  to  distension  of 
the  uterus  (hematometn)  and  tubes  (hematosalpioz). 

Bttnodii  may  l>e  due  to  an  arrest  of  development  or  to  hypeq)lasia  of 
certain  portions  of  the  vaginal  wall.  AdhMion  of  the  walls  may  result 
from  antenatal  inflammation. 

Donbling  of  the  vagina  occurs  with  reduplication  of  the  whole  >jciiito- 
urinary  tract,  but  is  excessively  rare.  Owing  to  imjierfect  fusion  of  the 
lower  emb  of  the  Miillerian  duct,  a  partial  or  complete  .septun.  may  be 
formeii  in  the  vagina.  A  <louble  vagina  of  this  type  is  foiiiul  in  the 
condition  of  uterus  septus,  uterus  duplex,  and  uterus  didelphys. 

OntOULATOET  DISTUBBANOES. 


IL^j 


ki 


These  are  comparatively  unimportant.  Aetive  hyperemU  is  found 
physiologically  during  sexual  excitement,  and  in  acute  inHainination. 
PaiiiT*  hyperemia  occurs,  as  elsewhere,  from  olxstniction  to  the  <;('nfral 
circulation,  and  during  pregnancy.  HemoRbages,  either  su|MTli('ial  or 
deep,  are  due  to  injury  during  parturition,  and  <xrasionally  to  viok-nt 
coitus.  (langrene,  varicose  veins,  tiunors,  and  other  pathologii-al  states 
pretlispose  to  the  i'on<lition. 

ALTERATIONS  IN  POSITION  AND  CONTINUITT. 

With  weakness  of  the  structures  forming  tlie  floor  of  tiic  pelvis  and 
consequent  tiescent  of  the  uterus  there  is  more  or  less  prolapse  of  the 
vagina.  This  may  \>e  acctimpanied  by  descent  of  the  jxisterior  wail 
of  the  Idadder  (cystocele)  or  of  the  anterior  wall  «»f  the  rectum  (rectocelei, 
or  !K)th.  A  torn  perineum  contributes  largely  to  the  latter  eveiii. 
CXn-asionally  there  is  dilatation  of  the  wall  of  the  bladder  or  rectnin 
without  any  defj-f-t  in  the  vaginal  support.  Dcsceniling  liM)ps  of  iiowel 
may  distend  the  Douglas'  pouch  (posterior  enterocele),  or  se|.iir,iie  to 
some  extent  the  bladder  from  the  vagina  (anterior  enterocele).  The 
same  effect  may  l)e  produced  by  prolapsed  ovaries  (ovariocele  vaginslis), 
tiunors,  and  fluid. 

Oontnsions  and  Lacerations. Contusions  and  laceration-  an-  of 
fre«|iieiit  tK'<'iirrence  during  lalM>r.  As  a  rule,  they  art'  situaliij  oii  the 
|)osterior  vaginal  wall.  Tears  may  extend  into  the  coiinediM  ti>siie, 
the  perineum,  j)r  even  into  the  rectum,  l^aceratioiis  have  aN"  iMciirreil 
from  violent  sexual  intercourse,  esinx-ially  when  tiie  feiiiah'  i>  in  a 
coiistraiiie<l  |M)sition,  or  where  there  is  a  disprojKJrtioii  iMivifii  the 
male  and  female  organs.  Injuries,  resulting  in  destruction  ■•(  ti-isiie. 
sometiiiM's  follow  the  use  of  the  obstetric  fon-cps,  jH-ssjirie-.,  nd  from 
caninoma,  syphilitic  lesions,  and  the  like.  Not  iiifn-qiieiiil  flsvaloni 
communications  are  o|)ened  up  with  the  neighboring  purls,  as  t!  Ulaiider 
{vem'ciniiglnal  Jintulii),  rectum  (rrctiiriiijiiinl),  and  tlie  uretlui  unthru- 
vaginul),  or  the  .several  forms  may  \>e  coinbinetl. 


VAGINITIS 


817 


DdaUtion.— Dilatation  is  due  to  the  passage  of  some  large  body, 
such  as  a  child,  a  tumor,  or  the  like,  or  to  the  retention  of  fluid. 


nrrLAMHATiom. 

Vaginitii.— Inflammation  of  the  vagina— colpitis,  vaginitis— is  brought 
about  by  a  variety  of  causes,  such  as  mechanical,  chemical,  or  thermic 
iiwiilts,  infection,  or  extension  from  the  adjacent  i.arts. 

Oatarrhal  V«ginltii.— The  commonest  form  is  catarrhal  vaginitis,  which 
may  lie  acute  or  chronic. 

It  is  due  to  irritation  of  any  kind,  the  decomposition  of  discharges 
from  the  uterus  or  from  fistula*,  ulcerating  cancers,  or  vulvitis.  It  mav 
arise  as  .-i  complication  in  the  infective  fevers,  measles,  scarlatina,  typhoid, 
and  variola.  Gonorrhnea  is  not  a  common  cause,  for  the  squamous 
epitluiium  of  the  vagina  is  rather  resistant  to  the  action  of  the  gono- 
cocciis.  Gonorrheal  vaginitis  is,  therefore,  found  chiefly  in  children 
and  in  elderly  women  where  the  mucous  membrane  is  atrophic  and 
the  resisting  power  lessened. 

In  acute  catarrhal  vaginitis  the  mucosa  is  re<ldened,  swollen,  and 
(ideiiuilous,  the  epithelium  more  or  less  desquamated.  These  appear- 
ances are  most  marked  upon  the  tips  of  the  rugie  and  papillw.  The 
exudation  is  at  first  scanty  and  serous,  later  may  \te  abundant,  milky, 
and  purulent.  The  reaction  is  acid  and  the  secretion  contains  pus  cells, 
epithelium,  and  various  kinds  of  bacteria.  Microscopically,  the  mucosa 
IS  somewhat  eroded,  the  vessels  congested,  and  there  is  a'  round-celled 
infiltration  of  the  underlying  connective  tissue. 

In  the  chronic  form  the  appearances  produced  are  at  first  not  greatlv 
different  from  those  of  the  acute  stage,  but  eventually  there  is  h,\-pef- 
plasia  of  the  papillie  and  connective-tissue  proliferation  in  the  deeper 
parts.  The  epithelium  is  thickened,  except  upon  the  papillie,  where  it  is 
enxled.  There  is  also  a  tendency  for  inflammatorv  cells  to  become 
a^%'ret:at.Hl  ni  little  clumps  resembling  follicles,  which  project  into  the 
lumen  f;ivmg  the  mucosa  a  rough  or  granular  appearance  (mginitia 
(jrnnulMu  or  nodularis).  Narrowing  of  the  vagina  mav  result.  \Miere 
also  enHle<l  surfaces  come  in  contact  fibrous  adhes'ions  mav  occur 
tiv(../.  wlhmva).  Adhesion  is  apt  to  occur  in  elderlv  women  in  whom 
tie  nnu  (.sa  l)ecomes  denuded  in  the  course  of  involution  {senile  vaginitis). 
Ihe  s.cretion  is  sometimes  thin,  grayish-white,  and  flocculent,  at  other 
time>  purulent.  Chronic  catarrh  may  follow  the  acute  aflTections  or 
may  ,1,  velop  mdependently.  Common  causes  are  excess  in  coitus,  and 
the  i)rc,(ii«>  of  pessaries  or  other  foreign  bodies. 

BxfoUative  Vaginitli.— A  rare  form  is  exfoliative  vaginitis  in  which  the 
nuu.Mi,  ,„e,nbraiie  is  thrown  off  in  one  piece.  It  is  liable  to  l.e  found 
m  ceriimi  forms  of  dysmenorrhoea. 

Membranous  VtgialtU.— Membranous  vaginitis  is  met  with  as  a  coiu- 
plieari,,!:  of  the  acute  infections,  such  as  measles,  variola,  scarlatina, 
t}piioi.!.  .holera,  and  dysentery.     Of  local  causes  may  be  mentioned. 


81S 


THE  VAGINA 


1  fi' 


injuries  <luring  parturition,  the  irritation  of  foreign  bodies,  putT|)eral 
sepsis,  dist'harges  from  cancers  or  fistule,  rarely  gonorrhoea,  iH)lypi. 
True  diphtheria  is  rare. 

PblegHMmoiu  Yacinitii. — Phlegmonous  or  erysipelatous  vaginitis  bs 
been  described.  In  this  there  is  diffuse  suppuration  in  the  vagi  mil  wall 
that  may  lead  to  exfoliation  of  tissue. 

Aphthous  Yaciiiitii. — Aphthous  vaginitis  is  due  to  a  micrdor^'iiiiisni 
resembling  the  oidium  albicans.  The  mucosa  is  reddened  and  studded 
with  white,  elevated  patches. 

Chueroidt. — Chancroids  are  not  common  in  the  vagina. 

ImphyMinatoiu  Vaginitii. — A  curious  affection  is  the  so-called  enipliy- 
sematous  vaginitis  (cdpohyperpltuia  cystica,  emphysevia  vagina).  This 
«lisease  is  met  with  usually  in  pregnant  women  or  shortly  after  coii- 
finement,  but  has  l»een  found  in  others.  In  the  vaginal  wall  are 
numerous  small  vesicles  or  cysts,  varying  in  size  from  that  of  a  niillet- 
see<l  to  that  of  a  hazelnut.  Otherwise  the  mucosa  appears  to  lie 
normal.  Numerous  opinions  (Winckel,  Schroeder,  Eppinger,  Zweifel, 
Klebs,  Chiari)  have  been  expressed  as  to  the  cause.  The  most  re<ent 
investigator,  Lindenthal,'  finds  that  it  is  due  to  an  anaerohir  jras- 
proihicing  micnnirganism,  belonging  to  the  malignant  a'deinii  }.Toup. 
The  Iwcillus  coli  is  not  a  cause,  except  possibly  in  diabetic  individuals. 

Inflammatory  processes  may  extend  from  the  vagina  or  rectuin  into 
the  perivaginal  connective  tissiie  and  lead  to  abscess  formation  or  fihrosis 
(pcrimfftnitis  nuppurativa,  perii'ag.  fibrosa). 

TnbercnlOBis. — Tuberculosis  is  uncommon,  and  as  a  priinarv  affec- 
tion, excessively  rare.  As  a  rule,  it  extends  from  the  uterus,  vulva,  or 
anus,  but  exceptionally  is  metastatic.  It  takes  the  form  of  shallow 
idcers  with  irregular  edges  and  nodular  bases  that  tend  to  coalesce. 
I^ss  commonly,  one  finds  grayish  tubercles  or  caseating  grauulonias. 

S3^1uli8.— The  primary  papule  or  sclerosis  of  syphilis  is  rare  in  the 
vagina.  It  is  found  at  the  entrance  or  near  the  posterior  coiiiini^sMre. 
Enithrmn,  ps(tr!aaia,  cotidylomas,  and  gummas  are  also  imi  with. 
Binh-Hirschfeld'  has  descrilied  a  perivaginitis  gummosa,  in  wiiic ii  the 
vagina  is  converted  into  a  stiff,  fibrous  tube. 

EETKOOKUIIYE  METAMORPHOSES. 

Atrophy.— Atrophy  of  die  ruga;  and  of  the  mucous  mcmiiraue  in 
gi-neral  has  already  been  referred  to  (p.  815). 

In  prohipse  of  the  vagina  the  mucosa  becomes  converted  into  a  striu- 
ture  closely  n-sembling  skin,  with  stratum  granulosum  an.l  ki  ratiniza- 
tion. 

Qangrene.  (iangrene  may  result  from  traumatism,  pi< -ure,  in- 
Haininaiioii,  carcinoiim,  etc. 

'  U<  Itr.  iwT  Aetiol.  u.  HiBtol.  der  ColpobvperpUwa  cystica;  Zeit.  1.  < .    '.  u.  Cyn , 
40:  18it«:  37."i. 
=  Lehrbuch,2:18e7:794. 


.iiiii 


FOREIGN  BODIES  AND  PARASITES 


819 


Cinumscribetl  vktn  due  to  ischemic  necrosis  have  been  described  by 

Zaiin.' 


PROORB88IVI  MITAM0RPH08IS. 

Tlip-se  are  rather  uncommon. 

Hypertrophy.— H>-pertrophy  of  the  vaginal  wall  from  muscular 
overactivity  is  found  m  association  with  atresia  and  retained  fluid. 
Maeona  polyp*,  sometimes  of  considerable  size,  are  met  with.  They  are 
usually  found  on  the  posterior  wall.  The  inflammatory  new-growths, 
sihIi  a.s  hyperplutie  papiUa  and  eondytomu  have  been  referred  to  already! 

Tumors.— Myoma.-^  Sessile  or  imhinciilate*!  myomas,  composed  either 
of  smooth  or  striped  mu.scle,  grow  occa.sionally  from  the  anterior  vaginal 
wall.  They  may  l)e  of  several  pounrls'  weight.  In  contradistinction  to 
inyomas  of  the  uteriLs  they  are  rarely  multiple. 

Sircoma.— In  young  children  multiple  papillar\  or  polypoid  sarcomas 
or  fibrosarcomas  (.see  vol.  i,  p.  (i()7).  often  containing  mascle.  are  some- 
times found.'  They  ap{)ear  to  l)e  congenital.  The  neoplasms  may 
rwiiaiii  latent  for  years  and  then  take  on  rapid  growth.  Microscopicallv 
the  >rr.mths  consist  of  round  or  spindle  cells.  In  adults,  round-,  spindle- 
xm\gmnt-relM  nummas  are  met  with,"  and  also  a  diffuse  sarcomatous 
iiiplfrdtimi  of  the  vaginal  wall.  Myxomatous  degeneration  may  occur. 
."^eccMidary  san-oma  has  Ix^mi  ol»serve<l. 

Ominonu.— Primary  carcinoma  {ipilhrlioma)  incurs  not  infrequentiv 
an.l  takes  the  form  of  a  cauliHowcr-like  mass  starting  from  the  p<xsterior 
«all.  I'.x.rptionally.  a  num-  diffuse  or  ring-like  infiltration  of  a  scirrhoun 
or  mrtliilliiri)  character  is  met  with. 

More  common  are  sw-oiidary  carcinomas  that  have  extended  from 
the  uterus,  rectum,  Mad.ler,  urethra,  or  vulva.  Metastatic  growths 
oriKHialuig  from  the  uterus  or  ovaries  are  rare,  as  are  the  cases  of 
implantation  of  cani-er  cells  from  the  uterus. 

raninoina  of  the  vagina  extends  rapidly  and  is  liable  to  ulcerate  so 
that  listulie  are  quickly  prcKluced. 

Oyste.  -rysts  originate  in  remains  .)f  the  Wolffian  or  Clartner's  ducts 
fnmi  implantation  of  epitlicliuin,  or  from  dilated  Ivmphatics. 

Foreign  Bodies  and  Parasites. -Apart  from  bacteria,  mav  I* 
mention,..!  the  Imvo!  «,f  certain  flies.  O.^yurh  vermicuhms,  AmtrU 
Im-lumwrn.^  vaginalis,  Oidlum  albicans,'  Monlla  alhicmia,  Manila 
caiimln.  and  various  yeasts. 

Evhiw^,Krus  cysts  may  penetrate  the  vagina  from  the  intestine. 

A  variety  of  foreign  IxMlies  have  Ikh'ii  found  in  the  vagina,  as,  for 
inslaiKr,  feces,  urinary  calculi,  calcified  mvomas  from  the  uterus. 
ppsxan.s  catheters,  tampons,  portions  of  "instruments,  and  objects 
mtrcKin, ,.,!  for  purpases  of  masturbation. 

;  Vi"l.    \rrhiv,  a5r  1884:  .388;  and  93:  1889:  167. 
ti  1^9'  ii.  "   '^''•'■'**  ^^^^""^  ''"  ^•'■ei'le  '™  Kindesalter.  Wion.  klin.  Woch., 


:« 


f    •      •! 


fu 


^11:1 


:|  -li^ 


!  i 


820 


THE  UTSnVS 


Foreign  bodies,  if  they  cannot  be  absorbed  or  dischw^,  Ijecome 
encrusted  with  triple  phosphates  and  carlxjnates 

TBI  UTBK7S. 

The  uterus  is  a  hollow  viscus,  compoaed  chiefly  of  unstriped  nmscle, 
with  a  certain  admixture  of  connective  tLssue,  and  lined  with  a.  iiukixis 
membrane  of  peculiar  type.  The  organ  is  formed  by  the  fusion  ..f  \\w 
MuUeriun  ducts  and  undergoes  certain  minor  modifications  of  ii.-i  form 
in  passing  from  the  infantile  to  the  adult  and  functioning  typ*- 

In  the  adult  nullipara,  the  uterus  measures  from  5.5  to  S  nii.  in 
length,  and  in  the  parous  woman,  U  to  9.5  cm.  Its  brendtii  vanrs 
from  3.5  to  4  and  5.5  to  6  cm.  respectively.  The  organ  <ontains 
abundant  Ivmpliatics,  of  which  those  of  the  cervix  dischargt-  into  ilie 
iliac,  and  tliase  of  the  corpus  into  the  lumbar  and  inguinal  gliinds.  The 
mucosa  is  about  1  mm.  thick,  and  is  compasetl  of  a  delicate,  niiiulated. 
fibrous  stroma,  containing  numerous  lymphoid  cells.  In  tins  are 
abundant  spiral  and  branching  glands  or  crypts  (glanduhi-  utriciilaresi, 
composeil.  like  the  mucosa  lining  the  cavity,  of  a  single  layer  ..f  dliaiwi, 
cylindrical  cells.  The  mucosa  of  the  cervix  is  thinner  and  more  .onipact, 
containing  short  gland-tubes,  many  of  the  cells  of  whicii  :m-  iniuiii- 
producing.  The  vaginal  |)ortion  is  covered  externally  wUli  >.|UHin()Us 
epithelium  like  the  vagina.  A  submucosa  does  not  exist  in  ili.-  uterus, 
but  the  glamls  pass  directly  down  to  the  muscle,  or  even  into  n 

During  menstruation  the'  uterus,  l)eing  to  some  extent  an  enn  ilt-  or;:aii, 
is  congestwl.  The  mucous  membrane  is  especially  hyiMivinir,  and 
hemorrhage  takes  pluc-e  fr»)m  its  surface.  Not  only  this,  l.ut  ili.re  is 
hvwrplasia  both  of  the  stroma  and  of  the  glands,  which  iKHoinc  lai^r 
and  more  elongated.  Later,  the  superficial  epithelium,  an.i  to  >()mf 
extent  that  of  the  glands,  is  cast  off.  Finally,  the  remamiii«  i  .ll-  pni- 
liferate  and  the  mucosa  is  restore*!  to  its  former  i-ondition. 

Ill  pregnancy  the  uterus  liecomes  greatly  enlarged,  rclatiy.ly  luore  so 
in  the  corpus.  '  In  the  first  half  of  gestation  there  is  said  to  be  a  tru.-  ii<«- 
fonnation  of  muscle  fil)ers,  but  later  on  there  is  simple  !)y|..itroi.i.v. 
In  the  cervical  jiortion,  in  addition  to  some  hypertrophy,  there  w  ii  imtahlc 
incn-ase  in  the  elastic  filers.  The  vessels  l)ecoine  thicken.-.!  innl  v'r.atly 
lengthenc.l,  and  the  veins  and  lymphatics  are  dilatcl.  '1  1h  mu.vu> 
membrane  is  onverteil  into  decidua,  which,  in  the  later  stag.-.  iiimI< tj.'d.'s 
fattv  and  necrotic  changes. 

After  delivery  the  uterus  l)ec.)ines  greatly  reduce.1  m  size,  at  i.ini  tmin 
(ontrartion.  aiid  later  from  atrophy  of  the  muscle  filHT>.  "In. Ii  a >«• 
show  cl.)udv,  hyaline,  and  fatty  degenerati.)n.  The  pnxrs^  ,  I  involu- 
tion usually  takes  about  six  weeks.  The  involute.1  uterus  i.  ur  f|Uite 
regains  its"  former  apjiearance.  The  corpus  remains  rvhi  .  iv  larpe 
and  thick-walle.1,  an.l  the  cavity  is  enlarged.  The  o  -  alinoM 
invariably  fissure.1  and  the  vessels  are  large,  tortuous,  an.!  nay  .sno« 
signs  of  endarteritis. 


CONOEfflTAL  ANOMAUES 


821 


OOVOBnTAL  AHOMALm. 


Two  great  classes  of  anomalies  may  be  recognized,  the  first  clue  to 
nutritive  disorders  (duHrophies),  resulting  in  abnormality  in  the  size  of 
ihf  orj.'an;  the  second,  due  to  eccentricities  of  development  {dy$jplana»). 
To  11  certain  extent  both  types  may  be  associated. 

Hyperplasia  of  the  uterus  is  occasionally  observed,  and  enlargement  of 
tlif  organ  is  deacribe«i  in  connection  with  many  of  the  dysplasias.  The 
uterus  may  be  completely  wanting  (apUaia)  or  diminutive  in  size  (hypo- 
pUsii).  Hv'poplasia  is  symmetrical  or  asymmetrical,  according  as  the 
.MuiU'rian  ducts  are  equally  or  unequally  involvetl. 

I'miisverse  flaaion  of  the  external  os  is  sometimes  met  with  and  may 
Ih-  confused  with  that  resulting  from  childbirth. 

riic  dysplasias  are  to  lie  divided  into  five  classes:  {1}  partial  or 
romplete  separation  of  the  two  Mulleriaii  flucts;  (2)  imperfect  fusion 
of  the  ducts;  (3)  imperfect  development  of  the  fundus;  (4)  anomalies  of 
the  cavity;  (5)  faulty  relationship  with  neighboring  structures. 

C()ni|)lete  aplasia  of  the  uterus  is  very  rare.  .\s  a  rule,  on  careftd 
examination,  scanty  rudiments  can  be  discovered.  In  these  cases  the 
vagina  and  external  genitals  may  Ik-  present.  The  tuU-s  and  ovaries 
may  Ih-  present  or  absent.  When  the  uterus  is  partly  formed,  the  cervical 
IM)rti(>ri  is  often  absent  or  represented  by  a  solid  mass  of  muscle. 

Anotiier  class  of  cases  is  that  in  which  there  is  an  uiiecjual  devel(i|>- 
ment  of  the  Miillerian  ducts  leading  to  asymmetry  of  the  uterus.  The 
most  marked  example  of  this  is  where  one  ihict  almost  completely  fails 
In  develop.  This  results  in  the  nt«rus  unicornis.  On  the  affected  side 
the  ovary  may  \x  well-formed,  but  cases  are  on  rei-ord  where  it  was 
defective  as  well  as  the  tulx>,  together  with  ab.sence  of  the  ureter  and 
kidney  of  the  same  side. 

Development  of  the  Miillerian  ducts  without  fusion  results  in  the  forma- 
ation  of  two  separate  uteri  and  vaginw  (uterus  didelphysV  In  certain 
rare  instances  Iwth  uteri  may  open  into  one  vagina. 

In  another  class  of  cases,  fusion  of  the  two  ducts  takes  place  only 
in  the  lower  fxjrtion  of  the  uteras,  while  above  the  ducts  remain  separate 
luterus  bicomis).  The  amount  of  separation  is  very  varialde.  The  line 
'if  diviMon  may  be  indicated  by  a  mere  depression  (uterus  arcuatus  sive 
bifundalis).  In  other  cases  it  is  anvil-shaped  (uterus  incudiformis). 
In  the  most  extreme  form  the  line  of  cleavage  extends  down  to  or  even 
into  ilie  cer\ical  portion.  Sometimes  lietween  the  halves  there  is  found 
a  v,M,(,rectal  ligament.  Rudimentary  and  a.symiiictrical  forms  of 
iilirii-  lii<ornis  also  exi.st.  The  uterine  cavities  may  Ih-  entirelv  separate 
uterus  bicomis  duplex)  or  may  unite  at  the  cer\ix  (nter.  bicom.unicollis). 
In  till'  first  case  there  may  be  a  double  vagina  or  one  with  a  .septum, 
hut  tlii>  is  not  invariable. 

^M!.  n  the  cavity  is  more  or  less  perfectly  divided  bv  a  septum  the  con- 
'lition  is  called  uterus  biloculuis  or  septiis.  Th<  se'ptum  inav  varv  in 
roniiil,  1,  ness.     \Vhen  it  extends  from  the  fundus  onlv  a  short  distance 


822 


THE  UTERUS 


into  the  cavity  we  speak  of  ntenu  bUoeolarU  fabttptiu;  when  it  niulirs 
the  cervix,  ntor.  biloe.  unieolUi;  in  other  coaes  the  .septum  is  onlv  fntind 
at  the  external  os,  ntonu  Uforii;  in  still  others,  the  septum  Ls  only  present 
in  the  cer>ix,  atar.  bieoUla  nnieorporaaa. 

Abnormalities  in  the  formation  of  the  cavity  are  common  in  the 
rudimentary  uterus.  The  cavity  may  l)e  completely  aUsent  or  liierc 
may  be  one  or  more  rudimentarj*  cavities.  It  may  lie  narrowtr  than 
normal  or  obstructnl  (itanoiii  atari). 

There  may  be  abnormal  union  with  neighboring  structures.  Tims,  the 
uterus  may  be  connected  with  the  bladder  by  a  tulie,  or  with  the  rccliim, 
either  direc-tly  or  indirectly  (eonganiUl  ntanrlieUl  flftnla;  anni  utarinni). 

Several  forms  of  anomalous  development  that  occur  suhstMnn-ntiv 
io  birth  should  be  referred  to.  The  uterus  may  never  progress  Ix-yond 
the  stage  to  which  it  attained  during  fu>tal  life  (ntanu  fatalis),  or  it  may 
]>r«'ser\p  its  infantile  characteristics  lieyond  the  period  of  |)iil>erty 
(ntanu  infantilii).  A  |HHiiliar  form  of  hy|M)plasia  is  that  in  wliiih  the 
fonii  of  the  uterus  !:•)  normal  but  its  niu.scular  elements  ure  (rn-atW 
lack  :.  The  uierine  wall  may  !)e  not  more  than  0.5  lo  1  nun.  thick 
(nterus  mambranKeos). 

Precocious  doTelopment  of  the  uterus  may  also  occur.  This  conilitiun 
may  lie  sissfx'iiitt'd  with  the  early  on.set  of  menstruation  an<l  fnl;ir);e- 
inent  of  the  breasts,  while  the  rest  of  the  body  remains  infantile  in  typ. 

The  uterus  is  occasionally  congenitally  retroflaxed,  retrovert«d,  or 
anteflexed.  In  children  with  spina  bifida  of  the  liunbosacral  re;;ioii  the 
uterus  had  lieen  found  prolapse<l.  In  .some  few  instances  tin-  uterus 
has  fornie<l  part  of  the  contents  of  a  crural  or  inguinal  hernia  (uterocelt; 
hystorocele). 


(1 


i  £i. 

f  iff 

'li- 


i(      :] 


.M 


ill 


ft' 


ACQUIRED  BCALP08ITIOM8  OP  THE  UTERUS. 

In  chi<  iren  and  young  women  (he  uterus  lies  in  contact  witli  tlie  |ios- 
terior  wall  of  the  bladder.  In  the  parous  woman,  it  may  in(  njiy  this 
position  or  may  in-  inclined  backward,  so  as  t'>  form  almost  a  iii.'lii  an;;ie 
with  the  plane  of  the  posterior  wall  of  the  Madder.  The  litinr  position 
is,  however,  generally  reganled  a.*  an  abtiorinal  me. 

The  uterus,  as  a  whole,  may  l)e  inis[il:tce(l  forwanl  ( antepositionl 
itackwarl  (retroposition),  to  the  side  (Utoroposition),  upwanl  elevationi, 
<l()wnwanl  (,m]ifmt).  It  may  lie  turned  inside  out  (inversion  .  'T  may 
form  part  of  the  <'ontents  of  a  hernial  sac  (hysterocele).  Tlie  (  IsmI Ciiist-s 
of  these  lunisiial  positions  are  pn-.ssure,  as  from  tumors.  Inn;  irriiajrr. 
and  exuilation;  weight,  as  from  uterine  growths;  and  teii>i"ii.  Irom  llie 
contraction  of  ligaments  or  inflannnalory  baiujs. 

Antej)ositioti  is  usually  due  to  tlie  action  of  tumors  in  ili.  |KMterior 
wall,  collec'tions  of  fluid  or  niisplaetnl  organs  behind  llie  ni'iii~.  l^ss 
commonly,  it  arises  from  the  contraction  of  inflaniinittoi  >  idhesion.* 
l)etween  the  uterus  and  the  bladder  or  alKlominal  wall. 

Retroposition  is  most  frequently  the  result  of  contnK  i        !  .mils  of 


ACQUIRED  MALPOSITIONS 


823 


adhi-sion  traversing  the  Douglas'  pouch  less  frequently  it  is  caused  by 
tumors  of  the  anterior  wall  or  of  the  bladder,  or  a  distended  bladder. 

I>ateroposition  is  due  to  tumors  or  cysts  in  the  broad  ligament,  to  exu- 
(lutcs  in  the  parametrium  pushing  the  organ  to  one  side,  or  to  the  traction 
of  inflammatory  adhesions. 

.\nother  important  class  of  malpositions  is  that  in  which  there  is  an 
alteration  in  tne  direction  of  the  axes  of  the  uterus.  The  organ  may  be 
rotated  in  its  transverse  axis  (Ttnton);  forward  (aatoTtnioa) ;  backward 
ir«troT6nion).  Rotation  on  the  anteroposterior  axis  leads  to  lataro- 
Tanion;  on  its  long  axis,  to  torsion. 

Retroversion  is  the  most  common  form.  The  degree  of  retroversion 
varies.  The  long  axis  of  the  uterus  may  form  an  angle  of  4.5°  with  the 
plane  of  the  superior  strait  of  the  pelvis  (first  degree),  or  Iwth  cenix 
and  fundus  may  lie  in  the  same  plane  across  the  pelvis  at  an  un^le 
of  \Xf  (second  degree),  or,  again,  the  axis  lies  at  an  angle  of  Vio°  (third 
'lepree).  The  dislocation  is  commonly  the  result  of  childbirth  or  alior- 
lion,  and  is  due  to  increase  in  the  weight  of  the  uterus,  disturbance  of  its 
nortnal  balance,  or  relaxation  of  its  sup]K>rts.  Potent  causes  are  sub- 
involution, relaxation  of  the  round  ligaments,  laceration  of  the  cervix 
and  perineum,  and  tumors  in  the  anterior  wall  of  the  uterus.  The  con- 
traction of  infiaminatoPi'  bands  in  Douglas'  sac  may  also  bring  it  about. 
On  account  of  the  impairment  of  the  circulation  induced  thereby,  the 
uterus  is  congested,  enlarged,  and  (edematous,  and  metritis  and  enilo- 
nietrilis  are  frequently  set  up. 

In  the  etiology  of  anteversion,  pregnancy  is  not  of  such  great  impor- 
tance, altiiough  pregnancy  and  subinvolution  may  play  a  part  if  the 
alKloniinal  walls  be  lax.  More  important  are  inflammatory  changes  in 
the  liody  of  the  uteriis  or  in  the  neighboring  connective  tissue. 

r.)iteral  version  is  usually  combined  with  torsion.  It  may  be  con- 
peniial,  l>ut  is  usually  due  to  adhesions  or  tumors  of  the  ovary. 

Inversion  of  the  uterus  generally  occurs  in  the  puerperal  uterus. 
rime  grades  exist:  (1)  Incomplete,  where  the  invaginate<l  fundus 
li<N  «itliin  the  uterine  cavity;  (2)  complete,  where  the  fundus  lies  in  the 
Na^rina;  and  (3)  inversion  with  prolapse,  where  the  uterus  and  vagina 
are  turned  completely  inside  out  and  the  uterus  ;ii'|>ears  at  the  vulvar 
i>riH(.'.  In  this  position  the  pneri)eriil  uterus  may  undergo  involution 
ami  iKiome  firm  and  hanl.  Uften,  however,  it  is  soft,  coiigest«Hl,  and 
tnun.Ms  membrane  thickened,  and  there  may  lye  ulceration  or  polyj)oid 
outj;r()\vt!is.  The  interstitial  tissues  show  inHarnmalory  hyjK'qilasia, 
the  ;.'hin(!s  gradually  atrophy,  ai  least  in  the  more  siij)erficial  jJarts,  while 
they  proliferate  deeper  down.  In  loiig-sfandiiig  cases,  the  epitlieliuin 
of  the  mucosa  is  converted  into  a  horny  layer  of  squamous  cells  resembling 
skin.  As  will  reailily  1k>  understood,  circulatory  disturbances  may  be 
extn  iiie  so  that  ulceration,  necrosis,  anu  gangrene  may  result,  with 
cimiph  te  separation  of  the  part. 

IVnlijisc  is  the  condition  in  which  the  uterus  a.s  a  whole  (x-cupies  a 
h'«>  r  |M.,ition  in  the  pelvis  than  normal.  Varying  grades  exist.  When 
the  i\!i  rnal  os  reaches  no  farther  than  th(   floor  of  the  pelvis,  we  speak 


!.§■■ 


ftM 


THE  UTERUS 


(Hi 


t  "3 


;•! 


SI 


of  dffrent;  when  it  prutrudes  through  the  vulvar  openinff,  it  is  innimfilrtt 
pnlapte;  wl»en  the  uterus  ia  entirely  outside  the  body,  it  is  awifilHt 
prolapae.  riomc  writers  consider  as  prolapse  a  condition  in  whiih 
the  corpus  remains  in  its  normal  site  but  the  cervix  is  fl(>n)(aliii.  It 
is  more  correti,  howtvrr,  to  tcnn  this  hypertrophy  of  the  cenix.  It 
mav  exist  hoth  with  and  without  true  prolapse  or  descent. 


Fio.  2IH 


(Vimplptr  prolipK  of  the  utcruii.     Frum  tbs  riynecoluci»l  Clinic  <.f  Ih.-  M..ii.r.iil 
Otntni  HnapitaJ.) 

The  causes  of 'prolapse  are  numerous  and  usually  several  arc  (i|Hrative 
at  the  sani>-  time.  The  chief  are,  retroversion  and'  n-troflcxioii.  « iili  ilie 
conditions  leadiiif;  to  them;  lack  of  tone  of  or  injurj-  to  the  |hI\ ii  lloor; 
relaxation  of  the  uterine  ligaments  from  freqtient  clii1dl)eariii^':  Iik  riii-^-d 
weight  of  the  uterus;  weakness  of  the  abdominal  wall.  Hardy,  m.  obvi- 
ous cause  can  he  made  out,  as  in  a  case  occurring  in  a  virgin,  iii:i  '1  M\tc<-n 
years,  rtrorded  by  Duncan.' 

In  prolapse,  the  circulation  is  markedly  interfered  with,  li  lin;;  lo 
congestion  and  uniema  of  the  organ  and  hyperplasia  InMh  of  lin  miwle 
and  the  endometrium,  together  with  chronic  metritis  and  tii.lniniiriiii. 
There  may  In;  wtropion  of  the  mucasa,  with  erosion.  As  a  iilf.  tlie 
bladder  or  rectum  or  both  accompany  the  uterus  in  its  descent  islmrle, 
rccUwcle). 

Elevation  of  the  uterus,  apart  from  the  gen  ral  increase  in  ■  i\w  to 
the  presence  of  a  foetus  or  the  accumulation  of  Huid  in  the  >  a\  i.     Imlro- 


*  Brit.  Med.  J'  III.,  1:1890:404. 


PLEXIOS 


828 


nirira,  henutometn),  may  lie  catued  by  tumors  growing  in  the  cavity 
or  vagina,  extravasations  of  blood  in  the  Douglas'  pouch,  or  by  tumors 
ill  (he  uterine  wall,  ovaries,  and  ligaments,  'llie  puerperal  uterus  may 
also  become  attached  to  the  abdominal  wall,  so  that  when  parturition 
tiikfs  place  involution  cannot  take  place  normally  and  the  uterus  re- 
riiiiiiis  |M*rmanently  in  a  high  position.  The  uterus  is  also  attachnl  high 
up  ill  the  operation  of  ventral  tixation.  The  condition  may  lead  to  elonga- 
tion of  the  organ,  atresia  of  the  cavity,  and  atrophy  of  the  cer\ix. 

( )ne  of  the  rarest  anomalies  of  position  is  Iqrttanctla.  Not  only  may 
lh<>  (jiiiescent  but  also  the  pregnant  uterus  be  involved.  As  a  rule,  the 
tiiU's  and  ovaries  are  first  engaged  in  the  hernial  sac  and  the  uterus  follows 
owing  to  the  traction.  The  utenis  has  been  found  in  ingiiiiiul,  crural,  and 
vfitrral  hernias. 

Wlu'ii  the  l)ody  of  the  uterus  is  lient  iipon  the  cer\-i«al  portion  we 
s|M'iik  of  flaxioB.    Antafltxion,  ratroflaxion,  and  lateral  flaxion  are  iIcxcrilHtl. 

It)-ln>flexiun  is  the  commonest,  ami  is  often  Hss(N'iated  with  retro- 
version. In  severe  cases  the  fundus  is  fouml  in  the  hulluw  of  the  .sacrum. 
When  pregnancy  occurs  in  such  a  uterus  the  organ  may  Ik-  iiican-cratetl 
in  its  false  {XKiilion.  Hetroflexion  has  iM-e ii  known  tt)  oiriir  in  iiulli|)ara' 
ami  ncwlM)rn  children,  but  pregnancy  is  the  most  iiniMirtant  pn  disposing 
(•aii>f.  Uclaxation  of  the  ligaments,  anterior  ii.xalion  of  tiie  ceni\, 
liiinors,  inflammaton-  adhesions  are  also  of  iniportaiice.  ItetroHexion 
is  fr«M|iiently  combined  with  total  prolapse 

.\ntfHcxion  is  present  when  the  uterus  does  not  assume  its  onliiiar>' 
elfvatwl  |H>sition  during  the  filling  of  the  bladder  and  remains  in  part 
of  its  length  tilted  forwanl,  or  when  the  angle  iK-tween  the  axes  of 
corpus  and  cervix  is  l.'J.'j"  or  less.  When  the  anjjic  is  from  \:\b°  to  W)° 
it  iKiislitufes  the  first  degree  of  anteflexion ;  when  from  !K)°  to  -1.')°,  the 
Msond  decree;  45°  or  less,  the  third  degree.  The  chief  causes  are 
Iraerion  on  the  cervi.x  by  adhesions  in  the  Douglas'  pouch  in  the  iieigh- 
lM)rluKKl  of  the  os,  or  by  bands  between  the  fundus  and  the  bladder. 
Ill  the  infantile  form,  shortness  of  the  anterior  vaginal  wall  is  of  chief 
importunce.  In  adults  the  weight  of  the  aixlominal  contents,  where 
the  MlHJoininal  wall  is  relaxed,  plays  the  main  n)le. 


ABNORMALITm  OV  THS  UTERINB  OAVITT  AMD  OF 
ITS  OOHTINUITT. 

Stenosis.— Narrowing  of  the  uterine  cavity  may  Ik-  (onj^-nital  or 
a(c|iiirrd.  I'artial  narrowinjj  (stenosii)  usually' (x-ciirs  at  either  the  ex- 
ltrii;il  c.r  internal  os,  rarely  at  lM)tli.  Stenosis  of  the  internal  os  is  common 
111  <l.|,rlv  jM-opIe.  Complete  obliteration,  atresia,  also  (K-ciirs.  The 
iliK f  reuses  in  the  ac(|uired  forms  are  mucus  or  tumors  blixking  the 
<;avii\    iiiHainmation  and  oedema  of  the  endometrinni;  flexions  or  elonpi- 

'  '•'*•  uterus;  and  traumatism,  such  as  arises  from  cauterization  or 

t'lirriiiiit;. 

Dilatation.— Dilatation  of  the  cavity  is  produc-e<l  bv  intra-uferiiic 
jtn.u'iK  (,r  collections  of  fluid.     In  young  and  vigorous  individuals  the 


MKROCOPY   RBOIUTION   TBT  CHART 

(ANSI  and  ISO  TEST  "HART  No.  2) 


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/^PPLIED  ItVHGE    Inc 

1653   Eost    Mam   St'Wt 

RochMtef.   New   Yorh  14609       USA 

(716)   ♦as  -  0300  -  Phone 

(716)   288  -  5989  -  Fa>. 


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826 


THE  UTERUS 


muscular  wall  hypertrophies  as  well,  but  in  elderly  persons,  in  whom  tlie 
uterus  lacks  tone,  dilatation  is  often  unaccompanied  by  hypertrojiln. 

According  to  the  nature  of  the  contained  substances,  we  sjx'ak  of 
bydrometnt,  hematometra,  pyometn,  locbiometta,  and  pbysometra. 

Hematometra  is  the  condition  in  which  menstrual  blood  colltcts 
within  the  uterus  owing  to  congenital  or  acquired  atresia  of  the  f;t'iiital 
canal.  When  the  occlusion  is  in  the  vagina,  hematometra  is  conihimd 
with  hematocolpos.  In  advanced  cases  the  Fallopian  tubes  are  (iiiatwi 
as  well  (hematosalpinx).  Perhaps  the  commonest  cause  is  imperforati- 
hymen.  In  these  instances  the  uterus  may  attain  the  size  of  tiie  heaii. 
Rupture  rarely  takes  place.  The  contents  are  thick,  brownish-black 
blood,  with  cholesterin. 

Hydrometra  comes  on  after  the  menopause.  Atresia  is  again  tlie 
cause,  or  sometimes  a  tumor  obstructing  the  cervical  canal.  The  ainonnt 
of  fluid  is  rarely  large.  In  appearance  it  is  clear  and  colorless,  gravish 
and  cloudy,  or  possibly  mixed  with  blood  or  mucus.  The  mucous 
membrane  becomes  atrophied  from  pressure  and  the  epithelial  cills  are 
flattened.  Pyometra  is  usually  due  to  the  suppuration  of  a  tumor  in 
the  cervical  canal. 

Physometra,  or  gas  in  the  uterine  cavity,  occurs  most  frequt'iuiy  in 
the  puerperal  uterus  from  the  decomposition  of  blooti,  membranes, 
or  placental  remains.  It  may  also  l)e  due  to  the  decomposition  of  a 
malignant  growth.  Anaerobic  bacilli  of  the  malignant  oetlenia  class, 
B.  Welchii,  etc.,  may  occasionally  lead  to  the  condition.' 

DivertiCllla. — Diverticula  may  form  in  the  uterine  wall  owinj;  to 
irregular  involution  (Klebs'),  or  to  the  scarring  of  the  wall  followini: 
partuntion  or  Cesarean  section. 


WOUNDS  AND  OTHER  INJURIES. 

Rupture. — Rupture  of  the  uterus  almost  invariably  occurs  in  coMncc- 
tion  with  the  pregnant  or  parturient  state.  The  tearing  of  llic  k  tvix 
is  one  of  the  con:.aioi..3t  events  during  delivery.  All  grades  cxi>i,  from 
a  slight  fissure  of  the  mucosa  to  a  rent  that  extends  into  the  wu^vk-  or 
even  into  the  abdominal  cavity.  The  laceration  is  unilateral,  liilaicral, 
or  stellate,  and  usually  runs  in  the  long  axis  of  the  uterus.  In  raic  cases 
the  cervix  is  torn  in  its  transverse  axis.  One  or  other  lip,  or  (m  ii  the 
whole  cervix,  may  be  torn  off.    Rupture  may  also  take  place  in  ilic  later 

ill  from 

li  has 

Ikii'm  or 

!Ii|clioII 


months  of  pregnancy,  in  cases  where  the  uterus  is  abnormall' 
inflammation,  thin-walled,  or  scarred  from  previous  operations, 
been  met  with  where  pregnancy  has  occurred  in  a  rudiinentarv 
in  an  incarcerated  uterus,  or,  again,  where  there  has  been  uli 
to  the  progress  of  labor. 

Bruising,  laceration,  and  perforation  of  the  uterus  sonictiirK 
during  operative   measures   (curetting)   and   in   attempts  at 

'  Sec  T.itiHonthal,  Mnnatswhr.  f.  Geh.  ii.  G)-n.,  7:  1S98:  2(i!> 
'Partielle  Erweiterung.  Handb.,  1:  2:  1876:  900. 


iicciir 
riiiiiiial 


METRORRHAatA 


827 


abortion.  As  a  rule,  the  rupture  is  at  or  near  the  fundus.  Besides 
this,  perforation  may  be  due  to  ulceration,  pressure  necrosis,  and 
tumors.  Fistulous  communications  may  b«  pened  up  vith  the  vagina 
[(■(rricovaginal  fisttUa),  the  bladder  (uierovesical  fistula),  or  the  rectum 
{rectovaginal  fistula). 


CIBOULATOET  DISTURBAMOES. 


Anemia. — Anemia  of  the  uterus  is  found  in  cases  of  generalized 
anemia,  and,  according  to  Rokitansky,  in  hypoplasia  of  the  organ. 

Hyperemia. — Hyperemia  is  found  physiologically  during  menstrua- 
tion, pregnancy,  and  for  some  time  after  full-term  delivery  and  abortion. 
It  is  said  to  be  caused  also  by  sexual  excitement. 

Pathological  activa  hyperesda  is  found  in  many  of  the  infective  fevers, 
as  typhoid,  influenza,  and  the  exanthemata.  As  a  rule,  the  mucosa  of 
the  corpus  is  affected,  being  reddened  and  swollen.  Collateral  hyperemia 
may  occur  when  one  part  of  the  uterus  is  compressed  from  any  cause. 

Passive  hypeivmia  is  very  common.  It  occurs  in  systemic  venous 
stasis  or  from  local  causes,  such  as  pressure  of  the  distended  rectum  or 
bladder,  prolapse,  anteversion,  retroversion,  and  inversion.  Hyperplasia 
is  not  infrequently  combined  as  well. 

Hemorrhage. — Hemorrhage  is  one  of  the  commonest  occurrences  in 
the  uterus.  This  is  not  surprising  when  we  bear  in  mind  the  physio- 
logical tendencies  in  this  direction.  The  extravasation  of  blood  takes 
place  into  the  uterine  cavity  or  into  the  endometrium.  WTien  retained 
witiiin  the  uterus  hematometra  results.  Hemorrhage  occurs  most  fre- 
quently during  or  subsequent  to  parturition.  It  may  also  be  due  to  trau- 
matism, ulcerating  new-growths,  or  to  retrograde  changes  in  advanced 
life. 

Metrorrhagia. — Metrorrhagia  is  hemorrhage  from  the  uterus  at  times 
other  than  those  of  the  usual  menstrual  discharge.  Apart  from  preg- 
nancy and  the  parturient  state,  it  occurs  in  hemophilia,  scurvy,  the 
hemorrhagic  diatheses,  typhoid,  sepsis,  the  acute  exanthemata,  acute 
yellow  atrophy  of  the  liver,  and  phosphorus  poisoning.  Local  disease 
of  tlie  uterus,  such  as  endometritis,  myomas,  ulcerating  cancers,  also 
accounts  for  many  cases.  After  abortion,  and  even  full-term  delivery, 
small  portions  of  placenta  may  be  retained  and  lead  to  hemorrhage. 
In  some  cases  the  blood  clots  upon  the  adherent  tissue  and  forms  a  fibrin- 
ous ))()lypoid  mass  (hematoma  polyposum,  Virchow).  In  extra-uterine 
fresiiition  a  special  form  of  metrorrhagia  with  exfoliation  of  the  decidua 
ni:iy  occur.  Hemorrhage  into  the  mucosa  may  Itid  to  the  formation 
of  liirjrp  coagula  (hematomaia).  A  special  form  is  the  so-called  apoplexy 
(<  riiveilhier)  of  the  uterus  that  occurs  in  ohl  women.  The  uterus  is 
iilf"l)hic  and  brittle,  the  vessels  stand  out  as  rigid,  tortuous  tubes,  and 
the  mucous  membrane  is  swollen,  friable,  and  infiltrated  with  blood. 
H.  -mrrhage  may  also  occur  in  the  muscular  wall.  The  cervix  and  the 
ponici  vaginalis  escape. 


4 


jl 

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Hi 
■  1- 

82S 


THE  UTERUS 


Menoirhagi*. — Menorrhagia  is  an  excessive  menstrual  discharge.  It 
is  due  to  a  variety  of  causes,  among  which  may  be  mentioned  gent- rul- 
ized  passive  congestion,  endometritis,  tumors  of  the  uterus,  and  polyps. 
In  some  cases,  in  addition  to  menstrual  blood,  shreds  of  memhnine 
are  cast  off  (dyamenorrhcea  membranacea).  The  entire  lining  of  (he 
uterus  may  be  exfoliated  in  this  way. 

Micrcscopically,  the  membrane  consists  of  a  cellular  mucosa  with 
infiltrated  connective  tissue  and  remnants  of  glands.  The  epitheliiiin 
may  be  unaltered  or  fattily  degenerated  and  desquamating.  In  otiier 
cases  the  membrane  consists  simply  of  a  fibrinous  cast  of  the  uterine 
cavity.  A  peculiar  form  of  membrane  is  one  consisting  of  squamoii.s 
cells  and  containing  the  orifices  of  glands.  As  the  cavity  of  the  uteras 
does  not  normally  possess  such  cells,  it  is  supposed  that  in  these  cases 
the  epithelial  lining  of  he  vagina  has  extended  farther  thr.n  usual  into 
the  cervix  and  that  the  membrane  b  derived  from  the  anomalous  cervix. 

(Edema. — This  is  due  to  passive  congestion  and  inflaiiiination. 
The  first  type  is  well  seen  in  casei  of  mddenly  acquired  malpo-sition,  as 
retroversion. 


■Ill-' 


XNIXAUMATIONS. 

Inflammation  may  affect  the  serous  covering  of  the  uterus  (peri- 
metritis), the  broad  ligaments  (parametritia),  the  myometrium  (metritis), 
ur  the  endometrium  (endometritis). 

Perimetritis. — Perimetritis  is  merely  a  local  peritonitis,  pr,<\  will  !«• 
dealt  with  under  that  head. 

Endometritis. — Endometritis  is  due  usually  to  an  extension  of  in- 
flammation from  the  vagina,  but  rarely  is  hematogenic.  It  nmy  l* 
confined  to  the  cervix  (cervical  endometritis)  or  to  the  corpu.s  {mrinmal 
endometritis),  or  may  involve  the  whole  of  the  lining  membrane.  The 
affection  arises  most  frequently  during  menstruation,  and  the  puerpcriimi. 
According  to  the  mode  of  development  we  can  recognize  acute  and 
chronic  forms,  or  according  to  the  morbid  changes,  exudative  and  pro- 
ductive. 

Acute  Oatwrhal  Endometritis. — In  acute  catarrhal  endometritis  tlie 
mucous  membrane  is  reddened,  swollen,  and  infiltrated  with  inllani- 
matory  products.  The  secretion  fiom  the  cervix,  which  noriiKilly  is 
scanty,  viscid,  and  mucoid,  becomes  more  abundant,  more  nin<oid.  or 
mucopurulent.  That  from  the  corpus  is  thinner,  serous,  or  .seropuniltiit. 
A  purulent  exudate  (fluor  albus;  leucorrhoea)  is  more  coinn  n  in 
cer\-ical  endometritis  than  in  corporeal.  In  very  severe  cases  vvv  dis- 
charge may  be  mixed  with  blood.  This  is  particularly  the  i.  -<■  in 
the  form  arising  during  the  infective  fevers,  such  as  typhoid,  <  iiojira, 
and  the  exanthemata.  Here  we  may  perhaps  speak  of  a  hrwonhnqic 
endometritis.  This  usually  affects  the  orpus.  Should  tiie  inicai 
canal  become  obstructed,  the  pus  accumulates  within  the  uterii"  avity 
(pyomeira).  In  some  cases  the  retained  material  becomes  in--]i  -  aied, 
forming  a  granular,  pulpy  detritus  resembling  caseous  matti  i     The 


ENDOMETRITIS 


829 


disease  is  usually  traceable  to  irritation  and  infection  of  the  endometrium, 
the  extension  of  inflammation  from  the  myometrium  or  uterine  adnexa, 
guiiorrhoea,  constitutional  diseaspj,  disorders  of  the  circulation  in  the 
uterus,  or  the  presence  of  neoplasms. 

Microscopically,  changes  are  found  both  in  the  glandular  structures 
and  in  the  stroma.  The  mucous  membrane  is  infiltrated  with  inflam- 
matory products,  and  the  celb  of  the  interstitial  substance  are  more  or 
less  dissociated.  The  bloodvessels  and  lymphatics  are  dilated  and  there 
may  be  minute  hemorrhages.  The  epithelial  cells  are  swollen,  granular, 
and  desquamating,  while  the  ducts  may  be  blocked  with  secretion.  In 
some  cases  the  most  marked  changes  occur  in  the  stroma  (interatiti«l 
endometritis),  which  is  cedematous  and  infiltrated  with  round  celb,  so 
that  the  gland-tubules  are  dislocated.  The  epithelium  here  also  shows 
degenerative  changes. 

Membranons  Endometritis. — Another  form  of  acute  endometritis  is 
the  membranous.  It  occurs  by  far  the  most  frequently  in  the  puerperal 
uterus,  but  is  occasionally  met  with  in  the  infectious  diseases,  such  as 
typhoid,  cholera,  and  the  exanthemata.  True  diphtheria  of  the  endo- 
metrium has  been  observed,  secondary  to  infection  of  the  vagina.  Mem- 
branous endometritis  may  also  be  found  associated  with  ulcerating 
cancers  or  other  tumors  of  the  uterus.  The  process  resembles  that 
obser\ed  in  other  mucous  membranes.  A  fibrinous  exudate  b  thrown 
out  which  coagulates  upon  the  surface  and  forms  a  membrane  that  may 
be  exfoliated.  Microscopically,  this  consists  of  interlacing  threads  of 
fibrin,  including  leukocytes,  showing  hyaline  degenci-ation. 

Chronic  Endometritis. — Chronic  endometritis  assumes  the  guise  of  a 
catarrhal  inflammation.  Inasmuch  as  it  is  accompanied  by  an  abundant 
excretion,  but  the  most  important  feature  is  the  proliferation  of  tissue 
(productive  endometritis).  Chronic  productive  or  proliferating  endo- 
miirUis,  as  it  affects  the  corpus  uteri,  takes  the  form  of  a  new-growth 
of  tissue  (endom.  hyper plastica),  which  later  on  gives  rise  to  a  form  of 
atiopliy  of  the  mucosa  {endom.  atrophica).  In  the  earlier  stages  tlie 
nuicous  membrane  is  thickened,  its  surface  smooth  or  irregular,  warty 
or  villous  (fungous  endometritis).  All  grades  exist  from  simple  nodular 
elevations  to  polypoid  or  pedunculated  outgrowths  (endom.  polyposa). 
Tile  mucosa  is  also  reddened  and  may  show  hemorrhages.  At  the 
menstrual  period  the  lining  of  the  uterus  may  be  exfoliated  in  shreds  or 
as  a  perfect  cast  of  the  cavity  (dysmenorrhcea  membranacea;  endom. 
i:rfi}llntlva).    The  tissue  is  soft,  loose,  and  friable,  often  porous. 

Microscopically,  in  ordinary  proliferating  endometritis,  the  gland- 
tiiliules  are  enlarged,  often  lengthened  and  tortuous,  and  present 
Miiinorotis  irregular  dilatations  even  to  the  extent  of  cyst-formation. 
The  overgrowth  may  be  so  great  that  papillary  masses  project  from 
the  ^urface.  The  epithelial  celb  have  in  great  part  lost  their  cilia, 
and  ;ire  clear,  swollen,  and  mucoid.  Active  mitosis  is  abo  going  on. 
Tli.  lumen  of  the  ducts  is  filled  with  mucus,  desquamated  epithelium, 
anil  le-ikocytes.  The  intei-stitial  stroma  is  infiltrated  with  leukocytes, 
and  shows  proliferation  both  of  the  cellular  elements  and  fibrous  tissue. 


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THE  UTERUS 


This  may  lead  to  increased  vascularity  of  the  membrane  with  permanent 
induration  and  contraction.  The  enlarged  tubules  commonly  penetrate 
between  the  muscle  bundles  of  the  uterir. ,  wall  {glandular  heterotopia, 
Cornil).  TL:s  must  not  be  mistaken  for  malignancy,  for  it  should  be 
remembered  that  the  uterus  possesses  no  submucosa,  and  the  >;luii(is 
normally  abut  upon  and  occasionally  penetrate  the  muscular  layers.  It 
is,  however,  doubtless  true  that  such  proliferation  forms  a  ready  starting 
point  for  malignant  transformation.  As  distinguished  from  the  ulH>ve 
type,  which  i-  ilso  termed  chronic  glandular  endometritis,  we  have  to 
recognize  an  interstitial  form  in  which  the  morbid  changes  predominate 
in  the  interstitial  substance. 

In  the  later  stages  of  the  disease  a  form  of  atrophy  may  set  in  not 
unlike  senile  involution.  The  mucosa  becomes  smooth  and  thin,  often 
pigmented,  and  is  firmer  an<l  more  fibrous  than  normal.  Not  infre- 
quently, it  contains  cysts  about  the  size  of  a  pin-head,  containing  a  clear 
or  slightly  turbid  fluid  (endom.  chronica  cystica).  Microscopically,  there 
is  proliferation  of  the  stroma  with  the  production  of  dense  fibrons  or 
scar  tissue.  This  leads  to  atrophy  of  the  gland-tubules  with  contniction 
of  certain  sections  of  them,  so  that  they  become  dilated. 

As  a  result  of  the  irritation,  or  perhaps  to  some  extent  from  pressure, 
the  cylindrical  cells  of  the  mucosa  may  become  converte<l  into  s(|ininH)us 
cells  {ichthyosis  or  psoriasis  uteri).  This  has  an  importaFit  l)earin};  in 
vii  w  of  the  fact  that  squan*  :)us-celled  carcinoma  may  occur  in  the  corpus. 
It  should  be  remarked  in  this  connection,  however,  that  while  emlonie- 
tritis  plays  a  most  imp'^rtant  part  in  this  metaplasia,  it  is  po.ssii)ly  not 
the  only  factor,  for  islets  of  squamous  cells  have  been  foiuid  in  the  dccidua 
(Gottschalk  and  Winckler;  Opitz  and  Gebbard),  and  in  the  uteri  of 
foetuses  and  infants  (Meier  and  Friedlander). 

The  causes  of  chronic  endometritis  vary  considerably.  An  important 
role  is  played  by  local  disturbances  of  the  circulation,  such  as  are  brouf;ht 
about  by  retroflexion  and  retroversion.  Intra-uterine  tumors  and  di.s- 
ease  of  the  ovaries  may  lead  to  irritation  of  the  endometrium.  Ivndo- 
metritis  may  also  follow  the  puerperium  when  portions  of  the  products 
of  conception  are  retained  or  when  infection  has  taken  place,  (ionor- 
rhoea  is  also  another  important  factor. 

Chronic  Cervical  Endometritis. — Chronic  cer\'ical  endometritis  is  almost 
invariably  accompanied  by  vaginitis.  The  mucosa  is  reddened  and 
.swollen,  and  polypoid  outgrowths  are  not  uncommon.  It  is  not  ini- 
common  for  small  cysts  to  be  produced,  the  so-called  ovula  Xnli'ithi, 
which  vary  in  size  from  that  of  t  hemp-seed  to  a  pea.  Tiny  may 
project  into  the  lumen  of  the  cenix  or  may  be  concealed  in  the 
deeper  layers.  The  contents  are  usually  a  clear  viscid  mucus,  or  miy  be 
cloudy  from  the  presence  of  degenerating  cells.    The  cvsts  may  t»  (ome 


infected  and  produce  follicular  abscesses.    They  are  of  the  n 
retention  cysts. 

Microscopically,  there  is  inflammatory  infiltration  with  seme  i 
ment  of  the  glands.  The  epithelial  cells  are  in  many  cases  co 
into  goblet  cells. 


It  ire 


of 


■ar^- 
>erted 


METRITIS 


831 


.Vs  a  rule,  there  is  an  abundant  mucoid  or  mucopurulent  secretion 
{kiicorrhaeay  In  women  who  have  borne  children,  and  in  whom  the 
external  os  is  therefore  large  and  fissured,  the  reddened  and  swollen 
membrane  may  be  everted  (ectropion).  As  a  result  of  this  ectropion 
erifsions  .ire  frequently  found  in  the  portio  vaginalis,  which  present  as 
red,  glistening  patches  that  are  moist  and  bleed  at  the  slightest  touch. 
Tlie  surface  may  be  smooth  and  velvety  (aimjJe  erosion),  papillomatous 
(papillary  erosion),  or  may  presei.t  ni  merous  cysts  (cystic  erosion). 
From  suppuration  and  rupture  of  the  cysts,  follicular  ulcers  are  pro- 
duced. 

Microscopically,  there  is  superficial  los."  of  substance,  with  congestion 
and  the  formation  of  granulation  tissue.  In  old  erosions  one  sees  futty 
dejieiieration  or  even  calcifica»'on.  A  point  of  some  importance  in  con- 
nection with  the  etiology  and  forms  of  carcinoma  is  the  replacement 
of  tlie  eroded  squamous  epithelit  i  of  the  portio  vaginalis  by  a  layer 
of  cvliiidrical  cells  as  well  as  the  Lxination  of  glands  similar  to  those  of 
the  cervical  cavity. 

Chronic  cervical  catarrh  frequently  gives  rise  to  hyperplasia  of  the 
niuscidar  structures,  and  occasionally  to  adhesion  or  obstruction  of  the 
canal  near  the  internal  os. 

Ttie  most  important  causes  of  the  condition  are,  traumatism  during 
cliil(ll)irth,  and  vaginitis  extending  to  the  cervix.  Gonorrhoea  is  the 
most  frequent  infective  cause.  The  erosion  is  brought  about  not  only 
from  the  irritation  of  the  inflammatory  agents  but  also  by  the  macerating 
action  of  the  secretions  that  escape  from  the  canal. 

Metritis. — Inflammation  of  the  muscular  wall  of  the  uterus  is  called 
metritis. 

Acute  Metritis. — Apa-t  from  the  puerperium,  acute  metritis  is  rare  and 
due  generally  to  trauma  or  to  hematogenic  infection.  The  uterus  is 
con<;ested  and  oedematous,  soft  and  doughy,  while  o.i  section  small 
hemorrhages  may  be  ob?er\-ed  in  its  substance  and  beneath  the  serosa. 

Microscopically,  one  sees  inflammatory  leukocytes  about  the  vessels, 
the  interstitial  tissue  is  (Edematous,  and  the  muscle  Sbers  swollen  and 
cloudy.  In  raie  instances,  abscesses  are  formed  that  may  attain  a 
larpe  size.  In  such  cases  the  pus  may  be  discharged  into  the  uterine  or 
peritoneal  cavities,  vagina,  rectum,  bladder,  intestine,  or  even  externally. 
Septic  peritonitis  can  be  sec  up  by  the  extension  of  a  metritis. 

Chronic  Metritis.-— Chronic  metritis  is  usually  attributable  to  chronic 
endometritis,  traumatic  insults,  and  subinvolution.  Potent  predisposing 
causes  are  repeated  or  chronic  congestion,  such  as  is  brought  about  by 
dislo(ations.  The  disease  occasionally  follows  the  acute  form.  The 
uterus  is  more  or  less  elongated,  and  the  anteroposterior  transverse 
diameter  is  increased.  Both  the  overlying  peritoneum  and  the  endo- 
mefrimn  are  thickened.  In  the  earlier  stages  the  uterus  is  sof^  congested, 
out  l.iier  Becomes  firm  and  indurated.  On  section,  in  long-standing 
cases,  the  tissue  is  grayish  in  color,  tough  and  fibroid. 

Microscopically,  there  is  an  accumulation  •  'sukocytes  about  the 
vessels,  although  this  is  not  a  marked  feature.  i  interstitial  connec- 


i,  ! 


01 


r 


!»    i 


i  - 


S  THE  UTERUS 

tive  tissue  is  increased.  Numerous  "  Mast-zellen"  may  be  seen  in  the 
interstices  of  the  stroma.  The  condition  of  the  muscle  varies  according 
to  circumstances.  It  may  be  normal,  or  hj^iertrophied,  where  excessive 
uterine  contraction  has  taken  place,  or,  again,  may  be  atrophic. 

TnberctllOBis. — Genital  tuberculosis  is  rarer  in  women  than  in  men. 
Tuberculosis  of  the  uterus  is  almost  invariably  a  descending  infection 
originating  in  the  Fallopian  tubes.  Not  infrequently,  the  lungs,  kidneys, 
and  peritoneum  are  involved  at  the  same  time.  Hematogenic  infettion 
is  met  with  in  the  disseminated  miliary  form  of  tuberculosis.  It  is 
questionable  whether  primary  tuberculosis  ever  takes  place  under 
ordinary  circumstances.  The  affection  has  been  found  at  all  apes, 
from  infancy  to  old  age,  but  is  most  common  during  the  period  of 
greatest  vitality. 

The  body  of  the  uteru?  la  the  site  of  election.  The  disease  begins  at 
the  orifices  of  the  tubes  and  thence  spreads  throughout  the  endometrium, 
generally  stopping  abrupdy  at  the  internal  os.  It  may,  however, 
extend  to  the  cer\-ix  and  even  to  the  vagina. 

Several  forms  may  be  differentiated:  (1)  Ac  >te  miliary  tuhercu- 
loaia;  (2)  chronic  local  tuberculosis;  and  (3)  diffuse  fibroid  tubercuhms. 
In  the  earlier  stages  the  lesions  produced  are  not  unlike  those  of  ciironic 
productive  endometritis.  The  mucosa  is  soft,  swollen,  and  retldened, 
often  noilular.  Microscopically,  the  resemblance  to  productive  endo- 
metritis is  also  close,  with  the  addition,  however,  of  giant  cells  in  the 
neighborhood  of  the  areas  of  cellular  infiltration. 

Sooner  or  later  caseation  sets  in  and  the  tubercles  are  recognizable  as 
grayish  elevations.  The  epithelium  of  the  glands  shows  evidence  of 
cloudiness  and  degeneration,  and  the  tubules  tend  to  disappear  in  the 
course  of  the  formation  of  what  amounts  to  tuberculous  gri>  puliation 
tissue.  Caseation  rarely  remains  local,  and  the  rule  is  for  neigiil)oring 
tubercles  to  coalesce  until  the  whole  endometrium  is  convert'  1  'iito  a 
caseous  mass.  The  surface  of  the  uterine  wall  becomes  un  ^ . 
and  eroded,  and  the  uterine  cavity  is  more  or  less  complete 
a  caseopurulent  detritus.  The  walls  of  the  uterus  are  oi 
The  destructive  process  gradually  extends  into  the  m- 
small,  caseous  foci  may  be  found  along  the  margin  of  th. 
zone,  or  simplv  areas  of  cellular  infiltration  with  giant  cells. 

Tuberculosis  of  the  neck  of  the  womb  as  a  primary  disease  is  exces- 
sively rare.  The  cer\'ix  may  lie  enlarged  and  the  lesions  prodiu  e<i  are 
similar  to  those  in  the  corpus. 

Syphilis.— The  indurated  primary  sore  may  be  found  on  tlic  portio 
vaginalis  and  within  the  cervical  canal.  The  cervix  may  bt  .swollen 
and  hvpertrophied,  and  there  is  frequenUy  a  complicating  entioiu.intis. 
The  ulcer  does  not  differ  materially  from  those  found  on  other  mucous 
surfaces.    Secondary  lesions  are  also  met  with. 

Parasites  and  Foreign  Bodies.— Bacteria  and  yeasts  nf  \arious 
kinds  are  found  in  the  cervical  secretion.  The  most  importniu  v^^^^ 
is  the  Echtnococcus.  The  cysts  are  usually  submucous,  but  lune  been 
found  also  in  other  situations.    The  disease  may  form  a  hiiilnmce  tg 


1. 

.a 

roved 


m 


HYPERTROPHY 


S33 


childl)earing,  as  in  8  case  recorded  by  Birch-Hirschfeld.'    A  calcified 
round-worm  has  Ij^en  found  on  the  jwsferior  wall  of  the  uterus. 

Among  foreign  bodies  may  be  mentioned  t«nU,  eathatwi,  nMdlM, 
fatal  ramaini,  eloti,  bits  of  tnmon,  and  frM  m^flbromai. 


KITKOORBSSIVX  MXTIMOSPHOSSS. 

Ateophy.— Simple  atrophy  of  the  uterus  is  of  common  occurrence, 
and  is  found  more  especially  in  women  past  the  climacterium.  It  may 
also  be  found  in  what  has  been  called  premature  senility,  where,  either 
from  operative  interference  (castration),  tumors,  or  inflammation,  the 
normal  function  of  the  ovaries  is  markedly  inhibited.  The  process 
affects  first  and  chiefly  the  portio  vaginalis,  in  contradistinction  to  what 
occurs  in  congenital  hypoplasia,  where  the  corpus  is  the  part  mainly 
involved.  The  uterus  is  small,  thin-walled,  the  muscle  fibers  wasted, 
so  that  the  connective  tissue  appears  to  be  increased.  The  vessels 
are  atheromatous.  The  mucous  membrane  is  thin,  flattened,  and  in- 
filtrated, while  the  lining  tells  have  in  great  part  lost  their  cilia.  A 
foi-ni  of  atrophy  is  also  met  with  in  Addison's  disease  and  exophthalmic 
(toitre.  Retained  secretion  leads  to  atrophy  of  the  wall  through  pressure. 
Occasionally  other  local  causes  are  at  work,  as,  for  instance,  the  pressure 
of  a  tumor  within  the  cavitv. 


PK0ORE88IVE  METAMORPHOSES. 

Hypertrophy.— Apart  from  that  form  which  occu,  during  the 
puer|)eral  periwl,  pathological  hypertrophy  affects  the  uterus  either  in 
whole  or  in  part.  In  partial  hypertrophy,  the  corpus,  cervi.x,  or  the 
endomt'trium  may  be  involved.  Many  cases  are  associated  with  in- 
tianiiiiation,  and  it  is  not  always  easy  to  draw  the  line  between  what  is 
inflainniatory  and  what  is  not.  Not  only  the  muscle  but  the  connective 
tissut'  may  be  affected.  One  important'type  is  hypertrophy  from  over- 
work, found  in  cases  of  retained  secretion'and  tumors  within  the  cavity. 
.\Ius(  iiiar  hypertrophy  may  also  be  seen  in  many  cases  of  chronic  endo- 
metritis. 

A  remarkable  form  of  partial  hypertrophy,  said  to  be  due  to  chronic 
inflaimnation,  leads  to  a  proboscis-like  elongation  of  the  whole  cervix. 
An  e.v  ( edingly  common  form  of  h>-pertrophy  of  the  endometrium  is 
seen  m  the  forn:ation  of  polyps  as  a  result  of  inflammation.  Some  of 
these  are  cystic.  A  form  known  as  foUienlar  hypertrophy  or  cystic 
gUndular  hypertrophy  is  found  at  the  os.  A  special  form  of  hypertrophy 
of  the  endometrium  should  also  be  mentioned,  namely,  the  formation  of 
a  (le<iiliia  in  cases  of  extra-utcrinc  gestation. 


o3 


'^Lehrbuch,   1887:  789. 


834 


THE  UTERUS 


IIP. 


Tmnon. — Among  the  benign  tumors  we  have  flbnoM,  toiomjrjmi, 
flhromjomt,  mjzonu,  Upoma,  tdenoina,  •denomjroBM,  and  elwndronu. 

By  far  the  mast  common  tumor  of  the  uterus  is  the  fibroma  (sn-  also 
vul.'i,  p.  6^7).  This  is  almost  invaritebly  a  mixed  tumor,  contaiiiiii);  a 
variable  quantity  of  muscular  elements  (myoflteoma,  ataiina  fibroid). 
The  appearance  of  the  growth  varies  according  to  the  amount  of  nniscle 
it  contains.  The  purer  myomas  are  usually  submucous  and  start  from 
the  fundus.  They  are  soft,  vascular,  and  of  a  reddish,  flesh-like  apjM-ar- 
ance.  They  are  apt  to  be  indefinitely  bounded.  The  niorf  Hlirous 
the  tumor  is,  howe\'er,  the  firmer  and  paler  it  becomes.     Myuliltrunms 


Vm.  310 


rl 


Mul>njU(;i>U!<  ixilyp  of  the  uterus.     (Fruin  tlie  Patliol<i(ical  Muaeum  nf  .Mctiill  VnitiT-iiy  ; 


are  generally  multiple  and  may  vary  in  a.  ,  from  that  of  a  piii-licail  lo 
that  of  an  adult  man's  head,  or  even  larger.  Most  of  tliciii  oiijrinate 
in  the  posterior  wall  of  the  corpus;  next  in  frequency,  in  tlif  anterior 
wall  and  the  fundus.     From  5  to  8  per  cent,  begin  in  the  cenLx. 

In  a  well-marked  example  of  a  myofibroma  the  mass  is  hard,  possibly 
more  or  less  notlular,  and  well-defined.  On  section,  it  is  hard.  <;ratin}: 
somewhat  under  the  knife,  and  of  a  pale,  grayish  color.  On  closer 
iaspection,  the  cut  surface  is  seen  to  be  glistening,  the  substain  .■  lu-inj; 
formed  of  interlacing  fibrillse,  and  has  a  sheen  like  watered  silk,  ^ery 
often  nodules  or  whorls  of  fibrous  tissue  can  be  made  out.  In  tin  middle 
of  the  smaller  nodules  a  bloodvessel  can  often  be  seen.  In  si  him'  forms 
{teleangiedatic  and  cavernoiu  myofibromas)  the  vessels  are  abuudniit  and 
form  large  sinuses. 

Microscopically,  both  muscular  and  fibrous  elements  are  to  in'  made 
out.  the  proportion  varying  in  different  cases.  The  connti  ive  tissue 
tends  to  be  grouped  about  the  bloodvessels.  In  many  case  le  tumor 
consists  of  little  else  but  interlacing  fibrillae  of  connective  tissu*   forming 


VTERIXE  FIBROIDS 


835 


strands,  whorls,  and  nodules.     Epithelial  remains  and  ner\e-fil)ers  have 
U't'ii  ilciiionstrated. 

A.ri.rJing  to  the  site  of  the  tumor  we  can  recognize  four  tvws- 
(1)  li.e  intramural  or  interstitial;  (2)  the  subserous;  (.{)  the  suhmwous;" 
and  ( li  the  mtraligninentous. 

Iiitruiuural  i.ivofihromas,  on  aceouni  of  their  favoral,ie  iMisition 
wtuTfl.v  they  receive  an  abundant  supplv  of  blcKnl,  grow  rapidiv  and 
may  a  lin  i  r.'latively  large  size.  They  ar^'  often  encapsuhitcd'  and 
siirroiinde*!  by  a  plexus  of  large  venous  sinuses.  In  other  cast's  they  are 
dinclly.  though  loosely,  attache*!  to  the  uterine  musculature  ami  mav 
form  diffuse  growths.  They  occur  in  simple  n.xlules  or  aggregations  of 
iiuliilcs,  which  are  often  more  or  le.ss  compressed. 

Fio.  220 


Jil.r„„,v..ma  ,,f  ,he  u.eru..     The  dark  area  to  ,he  left  i,  cump,„.d  of  m..«le  1„„„11.--  ,he 

't:i,.;;',,;'';;"A: o'vlz;.';''""'"  """"'■ """""'  -'"■  ^'-  =*■  "■"'"•" -  -•  *^-°  "■• 

Subserous  myofibromas  form  either  sessile  i: odules,  appearing  beneath 
the  peritoneal  investment  of  the  uterus,  or  pedunculated  growths 
Uttiiijr  ,o  torsion  of  the  pedicle,  grave  circulatory  disturbances  are  liable 
i>  siipirvene.  such  as  infarction,  necrosis,  and  gangrene,  unless  th'- 
tumor  neeives  an  adequate  blood  supply  through  the  formation  of 
^c  idan-  adhesions.  Occasionally,  the  mass  becomes  separated  froTi 
he  uterus  and  forms  a  free  body  in  the  peritoneal  cavit > .  When  situated 
o«  (lortn  a.  1  posttnorly,  compression  of  the  cervix 'and  elongation  of 
me  uter-H  n.ay  take  place.  The  tumor  may  also  grow  out  between  the 
la.ws  (.t  the  broad  ligament  (intraligamentous  myofibroma). 
Submucous  myofibromas  are  found  most  frequently  at  the  fundus. 


■^ 


!        f 


M  V 


I 

'    ■■  I  ; 

?     i    i 

i       ■'    .  ' 


836 


THE  VTERVa 


but  occasionally  ariae  from  the  internal  oa  and  cervical  canal.  The; 
aie  not  lobulated,  but  form  sessile  nodes  or  pedunculated  outniowths 
They  ai  asually  small,  but  may  attain  the  a\zs  of  a  child's  head,  (."on 
siderable  dilatation  of  the  uterus  may  take  piace. 

Histolopcally,  these  growths  consist  of  a  core  of  fibrous  and  miisciila 
tissue,  enveloped  in  mucous  membrane.  Owing  to  contraction  of  th( 
uterus,  together  with  retrogressive  changes,  submucous  tumors  ma; 
become  entirely  deUched  or  in  some  cases  shelled  out  from  »l«-i 
macous  investment  and  be  discharged  through  the  genital  pssanes 
Occasionally  such  growths  are  calcified.  _       .       . 

The  etiology  of  uterine  myofibromas  is  still  obscure.  Certniii  point 
are,  howe\er,  fairly  well  e^itablished.  Fibroids  do  not  occur  Ufon-  th 
age  of  puberty,  and  are  found  chiefly  in  elderly  women.  The  part  tha 
the  sexual  activities  play  w  doubtful.  A  relatively  high  percentage  o 
unmarried  persons  are  said  to  have  these  growths.  Cohnheiin'  lia 
advanced  the  view  that  the  uterus  rontains  "germ  centres"  that  ninaii 
more  or  less  in  abeyance  while  the  sexual  functions  are  in  operation,  am 
that  some  irritation. apart  from  the  physiological  one.  leads  to  the  atyi)i(  t 
and  excessive  development  of  these  centres.  Virchow  also  attril.ute 
fibroids  to  an  irritative  cause.  Race  plays  a  v  art,  for  it  is  siii.l  tliat  th 
condition  b  more  common  in  black  peoples.  With  regard  to  the  sit 
of  origin  opinions  also  differ,  Virchow  held  that  myomas  oriRinate  i 
the  muscle  fibers  of  the  myometrium.  Other  views  are  that  thev  ^roi 
from  the  walls  of  the  bloodvessels,  or  from  certain  round  cells  tliat  ar 
said  to  exbt  about  capillaries  that  are  undergoing  involution.  Soni 
have  also  held  that  certain  cases  are  the  result  of  endometritis.  A  part 
sitic  theory  has  also  been  advanced. 

Myofibromas,  particularly  the  intramural  and  submucous  forms,  hi 
also  to  some  extent  the  subserous,  lead  to  generalized  hypertro|)h.v  ( 
the  mvometrium  with  dilatation  of  the  cavity.  Where  multiple  tunmi 
exist,  atrophy  from  pressure  in  some  i.Tstanccs  takes  place.  It  i  nt 
uncommon  for  the  endometrium  covering  a  large  subi.uicous  >:rowt 
to  be  thinned  and  atrophic.  Secondary  inflammatory  chaiiircs  ai 
frequent.  The  Fallopian  tubes  often  show  changes,  the  miuosa  bein 
oedematous,  hemorrhagic,  and  infiltrated  with  inflammatory  pr«iucl 
while  productive  manifestations  are  not  \incommo.i.  The  ovaries  ai 
said  always  to  show  some  alteration.  They  are  enlarged  from  liypei 
trophy  and  hyperplasia  of  the  follicles  and  proliferation  of  the  roimectiv 
tissue.  The  interstitial  stroma  is  infiltrated  with  round  cells  and  th 
vesseb  present  signs  of  endarteritis.  .     , ,  , 

Myofibromas  are  subject  to  secondary  changes  that  shoulil  lie  mei 
tioned.  Fatty  degeneration  occurs  usually  in  patches  but  may  somctinii 
be  so  exteasive  as  to  convert  the  tumor  into  a  soft  yellowish  materii 
resembling  pus.  li  is,  however,  more  common  to  find  areas  of  softenin 
and  degeneration  cysts  in  these  tumors.    In  rare  instances  tlie  growt 

'AUg.  Path.,  1:1882: 744. 


UTERINE  FIBKOIDS 


837 


muy  entirely  diuppear.  Pregnancy  and  the  puerperal  state  are  potent 
iriHuences  in  bringing  al  .ut  these  retrogressive  char  'es.  ITie  tumor 
muy  (larticiDate  in  the  imuiution  process  of  the  puerperal  uterus. 

Hyaline  degeneration  and  necrosis  may  a£Pect  the  muscular  elements  to 
such  a  degree  that  the  muscle  tumor  is  gradually  converted  into  a  fibrous 
one  The  fibrous  tissue,  in  turn,  may  undergo  hyaline  and  myxo- 
matous transformation.  In  the  latter  event,  the  tumor  increases  rapidly 
ill  size,  and  may  contain  numerous  cvstic  areas  filled  with  mucin  (myxo- 
miioma).  Amyloid  infiltration  hi  i  also  been  observed.  Calcification  is 
nliiMvely  more  common  in  the  Dserous  variety.  The  lime  salts  form 
a  |K)rous  network  that  may  L  riMjapared  to  the  siliceous  skeleton  of 
asjjonge.  or  else  form  an  ex'  .,al  hard  covering.  In  rare  ■  -s  the 
entire  tumor  becomes  calcified.  Transformation  into  cartilai>  ,  ^  iro- 
myoma)  and  into  bone  {ptteomytma)  has  been  recorded. 

Inflammation  of  the  growth,  both  acute  and  chronic,  is  ..a  with. 
Suppuration  and  gangrene  may  lead  to  complete  disintegration  of  the 
turn- .  tr,  if  the  inflammation  be  more  chronic,  to  fibroid  induration. 
In  tii«  large  growths  oedema  is  of  common  occurrence,  giving  the  struc- 
ture a  soft,  gelatinous  appearance.  This  may  lead  to  the  formation  of 
cystic  cavities  filled  with  clear  fluid.  These  can,  however,  be  readily 
distinguished  from  true  cysts  in  that  they  are  not  lined  with  epithelium, 
and  are  often  traversed  by  shreds  or  bands  of  tissue.  Cysts  may  also 
be  due  to  dilatation  of  the  lymphatics  (myofibroma  lymphangiedaticum) 
or  hKxKlvessels  (w.  cavernoaum).  Rarely,  cysts  are  found  lined  with 
cylindrical  epithelium.  Some  of  these  are  be'ieved  to  be  due  to  pinching 
off  of  portions  of  the  uterine  glands  that  thus  become  included  in  the 
myomatous  o-ergrowth,  but  others,  notably  in  the  subseroas  forms,  are 
more  probably  derived  from  embryonic  epithelial  "rests."  According 
U  ( jillen,  the  forms  i-  vhich  there  ar  "pithelial  inclusions  are  apt  to 
be  diifused  throughout  iiu  uterus.  '  .  "rests"  have  been  definitely 
shown  to  be  derived  from  the  mucosa. 

An  important  modification,  tiuu  sliouid  be  referred  to,  is  sarcomatous 
tmnsforiiiation  of  uterine  cay  as,'  of  which  five  or  six  cases  are  now 
on  rnoni.  The  condition  gi\  nse  to  metastatic  myomatous  deposits 
m  the  various  org,'  The  tun  .n  grows  rapidly  and  on  section  presents 
a  more  homogene.  ippearan'-e  than  the  ordinary  myofibroma.  It  is 
hable  to  undergo  degenerative  changes,  necrosis  and  extravasation  of 
blood.  MicroscopicaUy,  the  cells  are  large,  spindle-shaped,  or  irregular, 
containing  large  nuclei  rich  in  chromatin.  Giant  cells  may  abo  be  seen. 
Iwo  torins  are  to  be  differentiated,  the  first  in  which  the  sarcomatous 
elenniits  arise  from  more  or  less  undifferrntiated  and  embryonic  muscle 
cells  ( miiosurcoma),  and  the  second,  in  which  there  is  transformation  of 
the  interstitial  fibrous  tissue  into  sarcoma  (myoma  sarcomatodes). 


2; 


It'  Mastuy,  Zur  Kenntnisa  der  malignen  Mycme  des  I'terus,  Zeit.  f.  Heilk., 
\hTii.   I,   Path.   Anat;    also    Schlagcnhaufer,   Myoma  teleaagiectodes   Uteri. 
Aicn.  kliii.  Woch.,  15: 1902: 523. 


I|i! 


I' 


I 

■HI 


1  ! , 


■ 


83S 


rff£  UTERUS 


The  combination  of  adenoiu  with  myoma  is  rare.  Here,  in  addition 
to  the  muscular  or  fibromuscular  ground  substance,  there  are  more  or 
less  numerous  glands  lined  with  epithelium,  in  some  cases  dilated  into 
cysts.  In  the  tumors  originating  in  the  centre  of  the  myometrium 
the  glandular  elements  have  been  shown  to  be  derived  from  the  endo- 
metrium (Cullen),  while  in  those  cases  where  the  tumors  start  in  tlie 
cornu  of  the  uterus  or  in  a  tul)e,  they  are  probably  derived  from  the  re- 
mains of  the  Wolffian  body  (v.  Recklinghausen).  The  growth  is  generally 
devoid  of  a  capsule,  and  is  adherent  to  the  tissue  in  which  it  is  foiiiid. 
Several  subvarieties  are  described:  (1)  One  in  which  the  miisenlar 
elements  are  in  excess;  (2)  one  in  which  the  glandular  elements  preiloinin- 
ate;  (3)  a  tumor  containing  numerous  dilated  bloodvessels  {adeiwiiiyomn 
teleangledaticum);  and  (4)  a  cystic  adenomyoma  (adenomyoma  cyntkum). 
Microscopically,  the  growth  consists  in  a  varying  amount  of  muscular 
and  fibrous  tissue,  either  well-formed  or  of  cellular  appearance,  in  wiiicli 
are  several  glandular  tubules  lined  with  epithelium,  from  which  l)rancli 
off  in  a  pectinate  fashion  subsidiary  tubules  ending  in  a  blind  ampulla. 
The  cysts  may  contain  blood-stained  fluid  or  pigment. 

In  a  few  cases  striated  muscle  tumors,  rhabdomyomas,  iiave  been 
descril)ed.  They  form  polypoid  excrescences  in  the  cervical  canal,  and 
are  very  malignant,  owing'  to  the  fact  that  the  component  cilis  are 
intrinsically  immature  and  endowed  with  great  vegetative  force.  In 
one  such  tumor  glycogen  and  amyloid  iiiiterial  have  been  found. 

Myocarcinoma  probably  only  occurs  in  the  form  of  a  carcinomatous 
transformation  of  the  glandular  elements  in  an  adenomyoma.  The  (oii- 
dition  may,  however,  be  simulated  closely  by  the  secondary  invasion  of 
a  myofibroma  with  carcinoma,  either  by  metastasis,  which  is  rare,  orby 
direct  extension. 

Lipoma.— Lipomas  havi  been  found  growing  as  polypoid  excrescences 
from  the  cer\ical  canal.     'I'hey  are  excessively  rare. 

Chondroma. — Chondromas  occur  generally  as  metaplasia.s  of  other 
tumors,  notably  rhal)domyoma  and  sarcoma. 

Cystic  Growths.— Besides  cystic  polyps,  cystadenomas,  cy.stic  myonias, 
and  sarcomas,  the  only  form  that  need  be  mentioned  is  tlie  dermoid 
cyst,  which  may  form  polypoid  outgrowths. 

The  malignant  tumors  of  the  uterus  are  the  malignant  adenoma, 
carcinoma,  sarcoma,  endothelioma,  atid  rhabdomyoma  (above  dexriluai. 
Malignant  Adenoma. — Here,  as  elsewhere,  it  i.s  difficult  to  dei  i<K'  wiili 
certainty  what  is  a  neoplastic  overgrowth  of  glandidar  tissue  mid  what 
is  merely  an  inflammatory  hyperplasia.  Some  would  regard  ilie  iiiHain- 
matory  "polyps  to  l>e  referred  to  later  as  adenomas.  Tlie  .lilficnhy 
ari.scs  from  tlie  fact  that  in  inflammation  the  glandular  eleninii-  ,ire  in- 
creased, both  ill  numbers  and  in  size,  forming  branching  and  citii  ii  eom- 
municating  tid)es,  with,  sometimes,  cy.stic  dilatation.  The  ^hind-tiilies 
also  tend  ta  invade  the  muscular  layers.  The  existence  of  d  Ihilar  in- 
filtration, again,  affords  no  clue,  since  it  is  present  alike  in  ii.  « -^'rowths 
and  in  inflammation.  There  can  lie  no  doubt,  however,  tluii  tlie  .so- 
called  malignant  adenoma  is  a  true  tumor.    It  consists  almost  entirely 


CARCINOMA 


S39 


of  glandular  elements  in  the  shape  of  branching  and  intercommunicating 
tubules,  which  may  present  dilatation  or  intraglandular  invagination, 
ht'id  together  by  a  scanty  stroma.  The  tubules  in  question  are  lined 
with  a  single  layer  of  more  or  less  distorted  and  closely  packed,  long, 
cylindrical  cells,  sometimes  ciliated,  and  showing  mitotic  figures.  The 
muscular  wall  of  the  uterus  may  be  extensively  infiltrated.  This  tumor 
is  found  usually  about  the  menopause  or  later.  The  importance  of 
the  growth  lies  in  the  fact  that  it  is  infiltrating  and  may  give  rise  to 
(iistui)t  metast&ses,  also  of  the  simple  adenomatous  type. 

Cucinonu. — The  uterus  is  a  favorite  place  for  carcinoma.  In  about 
30  per  cent,  of  women  suffering  from  this  disease,  the  growth  is  located 
in  the  uterus  (Orth).  With  few  exceptions,  carcinoma  of  the  uterus  is 
primary  in  that  organ.  The  affection  may  be  found  at  any  time  after 
pulterty,  but  is  generally  met  with  about  the  menopause  or  later.  In 
nullipanB,  cancer  of  the  uterus  is  rare,  and  when  it  does  occur  is  usually 
in  tlie  c-orpus.  In  parous  women  it  is  usually  at  the  cervix.  The 
etiology  is  obscure,  but,  so  far  as  we  can  judge,  the  most  imfmrtant  factor 
is  clinjnic  endometritis  leading  to  glandular  hyperplasia.  Whether 
trauinutism,  as  laceration  of  the  cervix,  has  much  to  do  with  it  is  per- 
haps debatable,  yet  it  seems  probable.  Tears  or  fissures  in  this 
situation,  if  they  do  not  heal  in  complete  apposition,  often  liecome 
coverefl  with  epithelium,  either  squamous  from  the  vagina,  or  columnar 
from  the  cervix.  Such  epithelium,  being  in  an  abnormal  situation,  is 
likely  to  be  unstable  and  more  susceptible  to  irritation.  Granular 
erosion  of  the  portio  vaginalis  is  possibly  a  factor  also  in  sonic  cases. 
Raw  plays  some  part,  for  the  disease  is  said  to  be  more  frequent  in  the 
white  peoples. 

Carcinoma  may  affect  any  part  of  the  uterus,  but  in  the  vast  majority 
of  cases  is  met  with  in  the  cervix.  We  have  to  recognize  three  points  of 
origin,  the  portio  vaginalis,  the  cer\ical  endometrium,  and  the  mucosa 
of  tiie  corpus.  With  regard  to  the  forms  occurring  in  the  cer\ix,  it  is 
only  possible  to  differentiate  lietween  them  macroscopically  in  the 
earlier  stages. 

Carcinoma  of  the  cer\'ix  presents  at  first  a  smooth,  slightly  reddened 
surface,  quickly  becoming  uneven,  granular,  warty,  and  eroded.  The 
outgrow  th  is  not  always  so  marked  as  the  infiltration,  but  very  commonly 
polypoid  or  papillomatous  excrescences  are  formed  giving  to  the  tumor 
the  well-known  "cauliflower"  appearance.  In  cancer  of  the  corpus  and 
eervi(  al  cavity  such  outgrowths  are  not  so  common.  The  tumor  takes 
tile  form  of  xquamous  epiihelioma,  adenocarcinoma,  scirrhous,  and  colloid^ 
mri'immm.    The  last  two  varieties  are  excessively  rare. 

\  InMiueiit  type  is  the  squamous-cellcd  carcinoma,  which  arises  almost 
inviirial)!y  from  the  portio  vaginalis.  It  forms  flat  rr  papillomatous 
outgnm  tils  originating  in  the  superficial  layers  of  the  mucosa.  It  is, 
nion  nvcr,  liable  to  spread  to  the  vagina,  and  may  extend  into  the  para- 
metrium with  extensive  destruction  of  tissue.     In  very  rare  instances,  as 


'  Waldeyer,  Vireh.  Arehiv,  55: 1872:  110. 


r 


if 


.^ 


840 


THE  UTERUS 


V.  Rosthorn'  and  Zeller'  have  pointed  out,  a  metaplasia  of  the  cylindrical 
epithelium  of  the  uterine  cavity  into  squamous  cells  may  take  |il;'ce, 
and  three  undoubted  cases  (Gebbard,*  Kaufmann,*  Fleiscnlen')  aie  on 
record  where  squamous-celled  carcinoma  has  developed  in  the  b(j<iv  of 
the  uterus.  This  form  may  also  originate  in  the  cervical  canal  in  cases 
of  erosion  where  the  pavement  epithelium  of  the  portio  \As  invadwl  the 
cavity. 

Histologically,  the  squamous-celled  carcmoma  presents  an  overjirovvth 
of  epithelial  processes,  more  or  less  branching,  which  invade  the  deeper 
layers.  The  stroma  is  infiltrated  with  round  cells,  and  cell-nests  are 
occasionally  to  be  seen.  In  some  cases  the  overgrowth  of  epithelium 
and  stroma  is  so  great  that  papillomatous  excrescences  are  pnMliiced 
Erosion  often  takes  place,  and  the  surface  presents  granulation  tissue 
together  with  masses  of  fibrin.  Rarely,  the  growth  assumes  the  tvpe 
of  a  rodent  ulcer,  being  of  slow  growth,  with  merely  superficial  loss  of 
substance,  and  separated  from  the  underlying  structures  by  a  zone  of 
round  cells. 

The  most  common  form  of  cancer  is  the  adenocarcinoma,  which  is 
found  in  the  cervi.x  and  occasionally  in  the  corpus.  The  growth  orijrinates 
in  an  atypical  proliferation  of  the  glandular  elements  of  the  endometrium. 
The  explanation  probably  is  that  it  arises  from  portions  of  glands  or 
cysts  (ovula  Nabothi)  that  have  become  pinched  off  from  the  .sui>erfioial 
mucous  membrane.  The  tumor  is  definitely  of  the  glandular  ty|H'  and 
penetrates  deeply  into  the  muscle.  The  cells  are  cylindrical  and  may  !« 
grouped  like  glands  about  a  central  lumen,  or  heaped  up  into  several 
layers,  forming  solid  masses  or  strands.  Cavities  may  be  formed  throuf;h 
softening  and  necrosis  of  the  central  portion  of  the  growth.  According 
to  the  amount  of  stroma  present  we  can  differentiate  carcinoma  simplex 
and  c.  medullare.  The  tissues  in  the  neighlwrhood  of  the  growth  show 
an  abundant  round-celled  infiltration.  Myxomatous  degeneration  of  the 
stroma  is  occasionally  observed. 

Palmer  Findley'  has  recorded  a  case  of  cancer  of  the  botly  of  the  uterus 
which  was  both  adenocarcinomatous  and  squamous  in  type.  .\  |)cculiar 
and  apparently  unique  form  of  adenocarcinoma  is  one  reconlcd  hy 
Cullen,'  where  the  tumor  formed  dome-like  elevations  aiTeciiiij;  lioth 
corpus  and  cer\'ix  alike,  in  which  the  epithelium  of  the  glandular  elements 
resembled  closely  that  of  the  normal  glands. 

'  Ueber  Schleimhautverhornung  li  r  Gebiirmutter,  Zeit.  zur  Frier  ili'<  fnnfzig- 
jiihrigcn  Jubiliiiims  der  Gesselsch.  f.  Ci   n.  Wien,  1894:  .319. 

'  Plattenepithel  im  Uterus,  Zeit.  f.  >  .ob.  u.  Gyn.,  11: 1884-85:  .W. 

'  Zeit.  f.  Geb.  u.  Gyn.,  24:  1892:  1. 

*  Jahresbericht  der  Schlesischen  Gesselsch  f.  vaterliindisohe  Cultiir.  .1  ilirc..  72: 
1894:  52. 

'  Ueber  den  primiiren  Hornkrebs  des  Corpus  I'teri,  Zeit.  f.  Goli.  n  ii\n.,  H2: 
1S9.'>:  .St7. 

•Squamous  Cell  Carcinoma  of  the  Body  of  the  Uterus,  Trans,  (li -vm  Path. 
Soo.,  5:  No.  6:  1902. 

'  CuUen,  Tumors  of  the  Uterus,  1900: 588,  D.  Appleton  &  Co.,  X.  \. 


SARCOMA 


841 


Primary  melanocarcinoma  is  described.' 

Numerous  secondary  changes  are  associated  with  carcinoma.  The 
surface  may  become  ulcerated  and  almost  gangrenous,  with  consequent 
enlargement  of  the  uterine  cavity.  Obstruction  in  the  cervical  canal 
often  leads  to  retention  of  secretion  and  necrotic  uiaterial  and  dilata- 
tion of  the  uterus.  Chronic  endometritis,  either  of  simple  or  membranous 
type,  may  complicate  the  condition  also.  Hypertrophy  of  the  uterine 
wall  may  occur. 

Extension  of  the  disease  to  neighboring  parts  is  common.  Cancers 
of  the  portio  tend  to  invade  the  vagina,  while  those  of  the  cervix  extend 
to  the  parametrium.  Both  the  bladder  and  the  rectum  may  be  involved 
and  fistulous  communications  established.  In  the  former  case,  cystitis 
may  be  set  up  with  obstruction  of  the  ureters,  leading  to  hydro-  and  pyo- 
nephrosis. In  exceptional  cases  the  bony  pelvis  may  be  attacked.  The 
peritoneal  membrane  is  often  involved,  especially  in  cases  of  carcinoma 
of  the  corpus,  but  also  of  the  cervix.  Local  peritonitis  with  adhesion 
may  occur.  Metastases  develop  relatively  late  and  are  never  extensive. 
Most  frequently  the  lumbar,  retroperitoneal,  and  inguinal  lymphatic 
glands  are  first  and  chiefly  involved,  and  also  the  ovaries.  Secondary 
carcinoma  is  rare  in  the  uterus.  Orth  has  observed  a  metastatic  polypoid 
melanocarcinoma  in  a  case  of  generalized  melanocarcinosis. 

Sarcoma. — Sarcomas  originate  either  in  the  connective  tissue  of  the 
endometrium,  possibly  as  a  sequel  of  chronic  productive  endometritis, 
or  in  the  myometrium.  In  the  latter  case  the  tumor  is  frequently  asso- 
ciated with  myofibroma,  forming  a  mixed  growth. 

Sarcomas  developing  in  the  endometrium  are  found  relatively  early 
in  life  as  compared  with  carcinomas,  even  before  puberty.  They  are 
common  relatively  in  nulliparae. 

Microscopically,  sarcomas  are  large  or  small  round-celled,  spindle-celled, 
oat-shnped,  giant-celled,  or  mixed.  In  some  cases  they  are  very  vascular 
(aiKjiosarcomn),  or  the  vessels  may  show  hyaline  thickening  (cylindroma). 
Sarcomas  originating  in  the  mucosa  are  found  in  the  corpus,  rarely  in 
the  cervix.  They  form  local  or  more  or  less  diffuse  growths  having 
alohulated,  warty,  or  papillomatous  appearance.  Ulceration  is  apt 
to  occur  early.  In  the  cervix  they  form  polypoid  or  cauliflower-like 
growths  in  the  canal  or  on  the  lips  of  the  os.  '  In  consequence  of  con- 
gestion and  oedema,  they  may  present  an  appearance  not  unlike  an 
hvdatidiform  mole.  The  substance  of  the  tumor  is  whitish,  soft  and 
briiiti-hke,  friable,  and  shows  evidences  of  degeneration. 

Tlic  sarcomas  of  the  myometrium  form  usually  single  or  multiple 
noiiiiKs  of  varying  size,  more  rarely  a  diffuse  infiltration  leading  to 
markcil  enlargement  of  the  uterus.  As  a  rule,  they  are  met  with  in  'he 
corpus  but  may  occur  also  in  the  cer\ix.  Pure  sarcomas  of  this  type 
have  ii  pale  homogeneous  appearance  and  are  of  soft  consistence.  " 

A-;  hefore  mentioned  sarcoma  may  be  associated  or  combined  with 
nivuliliroma  and  adenoma. 


>  Haeckel,  Arch.  f.  Gyn.,  32: 1888: 400. 


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TffB  FALLOPIAN  TUBES 


Sarcoma  of  the  uterus  may  for  a  loiijf  time  remain  latent  and  ilieii 
suddenly  take  on  rapid  action,  infiltrating  and  penetrating  the  uterine 
wall,  and  extending  to  the  peritoneum,  broad  ligaments,  tubes,  oMiries, 
intestines,  and  abdominal  parietes.  Implantation  metastases  an-  rarer 
than  with  carcinoma.  Distant  metastases  are  abo  rare.  When  they 
occur,  they  are  found  first  and  chiefly  in  the  lungs.  The  retroperilcuieal 
lymphatic  glands  are  commonly  implicated. 

Degenerative  changes,  particularly  hemorrhagic  extravasation,  necrosis, 
fatty  degeneration,  and  li(|uefaction,  are  apt  to  be  present  in  sareonias. 

Secondary  sarcoma  of  tiie  uterus  has  been  met  with.  There  is  in  the 
pathological  institute  at  Prague  an  interesting  specimen  of  a  uterus 
with  multiple  fibroids  in  which  there  are  secondary  nodules  of  inelaiio- 
surcoma. 

Endothelioma.' — Endotheliomas  originating  in  the  lining  cells  of  MchnI- 
vessels  and  lymphatics  have  been  met  with  in  rare  instances.' 

The  titerus,  it  should  moreover  be  mentioned,  is  a  favorite  .site  for 
multiple  and  independent  primary  growths.  The  as.s(KMation  of  uterine 
fibroids  with  carcinoma  is,  of  course,  so  common  as  scarcely  to  excite 
reinariv,  i>ut  instances  are  on  record  of  asswiated  malignant  j;ro\vtiis. 
A  case,  for  instance,  is  (lescril)e<P  of  carcinoma  and  .sarcoma  of  tlie  ImmIv 
of  the  uterus. 

THE  FALLOPIAN  TUBES. 


..^ 


ii 


CONGENITAL   ANOMALIES. 

Tongenital  defects  of  the  tul)es  are  usually  associate*!  witii  anomalies 
of  tlie  uterus,  although  exceptions  (K-eur.  The  tulje  may  l)c  almost 
completely  absent,  i'cing  represented  by  a  mere  tag.  Not  iiifrei|iieni.ly 
the  fimbriiB  are  imperfectly  developed,  a  persistence  of  the  infantile  cm- 
dition.  Another  anomaly  is  an  un  .sual  position,  as  prolap.se  or  a  vei.ical 
course.  In  about  one-fifth  of  tl.e  autopsies  on  women  a  sniali  cyst 
(hydatid  of  Morgagni),  filled  with  clear  fluid,  is  found  at  the  emi  of  the 
fimbrifp  or  attache<f  by  a  long  pedicle. 

Diverticula  occasionally  are  met  with  caitsetl  by  a  hernial  jirniiibioii 
of  the  mucosa  through  the  muscular  wall.  Accessory  openings  may  lie 
found  near  the  fimbriated  extremitv  of  the  tubes. 


ALTERATIONS  IN  POSITION  AND  CONTINUITY. 

Apart  from  the  congenital  anomalies  of  position,  alMive  n  li  irtd  to, 
the  position  of  the  tubes  depends  mainly  on  pathological  dianui  ~  in  ilif 
neighboring  structures,  uter'is,  ovaries,  and  peritoneum.  Disphu  .  iiienis 
of  the  ulrrtis,  ovarian  tumors,  and  inflammatory  adhesions  iV   jiitiiily 

'  See  ElizaI)Otli  Hurilon,  Johns  Hopkins  Hosp.  Bull.,  9: 18!IS;  1^,'. 
»  Emmanuel,  Zeitsch.  f.  Geb.  u.  Gyniik.,  34: 1896: 1. 


Mm 


STENOSIS  AND  ATRESIA 


843 


(ira^  the  tubes  out  of  their  noriral  position.  When  prolonged  tension 
is  put  upon  a  tube  it  atrophies  at  some  point,  r.sually  near  the  uterus, 
ami  may  even  Ijc  separated  from  the  uterus.  The  tube  may  abo  be 
twisted  spirally  upon  its  axis.  The  tube  has  been  found  forming  part 
of  tiie  contents  of  a  hernial  sac  (sklpingoceto). 

Stenosis  and  Atresia. — Stenosis  and  atresia  of  the  lumen  are  com- 
paratively comm  .1.  The  abdominal  rmd  uterine  ostia  arc  the  parts  most 
iiktiy  to  be  involved.  When  both  tubes  are  affected  sterility  results. 
A  slijjht  grade  of  the  affection  is  .Siud  to  be  one  of  the  causes  of  extra- 
uterine gestation.  The  cause  is  usually  salpingitis  or  pelvic  peritonitis. 
Ill  such  ca.ses  secretions  and  fluids  of  various  kinds,  blood,  pus,  or 
serum,  may  distend  the  tube  into  a  form  of  cyst  (hemato-,  pyo-,  and 


Fio.  221 


Uitil'le  hydrosalpinx.     The  specimen  shows  also  an  intrnmural  "  fibroid"  of  the  uterus. 
(Krom  'ho  Pathfilogical  Museum  of  McGill  T'nivercity.) 


hiidrnxdlpiiix).  In  cases  where  the  abdominal  end  only  of  the  tul)e  is 
tldstil,  iliere  may  be  a  periotlical  discharge  of  clear  or  bloody  fluid  into 
till'  iitcrus,  which  may  simulate  wienstruation  (hydrops  proflueiis). 
\\\ir\i  secretioi's  are  retained  the  mucous  membrane  is  fla  •  ■'d,  the 
itHs  liiive  lost  iheir  cilia,  while  the  muscle  bands  are  compresse  ophic, 

and  iiiiire  or  less  dissociated.  The  tube  in  this  condition  nia,  oe  con- 
vene 1  into  a  semitransparei.*,  thin-walled  3ac.  No  iimbrise  can  be 
sein.  ;(s  in  some  curious  fiishion  they  become  inverted. 

Tuboovarlan  Cyst. — A  brief  reference  should  he  made  here  to  a 
■pti ::!  Idrin  of  tubal  hydrops,  the  so-called  tuhouvarian  cyst.  Tiie  wall 
•)f  I  111'  cyst  is  composed  in  part  of  tube,  in  part  of  ovarj'.  it  is  usually 
l>riiii-ln  al)out  by  the  bursting  of  an  ovarian  cyst  into  the  tube,  and  b 
of  ilu  nature  either  of  a  true  cystoma,  a  hydropic  Graafian  follicle, 


I  I  ;i 


i, 


r  j   -i| 

II. 


i    I 


!  :.i  r 


;       , 

*            1  ; 

■i  ■      '  : 

;■  .  ■  1 1 

1 

'      ii 

y 

ii 

844 


THE  FALLOPIAN  TUBES 


or  a  cystic  corpus  luteum.  Aco  rding  to  Bland  Sutton,  there  is  in  some 
cases  an  accessory  fold  of  perito  leum  forming  a  sort  of  covering  uIkjui 
the  ovary,  analogous  to  the  tunica  of  the  testis,  in  which  fluid  tollttis 
{ovarian  hydrocele). 

Bnptnn  of  the  tube  is  rare,  except  in  casos  of  tub;:!  gestation. 

meention  iaaho  jare.    It  may  occr  in  tuberculosis  and  carcinoma. 

OZBOULATORY  DUTintBAHOIS. 

These  are  similar  to  those  occurring  in  the  uterus.  Hyperemia  is 
found  in  infective  diseases  and  in  obstruction  of  th"  inferior  veiiii  cava. 
Small  himoirhagei  into  the  mucosa  are  met  with  not  infreqiu'iitiy  in 
cases  of  burns,  phosphorus  poi^.iiing,  and  in  the  hemorrhagic  diatlii'st's. 

An  accumulation  of  blood  within  the  tube  (henutoulpinz)  inav  lie 
due  to  retention  of  menstrual  or  extravasated  blood,  owing  to  airtsia 
in  some  part  of  the  genital  canal.  It  may  be  associated  with  dironic 
inflammation  and  V  pertrophy  of  the  muscular  wall  of  the  tube. 

IKFLAUMATIONS. 

Salpingitis. — Inflammations  of  the  tubes  (salpingiti.s)  are,  for  the 
most  part,  comparable  to  those  of  the  uterus.  The  mucous  nuniKraiie 
may  be  chiefly  affected,  or  all  the  coats  may  be  involved. 

Aente  Oatairhal  Salpingitis. — In  simple  acute  catarrhal  ."alpinjiitis 
the  mucous  membrane  is  reddened,  swollen,  and  infiltrated.  'J'he 
secretion  is  scanty,  grayish  or  grayish-white  in  color,  and  contains  small 
masses  of  desquamated  and  degenerated  epithelium. 

Ohronie  Oatairhal  Salpingitis.— More  common  is  chronic  catarrh, 
where  the  most  'mportant  feature  is  productive  change  in  the  nnuous 
membrane.  The  folds  of  the  mucosa  are  thickened  and  iiililinittd, 
and  owing  to  the  lo.ss  of  the  epithelium,  become  adherent  or  eoiiMcctcd 
by  fibrous  bands.  In  this  way  small,  gland-like  structures  are  piiK  lied 
off  from  the  general  cavity,  which  may,  in  time,  be  converted  iiiio  <  vsi.s. 
In  this  feature  there  is  a  striking  similarity  to  glandular  endoimiritis. 
Under  the  designation  of  salpingitia  productiva  glandularis,  C'lii.ui'  has 
described  a  special  form  of  chronic  catarrh,  in  which  small  loilnlar 
outgrowths  are  found  at  the  uterine  end  of  the  tube,  composed  (it  hyper- 
plastic muscle  and  gland-like  structures  from  the  mucous  nii mlirane, 
ofien  cystic  in  appearance,  which  contain  a  clear  serous  fluid  ;iiid  are 
lined  with  non-ciliated  epithelium. 

In  cases  of  chronic  catarrh  the  muscular  coat  may  be  nliiixcly 
unaffected,  showing  either  hypertrophy  or  atrophy,  but  at  tiims  it  is 
also  infiltrated  with  inflammatory  products.  Pro<lnetive  li\))riplasia 
of  the  connective-tissue  elements,  chiefly  along  the  Moodve  ■> !  <ifte!i 
supervenes  (interstitial  sclpingitis). 

>  Zeit.  f.  Heilk.,  8:  1887:  457. 


SALPmOlTlS 


845 


Apart  from  the  simple  forms  of  salpingitu,  we  have  to  recognize, 
according  to  the  character  of  the  exudate,  suppurative  and  membranous 
varieties. 

SuppnntiTt  Salpingitis. — There  b  no  marked  difference,  etiologically  or 
aiiiitomically,  between  simple  and  suppurative  salpingitis.  In  both 
there  is  the  same  infiltration  and  adhesion  of  the  mucous  folds.  In  the 
suppurative  form,  however,  the  secretion  is  more  abundant,  seropurulent 
or  pill  lent,  and  tends  to  collect  in  the  ampulla.  7.'he  amount  of  de- 
ge'ier.uion  of  the  epitheliun>  is  also  greater  and  seta  in  earlier.  In  this 
way  most  of  the  mucous  'nembrutie  may  be  destroyed.  In  some  cases 
the  mucosa  is  greatly  innltrated  with  cells,  \nd  becomes  fibrous  and 
iiuiurated.  The  condition  of  the  muscular  cout  varies.  Cellular  infiltra- 
tion, the  formation  of  nultiple  small  abscesses,  and  productive  changes 
are  coiurnon.  In  many  cases,  owing  to  the  inflammation,  both  the 
uterine  and  the  abdom.ial  openings  of  the  tube  become  blocked,  and 
tlie  pus  accumulates  until  the  tube  assumes  a  sac-like  appearance 
(pyosalpinx).  The  tube  may  thus  become  greatly  distorted  and  present 
irrei;u!ar  swellings,  owing  to  the  sacculation  of  the  contents  through 
adhesions  (pyosalpinx  aaccata).  Mauclaire'  has  recorded  a  curious  case 
of  purulent  salpingitis  where  gas  was  produced  (pbyaopyoulpinx),  the 
exact  cause  of  which  w  .3  wot  determined. 

Membranous  Salpingitis. — Membranous  salpingitis  is  of  relatively  little 
importance;  it  is  characterized  by  necrosis  with  the  formation  of  an 
adherent  fibrinous  or  fibrinohyaline  exudation. 

Tlie  causes  o.*  salpingitis  are  various.  Among  ordinary  sources  may 
l)e  inentione*!  '  catching  cold,"  or  t  lumatism  during  the  menstrual 
period,  inflammation  of  the  uterus  or  ovaries,  tumors  of  the  uterus, 
dislocations,  and  general  systemic  infection.  The  majority  of  cases  are 
bacterial  in  origin.  Some  cases  are  extensions  of  septic  endometritis 
and  metritis.  The  most  frequent  cause,  however,  is  the  Gonococcus, 
whicii  may  not  only  produce  simple  acute  salpingitis  but  also  chronic 
and  suppurative  inflammation.  It  is  not  always  possible  to  determine 
the  microorganism  at  fault,  for  it  often  happens  that  the  bacteria  die 
out  in  long-standing  cases.  Gonococci  especially  tend  to  dicppear 
earlv. 

A  number  of  serious  results  may  follow  salpingitis.  A  frequent 
event  is  the  extension  of  the  inflammation  to  the  serous  membiane 
(perisalpingitis)  and  to  the  pslvic  peritoneum  (pelvic  peritonitis),  leading 
to  dish)cations  of  position  and  distortion  of  the  tubes  from  the  formation 
of  adhesions.  When  pyosalpinx  is  present  the  pus  may  escape  into  the 
peritoneal  cavity,  setting  un  <»  general  peritonitis,  or  it  may  be  walled 
off  hy  adhesions  so  as  to  ,orm  a  pelvic  abscess.  Abscesses  of  this  kind 
may  discharge  into  t'ie  vagina  or  rectum.  In  the  cases  that  undergo 
invohition,  the  nnz  is  often  absorbed,  becomes  inspissated  into  a  thick, 
whiti-.!),  putty-like  material  that  may  be  mistaken  for  caseation,  or  the 
coiiitiits  may  become  calcified. 


'  Bull.  et.  m^m.  de  la  Soc.  anat.  de  Paris,  April,  1901. 


-  I 


i  I     I 


i  I 


i, 


t; 


846 


THE  FALLOPIAN  TUBES 


Syphilis. — But  little  ia  kno  vn  of  syphilitic  legions  of  the  tiili«>s. 
So  far  as  we  know,  only  one  t.  oe,  that  ot  Boufhanl  unil  Lt'iiim,'  is 
recorded,  where  the  tub^  were  thickened  and  dilated  to  the  sizo  of  die 
Kneer  and  contained  gummas. 

Tabercolosis. — This  is  much  more  common,  and  is  priiiinrv  or 
secondary.  It  is  said  (Orthmann)  that  primary  tul>erc-ul(xsis  cKcurs  in 
about  18  per  cent,  of  all  cases  of  genital  tuWrculosis  in  the  feiiialt'.  'I'lif 
infection  is  almost  always  hematogenic,  although  it  is  conivivulilt-  that 
some  cases  may  arise  from  the  presence  of  sperm  containing  tiilHrcli' 
bacilli.  Secondary  tuljerculosis  may  arise  by  the  extension  of  iliscase 
from  the  peritoneum,  the  ovaries,  or  the  uterus.  In  both  types  the  |Kri- 
toneum  and  the  rest  of  the  genitalia  are  apt  to  be  involved  as  well.  .\s 
a  rule,  both  tubes  are  affected,  although  not  always  to  the  sunn-  <l(  ;;rt't'. 

Judging  from  the  extent  of  the  lesions  usually  found,  the  Fiilldpiuii 
tubes  form  a  particularly  good  soil  for  the  development  of  the  tiilMnle 
bacillus.  ^Vhat  constitutes  this  special  predisposition  is  not  exactly 
known,  but  it  would  seem  that  previously  existing  inflanunatorv  or 
circulatory  disturliances,  and  disorders  arising  during  menstruation  ami 
the  puerperium,  play  an  important  part.  Rokitansky  |M)inttMl  out  iliat 
the  disease  was  particularly  common  after  the  puerjxTitiin.  Wiiile, 
however,  it  is  true  that  the  disease  is  coinnuMily  met  witii  (liiriii>;  the 
j)erio(l  of  greatest  sexual  activity,  it  is  nevertheless  found  in  old  wonu'ii 
and  children. 

TuWrculosis  generally  l»egins  in  the  mucous  membrane  of  tlic  aiii|iiilla 
and  spreads  rapidly  to  the  a<ljacent  parts.  The  affected  tulH-  is  ^Tcatly 
thickened,  firm,  more  or  less  tortuous,  and  the  muscular  wall  i^  hyixr- 
trophic.  The  fimbria*  are  short,  thick,  and  firm.  As  a  rule,  (lie  iiiIk' 
is  bound  down  by  inflammatory  adhesions.  On  ojK'niiig  the  tiilx-.  in 
the  early  stages  the  mucosa  is  swollen,  reddene<l,  and  the  tnld-.  are 
adherent,  while  the  lumen  contains  a  small  amount  of  grayish  or  vtlluwidi 
secretion.  The  appearance  is  similar  to  that  in  simple  chronic  proiliKtivc 
salpingitis.  In  more  advanced  cases  grayish  points  can  1h»  scimi  in  tlu' 
mucosa,  or,  again,  caseous  nodules  or  streaks.  Later,  the  inii(i'-.a  may 
be  converted  into  a  den.se  caseous  mass.  The  lumen  may  In-  oliliicraifd, 
or  enlarged  when  the  necrotic  material  has  been  evacuated. 

Microscopically,  the  mucosa  is  swollen,  infiltrated  with  round  and 
epithelioid  cells,  while  here  and  there  can  be  seen  remains  of  the  ;;land- 
follicles,  frequently  showing  cystic  dilatation.  Definite  tid)er(  li^  are  to 
be  .seen  near  the  lumen  with  central  caseation.  In  the  more  advanced 
cases  the  mucosa  is  largely  caseous,  and  the  process  can  \>e  se«ii  ,i.h  ancinfr 
into  the  muscular  and  serous  coats.  In  the  more  chronic  Sm-nx  pant 
cells  can  be  made  out. 

The  caseous  detritus  in  some  cases  becomes  liquefied  and 
and  may  be  retained  and  sacculated  (tuberculovi  pyomilpiit.i 
of  these  cases  are  examples  of  mixed  infection.    Ulceration  ■■<■- 
tion  of  the  tube  is  rare.     Usually  the  abscess  produced  is  \\: 

<  Gaz.  .aid.  de  Paris,  1866:  .   6. 


iriforrn, 

Siiine 

licrfiira- 

'llcd  off 


TUMORS 


847 


by  lulhesions.  The  tube  may  become  adherent  to  the  uterus,  the  ap- 
peiiilix,  or  to  other  portions  of  the  intestinal  tract,  or  may  >)e  bound 
down  in  Douglas'  sac. 

Actinomycoiil.' — ITiis  is  rare  and  generally  is  due  to  ext»  sion  of 
the  disease  from  the  peritoneum.  The  tube  is  thickene<l,  studutd  with 
(tniriiilornata,  and  the  puriform  exudate  and  detritus  contain  the  actino- 
nncfs  "grains." 

foreign  Bodies  and  Ptmites.— These  are  of  little  ini|x>rtance, 
apart  from  bacteria.  Orth  records  a  curiosity  iti  the  form  of  a  round- 
worm that  had  made  its  way  into  a  tube  from  a  ruptured  intestine. 

BKTKOORUSin  MITAM0RPH08U. 

Simple  atrophy  affecting  the  muscular  wall  and  mucosa  is  met  with 
iiftt-r  the  menopaase.  It  may  also  be  due  to  the  pressure  of  retained 
secretions,  and  the  pressure  or  traction  of  tumors.  In  some  cases  the 
tuln-  may  be  actually  seprtraicd  from  the  uterus. 


PROORESBIVI  MITAM0RPH08U. 

Hypertrophy.— Hypertrophy  of  all  the  tissues  of  the  tulie  is  not 
iiiKomiiion.  Overgrowths  of  the  mucosa  are  met  with  as  a  result  of 
inflmiiiiiation  or  possibly  as  a  true  hyperplasia,  as,  for  instance,  iti  asso- 
ciation with  myofibromas  of  the  uterus.  Polyps  of  the  mucosa  are  verv 
rare.  HyfMTtrophy  of  the  muscle  results  from  overwork,  such  as  is  met 
will)  ill  stenosis  of  the  ostium  and  in  retention  of  bloo<l  or  secretion. 

Tiie  finibriiE  are  occasionally  thickened,  fibrous,  or  club-like. 

Tumors. — Tumors  of  the  tube,  at  least  the  primary  ones,  are  rare. 
Fibromas  and  myxomai,  often  multiple,  are  met  with. 

\yarty  or  papillomatous  outgrowths  of  fibrous  nature  are  descril)ed, 
at  times  containing  a  clear  fluid  or  dilated  into  cysts.  Subserous  lipomas 
have  lu-en  met  with.  Benign  papillomas  have  also  been  reported,  and 
a  cystoma  papilliferum  (Eberth). 

Sarcoma  is  excessively  rare.  Carcinoma  is  usually  secondary  to  carci- 
noma of  the  uterus  or  ovary.  As  a  rule,  it  takes  the  form  of  a  diffuse 
growth  in  the  mucosa,  or  forms  nodules  in  the  muscle  and  serosa.  It 
is  nsiiiilly  of  the  soft  type,  but  mpy  be  scirrhous.  Primary  carcinoma  of 
the  tiilie,  as  a  rule,  takes  the  papillary  form.  Le  Count'  has  discussed 
the  naiiire  of  these  growths. 


THE  OVAUES. 


The  ovaries  are  ovate  glands  situated  on  the  posterior  aspect  of  the 
broail  lijraments.    They  are  attached  by  a  reduplication  of  the  peri- 


'  Z'ln^.iin,  Wien.  med.  Jahrb.,  1883:  477. 

'  Ih.  I .enesis  of  Carcinoma  of  the  Fallopian  Tubes  in  Hvperplastic  Salpingitis, 
kins  Hosp.  Bull.,  12:  1901:  120. 


John?  H 


848 


THB  OVAMBS 


! 


hi 


i 

I 

f 

i  f    ! 


toneal  membrane — the  mesovarium,  which,  however,  ends  abruptly 
without  forming  a  complete  covering  for  the  organs.  In  the  uiluli 
the  ovaries  measure  2.5  to  5  cm.  in  length,  2  to  3  cm.  in  breadth,  and 
1  to  2  cm.  in  thickness.  Their  weight  ranges  from  5  to  7  grams.  Frum 
the  inner  end  within  the  layers  of  the  broad  ligament  runs  a  (ibrouj 
cord  containing  unstriped  muscle — the  ligamentum  ovarii. 

Microscopically,  the  ovary  consists  of  two  parts:  a  medullar^-  portion 
composed  of  strands  of  connective  tissue,  unstriped  muscle,  abumlutit 
bloodvessels,  and  in  some  cases  rows  of  cells  of  embryonic  type  derived 
from  the  Wolffian  body,  which  are  in  relationship  with  the  epooplioron 
(Markstrflnge-Kdiliker) ;  and  a  cortical  part  composed  of  rather  cellular 
connective  tissue,  containing  the  Graafian  follicles.  The  outi-niiost 
layer  of  the  cortex,  called  the  tunica  albuginea,  is  more  condensed  and 
contains  fewer  follicles,  but  does  not  form  a  defii  'te  membrant-. 

The  Graafian  follicles  measure  0.04  to  0.15  mm.  in  diameter.  Tiiey 
are  formed  externally  of  a  connective-tissue  membrane — the  thiva 
folliculi — which  is  composed  of  an  outer  layer  of  fibrous  character  (tunica 
fibrosa) .  an  inner  softer,  more  cellular,  and  vascular  layer  (tunica  propria), 
and  a  stratified  layer  of  epithelial  cells  (membrana  granulosa).  .Vt  a 
certain  point,  about  the  ovum,  these  cells  are  heaped  up  into  the  discus 
proligerus. 

The  cavity  of  the  follicle  is  filled  with  fluid,  the  liquor  folliculi.  The 
ovum  possesses  an  outer  layer  of  hyaline  appearance,  the  zona  jH'llucida, 
presenting  radiating  strite;  a  nucleus,  and  a  germinal  spot. 

The  ovary  is  developed  from  the  Wolffian  body  by  the  ingrowth  of 
connective  tissue  into  a  mass  of  epithelial  cells  derived  from  the  ciilora. 
The  follicles  are  by  most  authorities  believed  to  be  derived  from  tlie 
downgrowth  and  subsequent  separation  of  the  superficial  inesDilicliai 
cells  of  the  body  cavity.  The  ovary  is  thus  entirely  mesoblastic.  'I'licre- 
fore,  tumors  arising  from  it,  even  if  histologically  of  epithelial  or  cure  ino- 
malous  tj-pe,  are  from  the  point  of  view  of  development  to  be  classed 
with  the  sarcomas  (mesotheliomas). 

The  ovary  is  particularly  liable  to  circulatory  disturbances;  indeed, 
these  are  largely  physiological,  for  congestion  accompanies  the  functions 
of  ovulation  and  menstruation,  and  hemorrhage  takes  place  into  the 
follicles  after  the  ovum  is  discharged.  Neither  circulator  ■  (listurl)iin''es 
nor  inflammations,  however,  are  of  so  much  importance,  either  dinicaL 
or  anatomically,  as  are  cysts  and  tumors,  which  form  a  large  proportion 
of  the  pathological  conditions  found  in  these  organs. 


=t 


OONOENITAL  AMOBIALIBI. 

Complete  absence  of  the  ovaries  is  rare  and  generally  a.ss(X'iiii< d  with 
absence  of  rudimentary  development  of  the  uterus.  Unilateral  defect, 
associated  with  the  condition  of  uterus  unicornis,  is  more  frequent.  In 
such  cases  the  kidneyjon  the"same''side'[is  sometimes  abscit  or  dis- 
located.    In  exceptional  instances  a  uterus  of  normal  type  may  be 


iJ= 


HYPEKEMIA 


840 


prrstnt.  The  i-ondition  is  not  due  to  aplasia  then,  but  rather  to  some 
londidon  that  exerts  traction  or  torsion  on  the  Fallopian  tube.  In  thU 
way,  from  atrophy,  a  portion  of  the  tube  with  its  attendant  ovary  is 
comph'tolv  separated  from  the  uterus  and  in  time  disappears.  It  may, 
howfver,  become  attached  in  some  other  situation  or  form  a  free  body 
in  the  abdominal  cavity. 

riiiliiteral  and  bilateral  hjrpopUila  is  described.  The  ovaries  may 
either  lie  small,  with,  however,  normally  developed  follicles,  or  the 
follides  may  be  rudimentary  or  absent.  In  bilateral  hypoplasia  the 
iniiividual  often  presents  the  secondary  male  characteristics  of  develop- 
ment. 

Aeemory  oniin  have  been  obser\ed.  They  are  usually  of  small 
size,  nuiltiple,  and  situated  at  the  hilus  of  the'  normal  ovary  at  the 
free  inurjcin  nf  the  peritoneum.  It  is  possible  that  thev'are  not 
always  true  accessories,  for  some  hold  that  they  are  simply  portions  of 
the  main  ovary  that  have  lieen  pinched  off  throuffh  peritoneal  adhesions. 
Wintkei  reports  a  ca.se  where  a  third  ovary  was  found  in  front  of  the 
uterus. 

The  ovary  may  occupy  an  abnormal  litnation,  for  instance,  in  the 
canal  of  Xuck. 

DISLOOATIOITI. 

Henua.~MalpositioiLs  of  the  ovaries  are  on^nital  or  acquired. 
Hernia  of  the  ovary  (ovariocele)  is  usually  congenital  and  due  to  patency 
of  ill"  proiessus  vaginalis.  Tht-  conditio'n  is  often  bilateral.  The  ovary- 
may  In-  found  in  any  part  of  the  inguinal  canal  (hernia  ovnrica  m(fuinnll.i), 
even  to  the  labium  (hernia  ovarica  labialia).  The  acquired  form  is  usually 
met  with  during  confinement.  Hernia  ovarica  cruralis  is  also  acquired, 
{{are  varieties  are  the  hernia  iachiadica.  ahdominalis  (into  the  .scar  of  a 
Cesarean  section),  umbilicali)i,  and  that  into  the  obturator  foramen. 
rhe  dislocated  ovary  is  often  congested  and  inflamed,  rarelv,  cvstic, 
(■arcinoiniitous.  or  sarcomatous. 

Prolapse.— The  ovary  may  also  be  prolapsed  when  for  anv  reason 
the  uterus  is  dislocated.  Other  causes  are  increase  in  the  weight  of  the 
ovary,  as  from  congestion,  oedema,  cysts,  and  tumors,  in  .some  instances 
comhnied  with  diminished  elasticity  of  the  ligaments  or  the  traction  of 
fibrous  hands.    The  prolapsed  organ  is  generallv  swollen  and  congested. 


OlftOULATORT  DISTURBANCES. 

Hyperemia.— Active  Hyperemia.— Active  hvperemia,  apart  from  the 
physioloj-ual  congestion  that  occurs  in  the  course  of  the  various  sexual 
functions,  {oitiis,  menstruation,  ovulation,  and  pregnancv,  is  of  little 
import;,  nee.     It  occurs  in  the  early  stages  of  inflammation. ' 

For  literature  sec  Falk,  Berl.  klin.  Woch.,  44 :  1891 :  106«. 


Wt 

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r//e  OVARIES 


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PualT*  HjiMniBU.— Pa.<wivr  hyperemia  may  lie  a  part  of  a  pt 
sy.Mfeinic  foiulitioii,  nr  Iwalizni  to  the  m'ary.  In  the  latter  cum' 
due  to  any  caiue  that  interferes  with  the  proper  'JiscliarKc  of  hliMMJ  thn 
tlie  vfiiw.  Among  these  may  be  mentioned,  torsion  of  the  |hi| 
prulap.se  of  the  ovary,  the  pressure  of  fil>n>us  adhesions,  and  the  |»n'> 
of  cysts  or  tumors.  The  ovarj-  is  enhtrged,  reddened,  and  H-deniiii 
and  in  long-stamiing  cases  may  lie  liliroid.  PhtobMtMia  of  the  \cii 
the  medulla  is  descrilied  by  Kaufmann. 

BamorriMffS.— Hemorrhage  into  the  ovarv  may  occur  in  any  of 
foregoing  fonns  of  hypen*niia,  and  in  the  nifectious  fevers,  siid 
typhoid,  diphtheria,  ami  cholera,  in  the  hemorrhagic  diutheses,  in  p 

[>horus  poisoning,  and  in  severe  bums.  The  effusion  of  I)Iu<mI  inii' 
ocal  or  diffuse,  and  may  involve  the  .stroma  (interstitial  henmrrlii 
or  the  follicles  (follicular  hemorrhage). 

VMien  extravasation  takes  place  into  a  follicle,  the  follicle  is  (iilarj 
sometimes  to  the  size  of  the  '^n.    The  blood  mav  be  normal  in  iipp 
ance,  clotted,  or  resemblir„    ar.     Frequently,  from  degencmiion 
reactive  inflammation,  a  yt   owish  zone  is  formed  at  the  p«Ti|)h 
The  distended  follicle  may  give  way  and  leail  to  fatal  hlwdin;;  «> 
retro-uterine  hematocele.     Hemorrhage  into  a  follicle  is  gentT.illv 
to  the  rupture  of  a  distended  vest*el,  but  the  passii)iliiy  of  ovm 
pregnancy  must   also  l»e  borne  in  mind.      Should  r-pUire   not  i 
place,  the  theca  iH-comes  thickened,  the  blo.^1  is  gradually  alisorl 
and  a  pigmented,  fibrous  scar  is  the  result.     Small  heniorrluip-s 
sometimes  seen  in  the  stroma,  usually  about  the  follicles,    'riirse  r 
couli'sce,  forming  large  extravasations,  or  the  hemorrhage  may  In-  cxi 
sive  from  the  first,  leading  to  a  diffuse  infiltration  of  the  orpm. 
such  cases  the  ovarj-  is  greatly  enlarged  and  the  tissue  more  or 
destroyed,  so  that  it  resenil)les  a  sponge  filled  with  blood  [hnmih 
ovarii).    This  is  not  infref|uent  in  children. 

LAOkemia. — In  leukemia  the  vessels  of  the  ovaries  are  filled  w 
leukocytes  and  there  is  also  infiltration  of  the  .stromii  witii  wliiii-  (t 
wliicli  are  found  along  the  course  of  the  vessels  or  else  form  iliHi 
nodules. 

nrrLAMMATiom. 


Odphoritis. — Inflammation  of  the  ovary — oophoritis-  i 
secondary,  being  cause*!  by  the  extension  of  inflamniatim; 
uterus,  tubes,  broad  ligaments,  or  peritoneum.  The  iiifcdin 
immediate  or  through  the  bloodvessels  and  lymphatics,  'i'lit 
of  cases  arise  from  the  uterus  during  the  puerperium,  or  from  ';:< 
In  some  cases,  as  in  typhoitl,  measles,  septicemia,  pneumonia, 
fliphtheria,  and  cholera,  the  infection  is  hematogenic.  In  rair 
oophoritis  is  primarj'.  due  to  reactive  inflammation  aboii' 
degeneration  or  hemorrhage  in  the  ovary.  Among  the  g«•rnl^ 
as  exciting  causes  may  be  mentioned  the  Gonococcus,  iStri'j 
B.  coli,  Diplococeus  lanceolatus,  and  B.  typhi. 


I'i'iiin  I 

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■  iii'iiir 

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i'lfiiicn: 

iii.>taii( 

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tlKOC-C'l 


magt 


mPllORITIS 


Sfil 


Acconliiig  to  the  portion  of  th«-  wary  chipflv  »ff«t«l.  we  ran  divide 
c»se^  into  foUkulu  or  puMiclqriMtmi  and  intantiti*!.  Fmiuentlv, 
how. ver,  the  whole  stnutun-  is  involve.!.  Slavjanskv'  has  destrilied'a 
(ItvtiHTative  form  of  follirular  oophoritis  «xturrinj{  in  the  acute  infet-- 
liv.'  .li-ieasfs.  The  <fll.s  of  the  niernhrnna  granulosa  are  swollen,  cloudy, 
•ml  later  under>{<»  fatly  dcKenerutioii.  The  ovum  may  In-  affette''  in  a 
•liniilar  way,  and  the  whole  follicle  may  Ik>  destroyed,  mt  that  thr  vity 
iKsoities  fille.1  with  a  whitish,  grunular  detritus. '  The  follicle  in  some 
iu-<«s  uriderK<Jes  cystic  ihanj{e.  .Sirne  .-xtruvasation  of  blood  niay  l« 
found  ulK)ut  the  follicles.  esjM-cially  in  cholera.  In  more  .severe  cases 
the  follicles  or  the  coqwra  lutea  may  >>ecome  filled  with  pus  (rappois- 
On  foU.  oopboritii).  ()c-casioi,  illy  the'  infection  travels  alonj?  the  lymph- 
chariiicls  of  the  broad  ligament  to  the  ovary  (^ottph.  lympluuicttiak)  or 
takes  the  form  of  thrombophlcbitLs  (o<iph.  thromboiditobttin).  The 
ovarv  is  enlarged,  softened,  and  infiltrat«««|  with  inflammatory  products. 
Wlien  suppuration  occurs,  which  fre<|Uently  happens,  one  can  make  out 
yellowish  streaks  running  from  the  hilus  to  the  cortex  alone  the 
lym|>liatics  or  veins. 

It  is  by  no  means  always  possible  to  draw  a  hard  and  fast  line  between 
the  follicular  and  interstitial  forms  of  oophoritis,  for  in  many  cases  the 
mflaiiitnation  is  diffuse.  In  the  milder  grades  the  ovary  i.s  cnlaived 
rwldt'ii.-.!.  and  oxlematous,  being  infiltrated  mainly  with  serum  (oiiph. 
.w(Mf().  In  other  cases  suppur  tion  occurs  (oiiph  purulenta)  or  extra- 
vasation  of  blood  (oiiph.  hemorrharflcn).  In  the  most  severe  forms  the 
t-ntirc  ovary  may  become  purulent  and  necrotic. 

Tlie  suppurative  Torm  of  oopl.jritis  is  usually  due  to  the  Gonococt  us 
or  to  septic  microiii^anisms  that  gain  an  entrance  after  parturition. 
In  such  cases,  as  a  rule,  the  infecti\e  agents  spread  from  the  broad 
licamtiiis  or  from  the  peritoneum,  les.^  .ommonlv  from  the  tube 

Tile  results  of  .suppurative  oophoritis  are  various.     Frequently  the 
iiiHainiiuition  extends  outward  to  the  s    'nee  of  the  ovary,  to  the  peri- 
toiH'ui.i.  or  tulies  (perioophoritis) .  or  a  .ubotivarian  absce'ss  mav  form 
A  loial  pus  collection  may  hurst  into  the  peritoneal  cavitv.  .set'ting  up 
a  serious  and  often  fatal  peritonitis,  or  mav  burst  into' the  rectum 
l.la.M.r,  more  rarely  into  the  vagina,  or  even  externally.     Should  the 
iuiiuiit   sur^■lye,    the   abscess    may   l)ecome   encapsulatwl   and   partly 
at)sorU,l.     llu-  ovary  in  surli  cases  is  usually  tied  down  bv  firm  ad- 
hesion,,   .Vs  a  re.sult  of  secretion  from  the  walls  of  the  ab.scess'  the  cavitv 
mav  miaui  a  considerable  size.     The  largest  abscesses  occur  where  a 
pn;  iou,|v  existing  cyst  has  become  infected.     The  commonly  resultinjr 
Fjerioophontis  may  result  in  the  attcchmenf  of  the  ovarv  to  the  tul)e 
the  mrn.s.  or  to  the  Douglas'  pouch.     .Sterility  is  a  rom'mon  result  of 
oo|)ti(int!>  and  salpingitis. 

Chronic  Oiiphorltls.-Chronic  oophoritis  is.  in  the  main,  due  to  the  .same 
.au>e-, ..  ,(,f.  acute  form.  Thu.s,  it  may  suin-neiie  upon  the  subsidence 
ot  an  arute  attack  or  after  repeated  relapses.     It  may  also  result  from 

'  Arch.  f.  Gyn.,  3: 1872: 183,  and  23: 1890. 


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852 


THE  OVARIES 


prolonged  or  repeated  congestion,  as  from  excessive  sexual  exciteinei 
or  venous  stasis.  The  main  characteristics  of  this  form  are  those  of 
productive  inflammation  affecting  the  interstitial  tissue,  thouirh  tli 
follicles  usually  show  degenerative  changes. 

The  ovary  is  possibly  at  first  somewhat  enlarged,  but  diminislu-s  i 
size  as  the  process  becomes  established.  The  surface  is  often  niNJuJii 
but  may  be  even,  and  is  covered  with  bands  or  tags  of  adhesion.  Tli 
tunica  ulbuginea  is  thickened  and  of  a  pearly-white  or  grayish  appear 
ance.  On  section,  the  organ  is  cirrhotic  and  contains  numerous  smal 
cysts,  due  to  the  dilatation  of  the  follicles. 

Micnxscopically,  in  the  early  stages,  there  is  a  small<elled  infiltratioi 
in  the  stroma,  principally  about  the  vessels.  Later  this  is  less  iiiarkid 
and  fibrous  hyperplasia  predominates.  The  vessels  usually  show  liyaliin 
thickening.  The  follicles  in  some  parts  may  be  normal,  but  many  o 
them  show  degeneration.  The  membrana  granulosa  is  cloudy  or  fatlil 
degenerated  and  often  stripped  off  from  the  theca,  while  the  ovum  i 
destroye<l.  In  other  cases  the  follicles  are  atrophic  and  represente<l  oril' 
by  corpora  fibrosa,  or  are  converted  into  cysts. 

Syphilis. — (Jummas  analogous  to  those  found  in  syphilitic  onliiti 
hav«'  been  observed  (Lancereaux'). 

Tuberculosis. — Tul>erculosis  is  more  common  and  takes  the  fom 
of  milia,  large  caseous  f(X'i,  or  areas  of  colliquative  necrosis.  As  a  rule 
the  disease  is  bilateral.  It  is  rarely  primary  in  the  ovary,  but  ori^jiuate: 
in  tiie  uterus,  tul)es,  or  peritoneum.  Sometimes,  however,  the  ovariei 
are  alone  affected.  Occasionally  the  follicles  (Heiberg.  S(  lietlaiider 
or  cysts  of  the  ovary  are  secondarily  infected.  A  tuboovarian  ahseev 
may  be  formed  or  the  ovary  may  be  enveloped  in  a  caseofibroid  mass. 

Actinomycosis. — Actinomycosis  is  excessively  rare,  and  is  iiivarial)l,\ 
secondary.  Small  abscesses  containing  the  actinomyces  "grains"  art 
found  in  the  stroma. 

Parasites  and  Foreign  Bodies. — Echinm-occus  disease  hn^  Ix-cn  fnutm 
in  the  cary  (Schatz,  P^an),  and  in  a  dermoid  cyst  (Freund"). 

Xcrdles  have  been  discovered  in  the  ovary,  having  reached  it  fron 
the  uterus  or  bowel. 


RETROGRESSIVE  METAMORPHOSES. 

Atrophy, — Atrophy  of  the  ovary  occurs  as  a  .senile  change,  nr  as  tlic 
result  of  chronic  (Wiphoritis.  The  senile  ovary  is  -smaller  dmn  normal, 
firm,  nodular,  and  of  a  grayi.sh  or  pearly  white  color.  The  iilliuf.'im'a 
is  hard  and  nuiy  Ik;  several  millimeters  thick.  The  follieles  iiiv  in  all 
stages  of  atrophy  and  degeneration  and  for  the  most  part  are  (  otiverted 
into  minute  fibrous  nodules  (corpora  fibrosa)  with  marked  tl  i(kenini; 
of  the  theca.     The  arteries  .show  hyaline  change  and  often  caK  i!i  .iiii)n. 

■  Traitd  hist,  et  prat,  de  la  syph.,  1874:  228. 
'Gyn.  Klin.,  1885. 


PROORESSIVf  METAMORPHOSES  §53 

Cloudy  and  fatty  deguieratioii  are  found  in  the  ovum  and  the  membrana 
granulosa  m  the  various  forms  of  atrophy,  as  well  as  hyaline  chann 
in  the  vessels  and  connective  tissue. 


PR0OSES8IVX  MSTAMOEPHOSEB. 

As  has  been  frequently  remarked  with  regard  to  other  omans,  so  with 
the  ovaries,  it  is  difficult  to  draw  a  hanl  and  fast  line  between  develop- 
mental overgrowths  of  tissue  and  certain  forms  of  inflammation 

An  increase  in  the  number  of  the  follicles  or  a  precocious  ripenine 
of  the  same  is  met  with  in  young  children,  associated  with  precocious 
menstruation  and  puberty,  and  by  many  is  regarded  as  a  form  of  hyper- 
trophy (hyperpUsia)  of  the  follicles.  In  a  certain  numl)er  of  these  cases 
tlie  ovary  presents,  also,  a  numlier  of  small  cysts.  These,  as  Leo  Loeb 
has  .shown,  may  originate  in  follicles  that  have  atrophied  prematurelv 
(atn-sia  of  the  follicles).  This  atrophy  is  common  in  early  life  In 
some  cases  of  uterine  fibroids  the  ovaries  are  hypertrophic,  showing 
not  only  cystic  dilatation  of  the  follicles,  but  also'round-celled  infiltra- 
tion, proliferative  changes  in  the  stroma,  and  hyaline  thickeninir  of 
the  vessels.  " 

Ik-sides,  however,  the  cysts  just  mentioned,  there  are  certain  othere 
that  must,  like  them,  be  differentiated  from  the  large,  developmental 
cysts  or  cystadeiiomas.  Such  are  the  small  cvsts  that  are  commonlv 
found  in  the  ovaries  in  cases  of  chronic  oophoritis,  perioophoritis,  and 
salpm^itis,  originating  in  the  follicles  or  corpora  lutea.  These  are  to  be 
repnlfd  as  "  retention"  cysts  (hydrops  follicutaris).  Here  it  is  probable 
iliat  there  is  a  thickening  or  condensation  of  the  theca  or  tunica  albujrinea 
which  prevents  the  bursting  of  a  follicle  and  the  discharge  of  its  contents' 

Lsually  there  are  more  cysts  than  one,  but  evenfuallv  one  or  two 
prt^lonnnate.  A  thm-walled  sac  is  protluced,  reaching  in  ^ize  from  that 
of  a  walnut  to  that  of  the  fist  or  of  a  man's  head.  The  smaller  cvsts 
are  hne.l  by  cylindrical  epithelium,  but  in  the  larger  ones  this  is  inore 
or  less  altered  from  pressure.  The  contained  fluid  is  usuallv  dear 
transpart'iit,  and  serous,  resembling  the  normal  liquor  folliculi.  but  mav 
eontam  blood,  degenerated  epithelium,  and  pigment.  In  the  larger 
cysts,  as  a  rule,  the  ovum  degenerates  and  disappears.  The  remaiiiinjr 
stroma  ot  the  ovary  presents  but  little  change,  except  that  in  the  case 

0  the  hirger  cysts  It  becomes  fibroid  and  atrophied  from  pressure. 
UcraMonaily  the  wall  becomes  calcified.  Ovarian  cysts  of  this  tvpe  are 
unilateral  or  bilateral.  ' 

Analogous  to  follicular  hydrops,  are  the  retention  cysts  sometimes 
on^'.imiing  in  the  corpora  lutea.  They  are  usually  single,  although  two 
or  more  may  be  found.  In  size  they  do  not  often  excled  a  walnut,  but 
iiavc  u . ,.  found  as  large  as  a  child's  head.    The  cyst  ^^all  is  composed 

01  a  loosely  attached  corrugated  membrane  of  reddish  or  reddish-v^llow 
Imei:  ^""|^'n")K^«^«'Pi»ari«.  leukocytes,  and  pigmented   round  cells 

^mteiii  cells).     The  cavities  contain  a  thin,  ropy  fluid  of  reddish  or 


'I||i 


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854 


THE  OVARIES 


yellowish  color,  containing  more  or  less  altered  blood.    There  is  n 
epithelial  lining  in  this  type. 

Tumors. — In  tlie  attempt  to  arrive  at  an  adequate  scientific  classit 
cation  of  ovarian  tumors  we  are  beset  by  many  difKculties.  The  old* 
writers  boldly  cut  the  Gordian  knot  by  dividing  them  into  cystic  an 
solid  growths.  This,  while  a  fairly  good  practical  division  from 
clinical  point  of  view,  must,  however,  be  regartled,  pathologically  speal 
ing,  as  unscientific  and  misleading,  inasmuch  as  under  the  term  "cysti 
tumors"  are  grouped  not  only  the  true  "proliferation"  cysts,  or  cysi 
adenomas,  but  also  "retention"  cysts  which  are,  of  course,  not  properl 
neoplasms.  Further,  certain  growths  are  separated  that,  embryoiof;itall 
speaking,  should  be  classed  together.  Still,  when  all  is  said,  it  may  b 
qi'-'stioned  whether  we  have  much  better  to  propose  for  it.  The  difficult 
is  that  the  etiology  of  many  of  the  ovarian  growths  is  still  in  doubi 
Thus,  with  the  important  class  of  the  cystomas,  leaving  out  of  the  actour 
the  simple  retention-cysts,  and  confining  our  attention  to  the  <l;vtlop 
mental  cysts  (cystadenomas),  we  know  that  certain  of  them  u  A  tob 
unilocular,  others  multilocular,  wliile  the  fluid  contents  of  cysts  tha 
appear  in  the  main  to  be  the  same  van  considerably,  beinj;  at  on 
time  serous,  at  another  ropy  and  mucinous.  Other  cysts  afiain  ar 
papillomatous.  These  striking  variations  suggest  different'es  in  oriftiii 
but  what  these  are  we  are  not  able  to  say  positively. 

Theoretically,  it  is  possible  to  get  cystadenomas  developing  ( 1 )  fron 
the  follicles,  (2)  from  invagination  of  the  original  germinal  fpillitliun 
(Keimepithel),  (3)  from  remains  of  the  Wolffian  body,  and  (4)  fron 
e.xtra-ovarian  tissues.  The  ideal  classification  would  be  aloiii;  em 
bryological  and  developmental  lines,  but  in  the  state  of  our  prcsen 
knowledge,  or,  rather,  ignorance,  it  is  perhaps  better  to  fall  hack  oi 
morphological  differences,  at  least  in  the  main.  This  is  the  lia>is  o 
Pfannenstiel's  classification,  in  which  three  groups  are  redifriiizwl 
(1)  The  parenchymatous  growths,  divided  into  (a)  those  (leri\t(l  fron 
the  epithelium  and  (6)  those  derived  from  the  ovum;  (2)  growili^  nrisinj 
from  the  stroma;  and  (3)  mixed  types.  This  is  not  entin-iy  saii-lai  tor} 
as  it  brings  dermoids  and  teratomas  into  the  same  clas.s  as  ''  rvst 
adenomas,  with  which  they  have  little  in  common,  either  in  >tr;.  luiv  m 
in  origin. 

We  would  suggest  the  following  classification,  not  as  having'  liiialit\ 
or  being  scientifically  accurate,  but  as  having  at  least  the  a  lMiiiiat:e  ol 
grouping  like  things  together  and  separating  unlike  ones. 

rCystadenoma: 


I.  New-gronths  of  epitlivlial 
type 


Kenign, 


Malignant. 


1.  Arising  from  tlir  1 

!!:W,-.=. 

2.  From  the  coriiiis  1;' 

,'11111. 

3.  From  the  Rpniiiri:i!  . 

•iit'iclium 

4.  From  Woltliaii  ■  i. 

-. 

.■;.  From  remain?  of  . 

Mjilioron 

1.     6.  Frx'in  tuba!  '■r--- 

f  1.  Cvstic  carcinoma. 

(  2.  Solid  carcinoma. 

i'    1 


CYST  ADENOMA 


855 


II.  New-growths  of  connec- 
ti\e  tissue  type  . 


Benign. 


Malignant. 


'  1.  Fibroma. 

2.  Papilloma. 

3.  Hemangioma. 

4.  Lymphangioma. 


Endothelioma 
Perithelioma. 
Sarcoma. 


I  3. 


III.  Teratomas 


IV.  Mixed  tumors. 


1.  Epidermoid  cysts. 

2.  Pure  dermoid  cysts. 

3.  Compound  dermoids. 
[  4.  Compound  teratomas. 

Combined  and  cognate  forms: 
f  1.  Myofibroma. 
Benign.         -  2.  Adenofibroma. 
( 3.  Cystic  fibroma. 


Malignant. 


1.  Myosarcoma. 

2.  Adenosarcoma. 

3.  .Sarcocarcinoma. 

4.  Cystic  carcinoma. 

5.  Cystic  sarcoma. 


Teratogenous  blastomos: 
Benign.  1.  Cystadenoma  with  teratoma. 


Malignant. 


.1  1.  Sarcoma  with  teratoma. 
I  2.  Carcinoma  with  teratoma. 


Cystadenonu.— Of  the  epithelial  growth.s,  the  most  important  are  the 
c«ta(lenoma.s,  which,  indeed,  are  the  commonest  neopla.sin.s  found  in 
the  ovaries.    They  may   l)e  unilateral   or  bilateral.     Nowadays  thev 
rarely  reach  a  large  size,  inasmuch  as  thev  are  usually  operated  upon 
soniiwiiat  early,  but  in  former  times  cases  used  to  be  niet  with  in  which 
the  weight  of  the  cyst  actually  exceeded  that  of  the  patient  affectetl. 
Several  varieties  are  recognized,  according  to  the  numl>er  of  cysts,  the 
character  of  the  lining  epithelium,  and  the  nature  of  the  contents  '  As 
the  mam  t\-pe,  we  may  take  the  cor,,:    n  ovarian  cvst  or  .simple  cy.ifoma 
Ihis  IS  generally  unilateral,  and  consists  of  one  main  cvst  of  proportion- 
ately  large   size,  with    several  subsidiary    or    daughter  cysts.     The 
smaller  cysts   may   exist   more   or   less   "independently   in  the  fibrous 
stroma  or  may  encroach  upon  the  cavity  of  the  major  c«t.     On  examin- 
ing the  inner  surface  of  the  wall,  one  can  generali .  make  out  ridges  repre- 
sciitiiif;  the  remains  of  former  divisions  between  the  cvsts.     Hence  the 
major  cyst  is  evidently  developed  from  the  confluence  of  smaller  cvsts 
A  multil.Kular  cyst  may  thus  lie  converted  into  a  unilocular  one     The 
cyst-wall  ,s  often  tough,  thin,  and  translucent,  but  in  some  ca.ses  thick. 
Ihc  M,.,„l  supply  is  by  means  of  large  vessels  that  enter  in  the  pedicle 
and  raf.ify  over  the  surface.     The  fluid  found  within  the  various  cvsts 
ihtfer-  ^.)tne\vhat  in  character,   being  thinner  in   the  larger  cavities 
Ihe  .pcific  gravity  varies   from   1010  to   1030.      It  is  often  viscid' 
liiueiiinas,  or  stiff  like  honey.     In  color  it  may  Ik-  clear  and  gla.ssv    in 
other .  :,ses  turbid,  brownish,  or,  rarely,  tinged  with  blood.     The  char- 
acter ui  the  fluid  b  due  to  the  presence  of  certain  bodies,  regarded  by 


m  1 

i 

i   1 

■ 

'  f. 

■    ' 

.    '   ,: 

i 

(      : : 

1 

ft 

[ 

m 


t 

i:  * 


i   I 


Uui.l^ 


i 


'  r 


.Hi 


856 


THE  OVARIES 


Scherer  and  Eichwald  as  paralbumin  and  metalbumin,  but  whi( 
according  to  Hammerstein  and  Pfannenstiel,  are  more  nearly  relai 
to  mucin.    They  term  them  pseudomucin. 

Tlie  cyst-wall  is  composed  of  two  layers  of  fibrous  tissue,  an  on 
firmer  and  more  fibrous,  an  inner  cellular  and  vascular.  The  lini 
membrane  of  the  cyst  is  usually  composed  of  a  single  layer  of  hi 
cylindrical  cells.  In  the  larger  cysts  the  lining  cells  are  short,  cohiniiii 
cuboidal,  or  even  occasionally  flattened.    The  lining  epithelium  fori 

downward  evaginations,  so  tli 
*'""■  222  simplenr  compound  gland-tul)ul 

are  produced  in  the  wall  of  t 
cyst.  Some  of  these  may  Wecor 
pinched  off  and  form  niiiini 
intramural  cysts.  It  is  rare  f 
the  epithelium  to  be  stratific 
Some  cysts  are  lined  with  (iliari 
cells,  either  wholly  or  in  pai 
In  many  cases  the  cells  of  tl 
lininp  epithelium  present  collo 
chanj,!-  and  diseiiarjje  their  eo 
tents  into  the  cavity.  The  eel! 
also,  from  pressure,  fre(|iiem 
.show  fatty  degeneration,  atropli 
and  necrosis. 

Micro.scopieally,  the  flnid  coi 
tent  contains  fat  glol>uies,  leuk( 
cytes,  degenerating <ells,  (ictritii 
blood,  and  eholesterin.  In  man 
cases  the  typical  ovarian  striK 
ture  has  completely  disappriirei 
but  occasional'  some  more  or  le- 
flattened  and  atrophitij  remain 
can  still  be  made  out  (onlaiiiin 
active  follicles. 

A  second  but  rare  form  nf  rvsl 
adenoma  is  a  prdunciilntrJ,  mitlti 
loctdar  cyst  of  modcraic  sizt 
usually  unilateral,  linn  I  witl 
ciliated  cylindrical  e|iiilieliuiii 
The  cyst-contents  are  thin,  more  serous  than  in  the  last  foitu,  aiu 
light  yellow  or  greenish  in  eolor.  The  fluid  is  rich  in  albumin  and  con 
tains  no  pseudomucin.  The  cyst-wall  asually  contains  ghiiil-tiiljiilc: 
in  considerable  numbers,  especially  near  the  pedicle. 

A  third  and  important  type  is  the  papillary  cystoma  {ciiyi  idcnotM 
pnpilUfrnim).  This  is  a  multilocular,  or  occasionally  unil<>;  ■ !  r  fys^ 
and  is  liable  to  be  bilateral.  The  growth  may  extend  betiucn  the 
layers  of  the  broad  ligament  or  form  a  pedunculated  mass  springing 
from  the  surface  of  the  ovary.    The  cysts  are  usually  small  ;  than  in 


Ovarian  cyst.     (From  the  Gynecological  Clioio 
of  tba  Montreal  Cieneral  Hospital.) 


CYSTADENOMA 


857 


the  case  of  the  simple  cystadenoma.  In  this  variety,  the  cavities 
are  more  or  lew  completely  filled  with  warty,  villous,  or  tree-like 
excrescences  derived  from  the  proliferation  of  the  connective-tissue 
stroma  of  the  cyst-wall,  which  are  covered  with  ciliated  cylindrical  epi- 
thelium. In  some  few  cases,  the  cilia  arc  absent  or  only  lo  be  observed 
on  the  papillte.  The  stroma  is  composed  of  fibrous  tissue  containing 
numerous  bloodvessels.  It  may  show  mucinous  degencution.  Excep- 
tionally, papillary  outgrowths  are  found  on  the  external  aspect  of  the 
tumor.    This  is  due,  for  the  most  part,  to  the  fact  that  the  cyst-wall, 

Fio.  223 


CystadencK         MultiloeuUr  ovarian  cyst.     fDudley 


through  atrophy,  has  given  way  and  the  originallv  intracvstic  outgrowths 
appear  on  the  surface.  More  rarely,  there  is  a  true  invasion  or  infiltra- 
tion of  the  cyst-wall  by  the  papillae.  It  is  not  unusual  to  find  granules 
of  hiiif  (sand  bodies,  psammoma)  in  the  wall  and  in  the  papilla;.  The 
fluid  (cntained  is  thin,  watery,  and  more  serous  than  in  the  simple  cyst- 
aden..H!as  It  contains  little  or  no  pseudomucin.  The  color  is  often 
dark  hke  coffee.  The  tumor  is  clinically  of  great  importance,  since 
in  tifiif  it  invariably  develops  malignancy,  and  secondary  nodules  are 
found  scattered  over  the  peritoneal  membrane.    According  to  Pfannen- 


S58 


T''  ?  OVARIES 


stiel,  one-half  of  the  ovarian  papillary  cystadenomas  are  in  rcali 
carcinomatovis  from  the  start. 

With  regard  to  the  origin  of  these  cystic  growths  much  has  been  writti 
and  much  remains  to  be  learned.  It  is  not  likely  that  they  are  all  dcrivt 
from  the  same  elements.  Theoretically,  cystadenomas  may  arist-  fro 
the  epithelium  of  the  follicles,  from  the  corpus  luteum,  from  the  sii|)e 
ficial  germinal  epitholium,  from  certain  tubules  of  the  parwiphorc 
(Waldeyer),  from  c;  ^^ice6.  "rests"  of  the  ciliated  tubal  epitliiliui 
(Kassmann),from  remains  of  the  Wolffian  body(K6lliker's  Markstriiiipe 
Attempts  have  been  made  to  assign  a  particular  origin  to  the  cysts  accon 
ing  to  the  character  of  the  contained  fluid,  but  this  is  a  small  point  I 


Fig.  224 


i  i 


=■. 


XhJfLk 


CyBtoma  papilliferum  of  the  ovary.     Zeiss  obj.  A,  without  ocular. 

Dr.  A.  G.  Nicholla.) 


(From  tile  culli-rriwii  of 


decide  upon,  since,  as  is  well  known,  the  fluid  varies  considi  nililv  in 
different  parts  even  of  the  same  growth.  As  much  depends  \i\w\\  alisorp- 
tion  as  upon  secretion.  Again,  differentiation  has  been  nuidr  on  the 
ground  of  the  presence  or  absence  of  papillary  outgrowths  and  nf  ciliated 
epithelium.  As  Orth  points  out,  however,  it  is  difficult  ii>  liiaw  a 
hard  and  fast  line  between  the  simple  and  the  papillary  cystMiii nomas, 
inasmuch  as  all  sorts  of  transitional  forms  have  been  met  will'.  It  has 
been  shown,  moreover,  that  under  certain  circumstances  noii-<i!'i!cd  epi- 
thelium may  acquire  cilia,  and  in  man  the  existence  of  ciliatcii  :<  riiiiiial 
epithelium  has  been  proved.  This  being  the  case,  it  will  readii  lie  seen 
how  difficult  it  is  to  come  to  any  satisfactory  conclusion  as  to  il  ■'  etiology 
of  these  cysts.    A  developmental  origin  for  many  of  them  is    spported 


CARClNOlUA 


859 


bv  several  facts.  Cystadenomas  are  usually  met  with  during  the  period 
of  sexual  activity  and  not  infrequently  in  both  ovarii.  Again,  cases 
have  been  recorded  where  sisters,  or  mother  and  daughter,  have  been 
similarly  affected,  suggesting  an  hereditary  vitium.  Perhaps  even  more 
sujjgestive  is  the  not  uncommon  event  of  the  combination  of  acystadenoma 
with  a  dermoid.  In  some  multilocular  cysts  certain  of  the  cysts  are  lined 
with  cylindrical  epithelium  and  present  a  glandular  character,  white 
others  resemble  dermoids. 

The  origin  of  the  papilliferous  cystadenomas  has  been  variously 
referred  to  the  follicles,  the  germinal  epithelium.  Wolffian  "rests,"  or, 
bearing  in  mind  their  frequent  situation  between  the  layers  of  the  broad 
ligament,  the  parovarium.  Authorities  are  divided  whether  to  assign 
the  same  etiology  to  the  simple  cystadenomas  and  the  papillary  forms. 
Orth  is  inclined  to  attribute  the  majority  of  them  to  the  same  origin — 
the  germinal  epithelium. 

From  the  cystadenoma  there  b  a  natural  transition  to  the  eardnoma, 
for  the  epithelial  benign  tumors  of  the  ovary,  especially  the  cystic  forms, 
are  particularly  liable  to  undergo  malignant  metamorphosis.  This  is 
borne  out  by  the  fact  that,  like  the  cystadenoma,  carcinoma  of  the 
ovarj'  has  been  found  in  early  life,  even  before  the  age  of  puberty. 

Ourcinoma. — Carcinomas  may  be  conveniently  divided  into  ajatic  and 
sdid  growths.  The  former  arise  commonly  in  the  simple  cystaden- 
omas, but  still  more  frequently  in  the  papillomatous  variety.  The  cystic 
carcinomas  in  general  resemble  their  non-malignant  prototypes,  but 
seldom  attain  such  a  large  size.  In  the  malignant  cystadenomas,  the 
walls  and  septa  are  found  to  be  infiltrated  with  nodules  that  histologically 
are  composed  of  masses  of  epithelial  cells.  In  many  places  the  lining 
epitiu'lium  has  proliferated,  so  that  a  stratified  layer  of  cells  has  taken 
the  place  of  the  original  single  row.  The  fluid  contents  of  the  cysts 
are  clear,  or  cloudy  from  the  admixture  of  cells  and  blood.  The  material 
may  also  be  viscid  or  even  colloid.  In  the  latter  case  the  metastases  are 
also  colloid,  as  in  a  case  recently  under  our  observation. 

In  the  papillary  type  (cystadenoma  papilliferum  waligmim)  there  is 
an  exuberant  growth  of  the  excrescences,  which  are  more  cellular  than 
usual,  and  the  septa  are  infiltrated  with  secondary  cancerous  nodules 
of  papillomatous  appearance.  In  many  cases  the  papillae  extend  through 
the  septa  and  appear  externally,  giving  rise  to  peritoneal  and  other 
metastases.  The  stroma  frequently  presents  mucinous  degeneration, 
and  (x>casionally  sarcomatous  transformation.  As  in  the  benign  form 
psaninioma  bodies  may  be  found.  In  some  few  cases  it  has  been  thought 
that  simple  cystadenoma  and  cystic  carcinoma  have  arisen  independently 
in  tile  same  ovary. 

Till'  solid  carcinomas  of  the  ovary  are  also  unilateral  or  bilateral. 
Thtv  form  smooth  or  nodular  growths,  sometimes  attaining  the  size  of 
a  c!:i!il's  head.  The  ovarian  tissue  is  frequently  difTusely  infiltrated 
ami  (kstroyed,  or  the  main  mass  of  the  organ  may  be  pushed  to  one  side 
in  the  course  of  growth.  As  a  rule,  the  tumor  is  of  the  medullary  or 
acinhous  tj-pe,  but  may  be  colloid.    A  curious  form  is  the  so-called 


i  lii  . 


iiiJi  I 


J, 


lii 

tl  (| 


860 


THE  OVAHim 


tuperficial  papillary  carcinoma,  in  which  papillomatous  outgruwi 
develop  on  the  surface  of  an  otherwise  fairly  normal  non-cystic  ovurv. 
Histolof^ically,  carcinoma  is  made  up  of  cylindrical,  cuboidal] 
polymorphous  cells,  either  arranged  in  more  or  less  perfect  alvet 
or  forming  a  diffuse  infiltration,  ami  not  infrequently  showinj;  muciiio 
change. 

The  mode  of  origin  of  the  solid  carcinomas  is  obscurt-.  Tht-v  a 
supposed  to  arise  from  any  of  the  following  sources:  the  supeffici 
germinal  epithelium.  PflUger's  tubules,  the  follicles,  the  corpus  liK.ii 
(Rokitansky),  or  remains  of  the  Wolffian  body. 

tharian  carcinomas  of  all  kinds  spread  rcadilv  «>ver  the  peritoiKiii 
owing  to  grafting  in  the  Douglas"  pouch.  They  also  spread  to  tl 
broa<l  ligaments  and  produce  distant  metastases  by  invasion  of  t| 
lymphatics  and  blooilvessels.  Metastases  in  the  opposite  ovarv  a 
recordetl.  Secondary  growths  are  fonned  in  the  tulies  and  ovari 
either  by  local  implantation  or.  in  the  case  of  the  tubes,  by  .liiv 
infiltration  or  by  a  metho«l  similar  to  the  transportation  of  the"  norm 
ovum. 

Secondary  cancer  may  arise  by  the  extension  of  cancer  of  tlit-  inij:l 
boring  parts,  as  the  uterus  or  rectum.  The  primary  growth  inav  also  I 
in  the  breast  or  stomach.  A  curious  fact  is,  that  in  some  cases  tlu-  ovarii 
are  the  only  seat  of  secondarj-  growths,  and  this,  together  with  tlu-  ad.l 
tional  fact  that  a  considerable  length  of  time  (some  vears)  mav  flap. 
I)etween  the  txx-urrence  of  the  primary  tumor  and  the  appeariUKr  c 
the  secondary  growths,  has  led  to  the  suspicion  that  some,  at  l.a>t. . 
these  ca.se.s  may  not  be  examples  of  metastasis,  but  rather  of  ninjiipl 
independent  neoplasms.  This  possibly  has  also  to  be  thought  of  in  tlio> 
cases  where  in  primary  carcinoma  of  one  ovary  cancerous  i.odiilcs  liav 
been  found  in  the  other.  It  is  not  always  easy  to  decide  whether  the 
are  independent  growths  or  not,  but  it  is  quite'  probable  that  inanv  ar 
so,  when  we  remember  the  decided  tendency  of  ovarian  growths.  Kenici 
as  well  as  malignant,  to  \ye  bilateral.'  Metastatic  deposits  onirinaiiiii 
in  distant  organs  develop  through  the  blood  stream,  or  in  eaM>  c 
abdominal  growths,  by  means  of  the  peritoneum. 

Of  the  connective-tissue  tumors,  the  only  ones  worthy  of  iu)te  art  ihr 
fibroma  and  the  ureoma. 

Fibromas  form  usually  diffuse  growths  leading  to  uniform  <  luanre- 
ment  of  the  ovary,  but  circumscribed  nodules  are  occasionallv  t\.rnid 
They  may  be  unilateral  or  bilateral,  and  may  attain  a  consider;!  11,  size. 
Multiple,  warty,  nodular,  or  papillary  fibromas  are  occasionalK  me! 
with,  arising  from  the  surface  of  the  ovary.  Occasionalh  til'mma^ 
arise  from  the  corpora  lutea  from  overgrowth  of  the  theta  ai.i  fcrra 
tumors  the  size  of  a  walnut.  The  theca  is  thickened  and  tlinivu  iniM 
deep  folds,  while  the  centre  is  composed  of  loose  connective  t>-;if  ef 
soft  consistence  and  grayish  or  grayish-brown  color.     Oe.a-i  .;,aii.. 


'See  WooUey,  Boston  Jour.  Med.  and  Surg.,  Januarj'  1,  1903:  1; 
Montreal  Med.  Jour.,  32;  1903:  326. 


N  iciciii 


SARCOMA 


861 


note  ;irf  Ihr 


these  growths  contain  cavities  filled  with  serous  fluid  and  altered  blood 
pigment.  Leo  Loeb'  has  recently  described  a  curious  fibrocystic  tumor, 
containing  numerous  cells  derived  from  the  lutein  tissue  occurring  in 
the  ovary  of  a  calf. 

Several  modifications  of  fibromatous  tumors  are  described,  such  as 
nyoflbroma,  flbrocTitoiitt,  admoflbroiM,  and  flbro-adraoejntoma.  In  some 
cases  osteoid  tissue  is  formed  (fibroma  osteoidea)  or  true  bone  (fibroma 
mriim).  It  is  doubtful,  however,  whether  true  oataona  or  ehondroina 
are  ever  found  in  the  ovaries.  The  bloodvessels  and  Ij-mphatics  may 
be  ahimdant  and  greatly  dilated.  Suppuration,  gangrene,  and  calcifica- 
tion may  occur  in  fibromas. 

A  siinple  h«inu(ioina  has  been  met  with  by  Orth'  in  both  the  ovaries 
of  a  child,  assoc-iated  with  angiomas  in  the  skin  and  internal  organs. 

Lymphangioma  has  been  de.scribed  by  licopold*  and  others. 

'i'lie  malignant  growths  arising  from  the  stroma  are  andothelioma, 
paitheUoma,  and  lareoma.  Marehand'  was  the  first  to  describe  endo- 
thelionias,  or  tumors  arising  from  the  lining  membrane  of  bloodvessels 
anil  Ivinphatics.  in  the  i>vary.  Some  originate  in  the  lining  cells  of  the 
perivascular  lymphatics,  one  form  of  perithelioma.  These  tumors  vary 
considerably  in  appearance.  They  attain  a  considerable  size,  are  uni- 
lateral or  bilateral,  and  are  often  soft,  spongy,  and  friable.  Occasionally 
they  are  cystic. 

Histologically,  they  re.semble  carcinoma  or  sarcoma,  or  one  of  the  manv 
forms  of  mixed  growth.  One  may  see  ma.s.ses  of  cuboidal,  cylindrical, 
or  iM.iyhedral  c-ells,  arrangwl  in  bands  or  alveoli,  or  often  more  or  les.s 
(iefinitely  enclosing  a  lumen,  which  may  contain  blood  or  Ivmph.  In 
these  masses  giant  cells  may  sometimes  be  seen.  Hvaline  degeneration 
often  occurs.  The  nests  of  cells  are  separated  by  fibrous  tissue,  occa- 
siona  1  ly  presenting  a  myxomatous  appearance.  In  some  cases  the  fibrous 
tissue  |)enetrates  the  lumina  so  as  to  form  intracanalicular  papillomas. 
.\niaiin  has  also  described  a  form  of  sarcoma  (perithelioma)  arising  from 
the  adventitia  of  the  vessels.  The  most  recent  writer,  Ribbert.  however. 
It  may  he  said,  doubts  the  existence  of  tumors  arising  from  the  endo^ 
thehiini,  and  sees  no  reason  for  .separating  peritheliomas  from  other 
sarcomas.  It  should  be  remarked  in  this  connection  that  the  so-called 
endotheliomas  may  in  some  cases  arise  from  "rests"  derived  from  the 
mesothelial  lining  of  the  coelom,  a  possibility  that  does  not  seem  to 
have  siitrKested  itself  to  the  systematic  writere. 

Sarcoma.— Sarcomas  are  relatively  rare,  constituting,  according  to 
.VhrcHlcr.  only  1.5  per  cent,  of  all  ovarian  tumors.  They  are  frequently 
bilateral,  but  also  unilateral,  and  may  be  found  in  quite  young  children. 
Ihf  affected  ovary  may  be  uniformly  enlarged  or  present  a  nodular 
surtar, .    The  tumor  is  moderately  hard,  and  is  usually  covered  with  a 

'  Virchow'g  Archiv,  166:  1901 :  157. 

'Lehrb.,  2:  1893:572. 

»  Die  soliden  Geschwiilste  der  Ovarien.,  Arch.  f.  Gyn.,  6. 

'Beitr.  z.  Kenntn.  d.  Ovarialtumoren,  1879:  47, 


rfi 


1 


m 


in.; 


n  ' . 


i  M 


i  : 


Li.1  J I 


& 


862 


r//«  OVXWM 


8erosa>like  memhrnne.  The  (growth  originates  in  a  .linf^le  fix'iis  thai 
gradually  enlai)(i's  until  the  whole  ovary  is  involved.  NtNiulur  forms 
are,  however,  met  with. 

HUtologicttliy,  ovarian  surc'oinns  arc  apindU  lied  and  rouml-nllnl. 
Mixed  forms,  however,  otrur,  with  or  without  j  uit  celU,  and  Honiftiiiws 
rontuiniii);  much  fibroai  t'ls.'iu^-fihriMiarcimia.  Myxoniuloiis  eh 
may  often  l)c  ol>!ter\eil.  The  gmw-th  is  asually  isoluttnl,  uithoii^'li  ]ht,- 
toneai  aithesioiM  and  inetii.sta!«'s  may  oii-ur.  MetastoMis  in  ili  uini 
oiyaas  is  rare,  and  is  found  t-iiiefl^-  in  the  round-eelled  variety.  In  nil 
forms,  hyaline  and  fattv  degeneration,  net-rosis,  hemorrhage,  ami  ilintm- 
Ijosis  may  lie  seen,  \fartin  and  Hamilton'  have  recorded  an  appuniulv 
uni(|ue  ease  in  which  there  was  bilateral  mixed-celled  sarcoinu  of  the 
ovaries,  with  fairiy  generalize*!  sarcomatosis  and  purpura.  The  I>Iimh1 
showed  a  marked  leukocytosis  of  lymphocytic  type.  The  metasiasfs 
seem  in  the  main  to  have  fonneil  along  the  perivascular  lymplmtics, 
and  spindle-celled  emlmli  were  found  in  the  vessels  of  the  skin,  tlnis 
accounting  for  the  pur|)ura. 

In  some  cases  the  sarcoma  cells  are  seen  to  be  grouped  ni)(iiit  the 
small  and  middle-sized  blooilvessels.  Von  Ilasthorn  would  classifv  this 
form  with  endothelial  peritheliomas  above  mentioned.  It  sliouiii  lie 
noteil  that  sarcomatous  change  may  be  found  secondorily  in  adcnuriia, 
cystadenoma,  myoma,  and  carcinoma.' 

TentODUs  (EmteyonuU).— Under  the  term  "embryomata,"  Wilms 
in<-ludes  that  class  of  tumors  that  '.ve  generally  call  dermoids  ami  ttra- 
toinas.  on  the  ground  that  they  contain,  more  or  less  abumlaiulv, 
structures  similar  to  those  found  in  the  embryo.  These  tumors  ai* 
generally  cystic,  and  may  be  simple,  compose<i  of  structures  rcstiiil)ling 
skin  (hence  the  term  "dermoid"),  or  compound,  where  in  adilition  to 
epidermal  tissues  there  are  others  derived  from  the  mesoblast  and  liyjxv 
blast,  teeth,  bone,  cartilage,  muscle,  glands,  ner\e  tissue,  and  imiioiis 
membrane. 

It  should  be  remarked,  however,  that  the  term  "dermoid."  wliii  li  h.is 
had  such  extensive  vogue,  in  the  light  of  recent  researches  has  Iom  iinah 
of  its  significance,  if,  indeed,  it  is  not  now  actually  misleadiiii:  It  is 
commonly  held,  for  example,  that  the  dermoids  are  cysts  coni|H.Mil  of 
more  or  less  modified  skin  with  other  structures  of  epiderniMl  iri^'in. 
Careful  study  has  shown,  however,  that  even  the  simplest  of  ilipin 
contain  structures  from  the  other  primitive  germ  layers.  Cc.is,  .|i;fmi_v, 
the  distinction  l)etween  "dermoid  and  teratoma"  is  an  artili.  iil  one, 
and  had  l)etter  be  discontinued.  It  is  simpler  and  more  corrtc  t  i.m  lass 
all  the  growths  of  this  kind  under  the  one  generic  term  "t(  n?.  la." 
If  the  word  "dermoid"  lie  retained  at  all,  it  should  be  emplo\<  1  -impk 
for  convenience  of  description. 

Teratomas  are  rather  frequent   in   the   ovaries.     They  :ii     itner- 
ally  unilateral,  sometimes   hilatpml.      More  rarely,  multij'!^     '  :>,imte 

'  Jour.  Exper.  Med.,  1 :  1896:  595. 

'Wilms,  Die  Mischgeschwiilste,  Leipzig,  1899  and  lOfC 


DERMOIDS 


863 


lemtomas  are  found  in  one  or  l)oth  ovarii.  These  tumors  are  of  slow 
({ri.Mli,  remain  Intent  for  a  long  time,  ami  UHually  j{ive  rite  to  symptoms 
fir.1  .JiirinK  the  period  of  sexual  a«-tivity.  'Hie  growths  are  in  the  vast 
niajority  of  cases  cystic,  and  range  in  'sisee  from  that  of  an  apple  to  a 
mini  -  head  or  larg«'r.  They  are  usually  pe<lunculated  ami  pmject  into 
thf  ixritontal  cavity.  More  rarely,  they  extend  partially  U-tw.-en  the 
lay.r.  of  the  broad  ligament.  We  may,  jK-rhans,  n-<()gniiM',  with  f)rth: 
I.  EpidtnmideTiU,  in  which  there  i.s  a  layer  of  .strati(ie<l  ami  kerafinous 
«i.|iiiitii<)iis  epithehum,  linwl  with  connectivt  tissue.  The  usual  structure 
of  ill.-  skin  IS  only  in  a  general  way  pre.s«-r>wl.  The  surface  is  Hssured 
atiii  -.aly,  and  of  a  grayish-white,  often  mother-of-|K'arl,  ai.jH-aranc.'. 
ill.'  cavity  contains  deliris  of  keratin  of  a  firm,  friable,  soapv,  and 
cholc'itcatomatous  character. 


Flo.  23S 


rt-f 


I.,..rior  view  of  an  ovarian  teratoma  C  dermoid  ey.t  "),  -hnwing  Rokitan.,ky'«  inland 
bearing  c,  Imirs  with  d.  teetli  surruundinc.     (Scllwalbe.) 

2.  Pme  dermoid  cysts.  These  are  the  most  frequent  tvpe.  Here,  there 
H  an .  pi  Urmis  and  cutis  in  which  rudimentary  papilla  can  he  made  out. 
Hair-f.,lli,  les,  sudoriparous  and  sebaceous  glands  are  very  numerous  in 
waiii  parts.  Hair  is  present,  usually  in  considerable  quantifies,  fom> 
1%'  f.  It«l  masses  or  long  tresses  lying  free  in  the  cavitv,  or  growing  from 
the  wall  ,„  t,:fts.  Besides  hair,  the  cavitv  is  filled' with  a  yellowish, 
rath.r  ;;ranular,  fat  (sebum),  which  during  life  is  fluid,  together  with 
^•al- -  .t  tpithc-Iium,  debris,  and  cholesterin  crystals. 
^  3.  Compound  dermoids  (simple  teratomas).  In  addition  to  the  structures 
^'!P.  ;•:  tiie  pure  dermoids,  there  is  the  formation  of  teeth  and  bone. 
lie  lK,ii,  usually  forms  irregular  pates  in  the  wall  of  the  cyst,  but 
o'ta„„nalIv  from  its  shape  suggests  a  maxilla.  The  teeth  have  the  char- 
a<!en,!„ ,  of  the  permanent  and  milk  teeth,  and  ar«  of  all  types.    At 


m- 


ait 


J 

1  M      ' 
.  j  •  '      I 

!   -i 

■    !      : 

Ml  i 

iM 

864 


THK  OVARIU 


timea  they  are  only  rudimentary.  In  number  they  may  greatly  exct-nl  i 
normal  eomplrment  of  teeth.  From  one  to  three  hundred  have  !>« 
counted.  Tiie  teeth  may  project  into  the  cavity  or  lie  embedded  in  i 
wall. 

4.  OompMsd  tantonaa.  Here,  in  addition  to  hair,  bono,  rurtiliij 
and  teeth,  are  foun.l  iiion'  complicated  structures,  .such  an  iniui 
membrane,  mucoas  ami  salivary  glands,  smcKith  and  striated  imu 
nen<'-HI»er!i,  brain-.tulMtance,  rudimentary  eyes,  fingers  with  imi 
mammiF.  ribs,  and  extremities. 

Teratomas  an-  {tarticularly  liable  to  complicatioas.  The  pe<li('l)-  ni 
be  twi.Hted,  oaiisiii);  anemia  and  necrosis,  llemurrhages  may  (N-ciir  ii 
the  substance  or  into  the  cavity.  The  cyst  often  becomes  influiiiiil  a 
suppurates.  It  is  common  to  find  it  more  or  less  bound  down  l>y  inllui 
matory  adhesions.  Peritoiiitui  may  result,  or  the  dermoid  perfonilc  in 
the  bladder.  re<-tum,  vagina,  or  through  the  abdominal  wail. 

Mizad  tUBon  of  the  ovary  asually  constitute  merely  a  vnriiilion 
the  ft>rms  hitherto  descrilted.  They  mav  be  dividetl  into  two  class* 
(1)  those  in  which  two  distinct  tj-pes  of  tissue  develop  indept-ndeni 
and  simultaneoiLsly  (mixed  tumors  proper),  and  (2)  those  in  whit  It  i 
have  a  modification  or  transformation  occurring  secondarily  in  ii  pi 
vioasly  existing  new-growth. 

In  the  first  class  of  the  lienign  growths  may  be  mentioned  myoflbron 
adanofibroma,  eyttoflbroma;  of  the  malignant,  myoiareoma  (?),  cystoii 
coma,  CTttadanosareoiiia,  and  ureoeareinoma.  In  the  second  ^'ronp  v 
may  re<-ogiiize  mjrzoiareoma,  eTttadanoma  eardnomatodai,  cyttadenot 
aareomatodaa,  eyatadanomatona,  eardnomatona,  or  aarcomatoui  transform 
tion  of  teratomas.  In  the  last  connection  it  may  lie  niention<(i  ili 
Amann'  has  reported  a  melanotic  sarcoma  developing  in  an  ovaria 
dermoid. 

Owing  to  their  structure  and  position,  ovarian  tumors,  pariiViilar 
the  cystadenomas,  are  liable  to  undergo  important  secon»iarv  dmn^.'e 

Carcinomas  show  frequently  oedema,  fatty  or  mucinous  ilejicm  ratioi 
hemorrhagic  infiltration,  or  necrosis.  Many  of  these  rcii. ..ressii 
changes  result  in  the  formation  of  pseudo-  or  degenerative  cvsi  Wiie 
the  tumor  is  pedunculated,  torsion  leads  not  infrequently  to  nuijriili 
tion  of  the  bloodvessels  and  its  well-known  coasequences.  The  L'r<>wt 
l)ecomes  swollen  and  (edematous,  'he  veins  ore  oveTdistende<l  with  lilom 
and  the  tissue  is  often  infarcted  ana  necrotic.  In  such  cases  inftitio 
and  suppuration  readily  take  place.  Sometimes  the  peflicli-  i«  roii 
pletely  severetl  and  the  growth  lies  free  in  the  abdominal  cn\  iiv.  wher 
it  will  necrose  unless  it  becomes  vascularized  through  new  aijiiesion 
forming  about  it. 

Peritonitis  is  also  not  uncommon.  Should  the  cyst-wall  ni|iiiire.  th 
contents,  if  unirritating,  may  be  absorbed,  but  if  infected,  set  up  sepii 
peritonitis,  In  the  case  of  rupture  of  a  cystadenoma.  f!."  p^ud^ 
mucinous  material  is  only  imperfectly  absorbed,  and  part  if  it  ma; 

'  Monatmch.  f.  Geb.  u.  Gyn.,  January,  1903. 


HEMORRHAOE 


805 


bfcome  encysted  through  the  formation  of  inflammatory  adhesions. 
giving  rue  to  a  structure  resembling  at  first  sight  a  tumor  (pteudo- 

myxima).  "^ 

Hvuliiie  md  calcareoas  ilegeneration  in  the  wall  have  also  been 
olwned.  ixjcondary  tuln-rculous  infection  of  an  ovarian  cyst  has  been 
recorded. 


TBI  UTUmn  UOAIOIITS:  THK  PILVXO  PmTONIUK 

AHD  oomnoTiyi  tusui. 

OOXOUflTAL  UrOMALIIt. 

In  ciwcs  of  CI  nplctc  defect  of  the  uterus  the  lixamcnts  arc  also  abtrat 
\\h.-n,  howev  t!ie  'u1k«.s  ami  ovaries  an  present  the  round  liuanient 
IS  oft.n  well-i  .  .ned.  One  round  li^'ament  mav  lie  ihortar  than  the 
'■^Im.  ieuding  to  dishxation  of  the  uterus.  EmlapUeaUon  of  the  round 
liK'anunts  has  l.een  obserxe*!.  A  comparativflv  common  anomaly  is 
the  ptnlttaiiea,  either  portial  or  complete,  of  the  canal  of  Hnek,  cainine 
henna  and  hy.lrocele.  Ramaini  of  the  paroTariom  and  its  attendant 
(liicts  fnuy  give  rue  to  disturlmnce. 


rt  lit'  It  mav 


OIROULATOST  OUTUKBAK0E8. 

The  veins  of  the  round  and  broad  ligaments  and  those  in  the  neighbor. 
h.).^l  of  the  ovaries  may  lie  dilated  and  tortuous  (varicocale).  Throm- 
bo^  fntiuei.tly  occurs,  with  the  formation  of  phleboliths. 

Hemonhajje.  -Of  more  importance  is  bemoirhaca,  which  may  lie 
ui.mix.r,...ncal  or  cKtraperitoneal.    This  usually  fakes  place  between 
the  lavers  of  the  broad  ligament  or  in  the  round  ligament.    The  most 
c-o,„m..n  causes  are.  the  rupture  of  a  vessel  .luring  parturition,  more 
mrtv  .luring  menstruation;  the  giving  way  of  a  varicose  vein;  and 
tubal  ^station.     The  extravasation   may   l,e  extensive  and   remain 
more  or  less  localized,  forming  a  tumor-like  mass  (hematoma).     In  other 
eases  it  infiltrates  the  connective  tissue  about  the  uterus,  bladder,  and 
^•tum,  and  exceptionally  may  be  dischai^ed  into  the  vagina  or  rectum 
h.^r.lT"^'  the   blood   is  effused   into  the  abdominal  cavitv 
ihenuM)      The  usual  site  for  this  is  the  Douglas'  pouch  (hema- 
S'.r  "f  "S-    f"*"''-V'  ''  '"•"  *^"  "t^rovesical  poudi  (hematocele 
or  0  ti„,  f„,^  (hat  the  Douglas  pou<h  has  been  obliterated  bv  inflam- 
matorv  proclucts.      The    most    f-- -,uent    causes   are   ruptui^d    tubal 
eMa,,„„  and  hemorrhagic  pcntonitis,  where  there  is  a  formation  of 
rhlT'    :i  I-         '^°™""n'y.  it  may  be  due  to  the  rupture  of  a  vein 
n  the  hroad  ligament,  a  ruptured  Graafian  follicle,  a  cyst  or  varicose 
^ein  ot  the  ovary,  hematosalpinx,  the  operative  ablation  of  an  ovaiy 


!       ^ 


i  I 

'  ! 


866 


THE  PERIVTERIKE  STRUCTURES 


and  the  discharge  of  blood  through  the  abdominal  ostia  of  tiic  tiil 
The  blood  is  not  necessarily  free  in  the  cavity,  for  it  may  happen  tli 
it  is  extrava.«ate<l  into  a  sac  formed  of  previously  existing  adhesions,  j 
many  cases,  from  reactive  inflammation,  a  fibrous  limiting  wall  is  pr 
ilucetl.  Providetl  the  patient  survive,  the  blood  may  Ik?  absorljcd  or  tl 
resulting  clot  may  become  organized  after  the  fashion  of  a  thronihii 
In  this  way  a  pigmented  mass  of  fibrous  tissue  may  be  produced.  1 
less  favorable  cases,  where  infection  has  cK-curred,  the  mass  may  \iv  coi 
verted  into  an  ab.scess.  This  may  discharge  into  the  bowel  or,  riirel 
into  the  abdominal  cavity,  bladder,  or  vagina.  In  this  way  fecul  fisliil 
are  pnxluced  that  often  lead  to  extensive  disorganization  of  the  pdv 
connective  tissue.  Some  few  cases,  after  the  discharge  of  the  pu 
may  heal. 


INFLIMMATIOMS. 


I 


;'  1 


^1 
I 

I-  ' 


Inflammation  about  the  uterus  and  its  appendages,  both  in  tlie  ove 
lying  serous  membrane  and  in  the  loose  connective  ti.ssue  of  the  pelvi 
is  not  unconnnon.  According  to  the  localization  of  the  prcx-ess  to  tl 
serosa  covering  the  uterus,  tubes,  and  ovaries,  we  can  speak  of  u  pei 
metritis,  perisaipingitis,  and  perioophoritis.  When  the  coiuiective  tissi 
is  involved  the  condition  is  termed  parametritis. 

Parametritis. — In  simple  exudative  parametritis,  the  tissues  are  ii'(i( 
matous  and  .sodden.  No  clear  line  can,  however,  be  drawn  lietwce 
this  and  the  suppurative  form,  where  the  ti.ssue  is  diffusely  infiltralcd  wit 
pus  or  presents  absce.s.s-formation.  In  verj-  severe  ca.ses  tiie  stnictiin 
fiecome  gangrenous.  The  pus  may  remain  localized  or  may  hiirro' 
along  the  ligaments  to  the  alxloniinal  wall;  into  the  tliigli.  into  tli 
pelvis,  or  behind  the  rectum.  In  this  way  caries  of  the  bony  parts  ma 
lie  prixluced.  Perforation  may  occur  in  the  inguinal  region,  in  tli 
ischiadic  fossa,  the  vagina,  rectum,  or  bladder.  Should  healinj:  tak 
place,  tiie  abscess  l)ecomes  encapsulated  and  more  or  less  alisorlicil,  i 
the  whole  of  the  affected  area  may  Ih"  converted  into  a  deii^r  iiiii- 
of  fibrous  tissue. 

The  commonest  cau.ses  of  parametritis  are  injuries  during  ]iaiiiiriti(i 
and  puerperal  .sepsis.  The  inflammation  cx-casionally  spread^  fioin  tli 
rectinn.     An  actinomycotic  form  is  also  dcscriUfl. 

A  fibrinous  or  fibrinopurtilent  inflammation  is  frecpiently  (ilscrvcil  ii 
the  Douglas'  pouch  (pelvic  peritonitis).  It  is  due  to  tiie  eMi  n-ioii  <i 
inflanunatiim  from  any  of  the  pelvic  organs,  and  is  met  willi  a! '>  in  ( ani 
noma,  tuberculosis,  and  ovarian  cy.sts.  Abundant  adhesions  ni.iv  forn 
so  that  the  pus  is  completely  walled  off  from  the  aMominai  <  :!\  ii.v  ir</n 
iitrrhif  p!)ocflc).  As  in  the  case  of  suppurative  parametritis,  i!i''  |ius  nia' 
1h'  discharged  into  the  rectum,  vagina,  bladder,  the  general  ixTitoiica 
cavity,  or  externally.  The  causes  are  the  same  as  those  of  jKiMinu'tritis 
except  that  here  gonorrhcea  plays  an  important  role, 
results  in  the  formation  of  den.se,  fibrous  mas.ses  or  adhesion^ 
various  parts  {productive  pelvic  peritonitis).     This  may  lead 


■'  u  ceil  th( 
'  lie  ocelli- 


CYSTS 


867 


sion  <.f  the  tubes  aad  dislocation  of  the  tubes  and  ovaries.  When  tlie 
adlusions  are  extensive,  pockets  may  be  formed,  filled  with  clear  sero- 
puriilciit,  or  colloid-looking  fluid.  ' 

Tuberculosi8.-Tuberculosis  of  the  ligaments  is  alwavs  se<ondary  to 
tulKrculosis  of  the  J^allopian  tubes  or  general  peritoneum. 


R'/'.'KOORZSSIVE  BIETAMORPHOSES. 

At.-orhy  <  f  the  round  ligaments  accompanies  atrophv  of  the  uterus 
or  may  foUow  p  rametritis  and  rapidly  recurring  pregnancies 

.\f(ir  the  menopause  the  vessels  of  the  broad  ligaments  freiiuentlv 
Ijeiome  tortuous,  thickened,  and  ealeuwm*. 


iwtivc  tissue 


PROGRESSIVE  METAMORPHOSES. 

The  round  ligaments  are  often  hypertrophied  in  cases  of  hvpertroni.v 
of  the  uterus.  Hypertrophy  of  the  muscle  of  the  broad  lijra.nei.ts 
iKcurs  in  connection  with  ovarian  and  parovarian  cvsts 

Tumors.-The  majority  of  the  tumors  found  in 'the  broad  ligaments 
are  due  to  the  extension  of  growths  of  the  uterus  and  ovaries  between  the 
lavers.  Subserous  myofibromas  of  the  uterus  sometimes  grow  out  into 
the  i)r.>a.l  ligament  and  may  lie  eventually  detached  from  the  uterus 
lapomas.  leiomyomas,  and  myxofibromw  have  been  found  both  in  the 
l.roa.l  atul  round  ligaments.  Cullen'  has  reconled  an  example  of  ade- 
nomyoma  of  the  round  ligament,  and  three  cases  have  l>een  described 
>:»...-<  I- annenstiCx-^Heuff.  Blumer).  The  growth  is  compose.!  of 
non-striated  muscle  fibe^,  together  with  glandular  elements  strongly 
n-seml,lii,g  the  glai.ds  of  the  uterine  mucasa.  The  tumor  has  l^e^i 
-und  also  within  the  groin  and  in  the  vagina.      It  is  thought  to  be 

IT    /"'"  T^'^rV^-  ''^^^^"'ffi^"  »>«Jy  (V.  Ilec-klinghauscn),  or 
IKKsil)ly  from  the  Mullerian  duct.  ^ 

Cysts   -Hy  far  the  most  common  tumor-like  masses  in  the  uterine 

•Mende,!  ii.to  the  broad  ligament,  cysts  derived  from  the  parovarium 
..-erv  rarely  from  the  paroophoron  between  the  parovarii;in  and  S 

Parovarian  cysts  vary  greatly  in  size,  but  may  be  as  large  as  a  mans 

he  ^■/'■'"•^V    rr'  ^'^'  '•"'^■"*"  '^'  alKlominal  end  of  the  tube 

,1, '  ••    ^^^  *."^'*^  "^^y  ««  ^«n'e  extent  encittle  it.  but  in  the  case 

..r,..r  growths  is.  o   course,  elongated,  more  or  less  fli.ttene.rand 

n      ,;,.,     i  'r  7y!^f '««""''•»»  flattened  so  that  it  may  be  difficult 

te    '  >  Y-  '*•     ^  '^"  'y''  '•''^■'''"P''  ''^'««'"  *he  two  hners 

•'I'd  siroM,  which  can  usually  l,e  readily  stripped  off.     As  a  rule,  it 

'  '"Kns  Hopkins  Hosp.  BuU..  62-63:  1896:  112;  Ibid..  87:  1898;  142, 


'     i 


if  T 

1! 


!  !'  I- 


868 


THE  PERIUTERINE  STRUCTURES 


possesses  no  pedicle  and  the  wall  is  thin,  being  composed  of  coniiu 
tissue  and  more  or  less  hypertrophic  muscle  derived  from  the  musd 
the  broad  ligament.    The  wall  internally  sometimes  presents  fluttt 
or  papillary  outgrowths,  in  some  part,  at  least,  of  the  surface, 
contained  fluid  is  dear  and  watery  with  relatively  little  all)Uiiiiii 
few  cells.     Its  specific  gravity  is  l'()04  and  1005.     In  other  casis 
more  viscid  and  mav  be  mixeil'with  bled.    The  wall  is  lined  witli  ( ili 
cylindrical  cells,  although  in  some  cases  the  cells  are  somewhat  tliittt 
and  the  cilia  lost. 

Fio.  226 


Cyit  of  the  parovarium;  there  in  no  distortion  of  the  ovary;  the  Fallopian  tul>e  l.ai.  h 
much  elont   ted.     CBeyea.) 

Rarely,  dermoid  cysts  have  been  found  in  the  pelvic  connective  ti 
supposed  to  be  derived  from  embryonic  "rests." 

Primary  sarcoma  has  been  recorded  occasionally  in  the  broad  lijra 
and  on  the  surface  of  the  uterus  (Sanger). 

Carcinoma  is  alwavs  secondary  and  generally  arises  by  ext.iiMon 
the  cervi.x  uteri  or 'ovary.  Occasionally  it  is  produced  by  Ivrap 
II  etastasis. 


CHAPTER    XXXIX. 


TliK  PUERPERAL  UTERUS  AND  THE  PRODUCTS  OF  CONCEPTION 

AFFECTIONS  OF  THE  PUERPEBAL  UTERUS. 
OIROTTLATORT  DISTURBANCES. 

During  the  act  of  parturition,  and  for  some  time  subsequent  to  it, 
a  certain  amount  of  blood  is  lost,  chiefly  from  the  placental  site.  Occa- 
sionally, this  passes  physiological  limits,  and  the  bleeding  may  be  so 
severe  as  to  endanger  the  life  of  the  individual  (postpartum  hemorrhage). 
Bleetiinj;  also  takes  place  from  the  lacerations  of  the  cenix  normally 
prodiueii  during  labor,  or  from  actual  rupture  of  the  corpus  uteri. 

Placental  remains  that  have  been  retained  within  the  uterus  give 
rise  frequently  to  menoRhagia  and  metrorrhagia.  Such  placental  tissue 
may  become  crusted  over  with  fibrin  and  form  large  polypoid  masses 
(fibrinous  placental  polyps).  A  noteworthy  form  of  metrorrhagia  is 
that  where  in  extra-uterine  gestation  the  deciduu  is  cast  off  with  discharge 
of  blood. 


[I  ^ 

4  1   ij 


-    1 


>ian  tul>e  lia."  been 


INJURIES.     (See  also  p.  S26.) 

Lacerations  of  greater  or  less  extent  occur  commonly  in  the  cenix 
uurinj^  labor.  Rarely,  the  fundus  of  the  uterus  is  ruptured.  The  uterus 
may  be  perforated  by  instruments  during  operations  and  in  attempts 
at  criniiiial  abortion.  It  may  also  be  injured  by  contusions  of  the 
alxlonuii,  bullet  wounds,  and  the  horns  of  animals' 


•<i*^4 


onnective  tissue, 


INFLAMMATIONS. 

Inflatiitnations  of  the  pueq)eral  uterus  may  be  purely  local,  but  fre- 
quently </ive  rise  to  systemic  manifestations  (puerperal  fever).  The 
endometrium,  the  muscular  wall,  or  the  serosa  may  be  involved  (endo- 
nwtritis  puerperalis,  metritis  puer.,  perimetritis  puer.). 

The  [inKess  usually  begins,  as  one  would  expect,  at  the  point  of  primary 
injiirv,  such  as  the  cervix  and  the  placental  site,  and  mav  extend  to  any 
part  of  the  uterus. 

Endometritis.  Two  main  types  of  puerperal  endometritis  are  to 
be  ret  o;,Miized,  the  putrid  and  the  septic.  The  former  is  characterized  by 
the  decomposition  of  the  lining  membrane  of  the  uterus  with  the  pro- 


5     \ 


mT^ 

■  * 

ii !; 

1      '  ■ 

1.  i 


1  i 


870 


THE  PUERPERAL  UTERUS 


duction  of  foul  gases;  the  latter,  by  various  forms  of  necrosis,  coapulatii 
or  suppuration.     Both  ar«>  not  infrequently  combined. 

Putrid  Endometritis. — Putrid  endometritis  originates  in  retained  fa 
produ'  is,  stagnated  blood,  pent-up  lochia,  or  sequestrating  portions 
the  uterus,  to  which  putrefactive  microorganisms  have  gained  acct 
either  directly  through  manual  or  instrumental  manipulation,  or 
extensio'   '.om  the  vagina  and  vulva. 

The  uterus  in  advanced  cases  is  enlarged,  the  wall  thickeiifd  a 
oedematous,  and  in  parts  congested.  The  endometrium  is  conven 
into  a  dirty  green  or  brownish-black,  pulpy  mass  having  «  vi 
ofiensive  mlor.  The  process  may  extend  to  the  muscle  which,  in  lii 
iHJConies  soft  and  rotten  (putrid  metritii).  Physometra  may  l)e  p 
duced. 

Microscopically,  the  affected  tissue,  when  decay  is  advanced, 
cloudv  and  the  nuclei  stain  badly,  while  numerous  bacteria  of  ma 
kiudsare  present.  At  the  periphery  the  necrotic  portion  is  boundeti 
a  zone  of  inflammatory  leukocytes. 

The  pro  s  leads  to  the  sequestration  of  uterine  tissue  and  soinetiii 
to  the  formation  of  fistulse  between  the  uterus,  or  the  uterus  and  vajrii 
and  the  bladder.  Perforation  into  the  peritoneal  cavity  is  rare.  Mas 
of  clot  at  the  placental  site  may  be  involved  in  the  necrotic  ynw> 
(putrid  thrombosiinmtis).  \Vhen  a  strong  line  of  demarcation  is  t'onin 
portions  of  the  endometrium  or  even  of  the  muscle  may  be  exfoliai 
(metritis  diseccans).  Complete  cure  may  result  with  the  forniatioii 
scars  and  contraction. 

Septic  Endometritis. — Septic  endometritis,  in  its  simplest  expressic 
consists  in  superficial  suppuration,  which  is  particularly  liable  to  invo! 
the  site  of  the  cervical  lacerations,  converting  them  into  discharj;iii<:  nice 
More  commonly  there  is  the  formation  of  a  grayish  adherent  iiiciiil)rai 
perhaps  limited  to  the  eroded  surfaces,  although  at  times  it  ;ti  iv  extc 
over  the  greater  part  of  the  uterine  cavity.  WT.cn  aircoiiif;  t 
placental  site,  the  membrane  is  most  marked  on  the  top  of  the  pror 
nences  of  the  uneven  uterine  wall  and  may  be  slight  or  alisciu  in  t 
fissures.  It  can,  in  some  instances,  be  peeled  off,  but,  as  u  rule,  t 
necrotic  process  extends  some  little  distance  into  the  deeper  tissii 
The  surface  of  the  affected  area  is  usuahy  dry  and  of  a  dirty  j;ra\  isli- 
brownish-gre€    color. 

Microscopically,  the  superficial  layers  of  the  placental  >itc  slu 
necrosis,  the  cells  staining  badly,  while  there  is  a  thick  network  of  filn 
often  presenting  a  certain  amount  of  hyaline  transformation.  1  jio.i  t 
surface  is  an  exudate  of  similar  appearance.  Small  niasM  -  ot  Iciik 
cvtes  can  also  l)e  seen  both  in  the  membrane  and  in  tin  inidcrhii 
necrotic  tissue.  The  glands  show  more  or  less  erosion,  with  > !■  -cncraii 
changes,  and  the  lumina  may  contain  fibrin.  Bounding  the  ncrn  .Miipar 
is  a  zone  of  infiammatory  leukocytes  with  great  hypeivnu...  ?ni; 
clusters  of  micrococci  can  generally  be  demonstrated.  'Jhe  proce 
often  spreads  to  the  uterine  muscle,  and  cases  occur  where  mr  all 
affected  from  the  start  (septic  metritis). 


METRITIS 


871 


ZndometrltU  DeeidiuUi. — A  variety  of  inflammation  affecting  the 
lining  membrane  of  the  uterus,  that  should  be  mentioned,  is  that 
involving  the  decidua  (endometritis  decidualis).  This  rarely  occurs 
except  when  the  patient  is  suffering  from  some  infectious  disease, 
notably  cholera  or  measles.  As  a  rule,  it  is  traceable  to  preexisting 
entlonietritis.  The  process  may  occur  in  all  parts  oi  the  decidua  and 
is  of  the  nature  of  a  productive  fibrosis.  The  decidua  is  thickened  and 
often  presents  nodular  or  polypoid  outgrowths  (endometritis  decidualis 
poli/posa).  The  tissue  is  dense  and  firm  and  has  lost  the  normal 
veliowish-white  appearance.  In  some  cases  the  surface  may  be  covered 
with  pus.  Occasionally,  secretion  collects  ijetween  the  deciduie  and 
gives  rise  to  discharge  (tiydrorrhcea  gravidarum). 

Mii-roscopically,  the  large  decidual  cells  are  increased  in  size  and 
nuinl)ers,  and  present  fatty  degeneration.  The  tissue  is  infiltrated  with 
round  cells  and  shows  marked  productive  change,  'i'he  glands  in  the 
deeper  parts  are  rarely  increased  nnd  still  more  rarely  dilated.  In  the 
lower  strata,  the  lymph -channels  may  be  considerably  distended,  giving 
to  tlie  tissue  a  cavernous  structure.  Hemorrhage  readily  occurs  so  that 
al)ortion  is  frequent,  or  there  is  the  formation  of  a  blood  or  fleshy 
mole.    The  placenta  sometimes  also  bei-omes  adherent. 

Septic  Metritis.— Septic  metritis  may  \te  diffuse  (m.  phlegmonosa), 
or  ai;ain  the  infective  process  may  e.\tend  along  the  lymphatics  (m. 
iymphanfjitica)  or  veins  (m.  thrombophlebitica). 

Phlegmonous  Metritis. — In  phlejjmonous  metritis,  the  uterine  muscle 
is  relaxed  soft,  swollen,  and  ci'deniatous,  and  has  a  doughy  feel.  The 
interstices  of  the  muscle  contain  an  abundant  thin,  bloofl-stained  fluid, 
or  actual  pus.  The  condition  is  generally  best  marked  in  the  outer 
layers  of  the  wall. 

Microscopically,  there  is  a  more  o"  less  abundant  accumulation  of 
lenk(K'\tes  in  the  interstitial  stroma,  which  is  also  ccdematous.  The 
muscle  fibers  are  swollen,  cloudy,  anti  vitreous.  Clusters  of  micrococci 
may  lie  seen.    This  form  is  frequently  combined  with  lymphangitis. 

Ljinphangitic  Metritis. — In  lymphangitic  metritis  one  can  recognize 
in  tlie  uterine  wall  and  adjacent  parts,  dilated  lymph-channels  con- 
tainirif;  detritus  and  pus.  On  cross-section,  the  lymphatics  appear  as 
cavities,  the  size  of  a  pet.  or  larger,  filled  with  yellowish  material  com- 
posed of  fibrin,  pus  cells,  and  bacteria.  The  wails  of  the  lymphatics 
siiow  \arious  grades  of  degeneration  and  may  give  way,  so  that  irregular 
absroses  are  formed  by  the  extension  of  the  infection.  These  abscesses 
are  often  very  numerous,  and  may  sometimes  be  .seen  projecting  upon 
the  serous  surface.  This  form  of  metritis  is  liable  to  occur  in  cases  of 
inftHiion  that  are  running  a  not  very  acute  course. 

Thrombophlebitic  Metritis. — ^Thrombophlebitic  metritis  is  somewhat 
rarer,  and  begins  generally  at  the  placental  site.  Atony  of  the  uterus 
prciii^jMHcs  strongly  to  the  condition,  but  not  infrequently  membranous 
endoiiictritis  is  present  as  well.  Large  thrombi  are  found  in  the  veins, 
pres^'iting  all  grades  of  softening,  necrosis,  and  purulent  infiltration. 
TL  :i  J  iper  ranees  are  analogous  to  those  in  lymphangitis  of  the  uterus. 


^^^■K^ 


!  '. 


I    i 


hiii 

Hi: 


A 

n 

A 

iiiliilli 


872 


THE  PUERPERAL  UTEP''S 


The  process  may  spread  to  the  para-uterine  veins  and  even  to  the  sper- 
matica  interna. 

In  all  forms  of  septic  metritis  the  process  may  extend  widely  from 
its  original  starting  point.  The  inflamma'  ion  may  reach  the  parumvtriuni 
and  the  retroperitoneal  tissues.  Large  aL  sce&ies  in  the  connective  tissue 
may  result.  Lymphangitis  sometimes  extends  to  the  ovaries  and 
along  the  vertebral  column  to  the  diaphragm.  Thrombophlebitis  mav 
extend  to  the  femoral  veins  and  the  inferior  vena  cava.  Peritonitis 
{perimetritis)  is  not  uncommon,  and  may  spread  to  the  pleura  and  peri- 
cardium. Septicemia  is  a  not  infrequent  sequel.  Ulcerative  emlm-urdhh 
and  abscesses  in  the  various  viscera  have  been  observed. 

Puerperftl  Perimetritis. — Puerperal  perimetritis  is  characterized  bv 
the  formation  upon  the  serosa  of  the  uterus  of  an  exudate  that  is 
fibrinous,  fibrinopurulent,  or  purulent,  accordii  ••  to  the  nature  and 
intensity  of  the  infection.  In  the  more  chronic  cases,  the  deposit 
becomes  gradually  organized,  adhesions  form,  and  the  exudation  may 
be  walled  off.  In  acute  cases,  general  peritonitis  may  occur.  Wlieii 
healing  takes  place,  bands  of  adhesions  may  dislocate  the  uterus  from 
its  normal  position. 

With  regard  to  the  etiology  of  puerperal  sepsis,  the  excitinp  cause  is 
the  presence  of  septic  or  putrefactive  microorganisms.  I'lie  most 
important  offenders,  in  order  of  frequency,  are,  the  StreptiH-oeeus 
pyogenes,  the  Staphylococcus  albus  and  aureus,  and  the  Diplococeus 
pneumoniae. 

PROGRESSIVE  METAMORPHOSES. 

Tumors. — Pregnancy  may  of  course  occur  in  a  uterus  that  is  already 
the  site  of  tumor  growth.  Among  these  may  be  mentioned  myofiUronia 
and  carcinoma,  but  the  only  tumor  that  need  specially  be  diseiissed 
here  is  a  very  remarkable  one — the  chorio-epitheUoma  maliguum  -first 
described  by  Sanger. 

Many  differing  opinions  have  been  advanced  as  to  its  nature,  ;>  may 
be  gathered  from  the  variety  of  names  that  have  been  projjosed  for 
it^deciduoma  malignum  (Pfeiffer),  syncvtioma  malignuni,  deeidiiosar- 
coma,  chorio-epithelioma,  syncytia"  carcinoma,  sarcoma  decidiio-cliorio- 
cellulare.  It  is  now,  however,  practically  settled  that  it  is  a  new  -j;rowtli 
originating  in  the  foetal  epiblast  of  the  chorionic  villi.  Consei|nently, 
being  a  tumor  of  foetal  origin,  growing  in  the  tissues  of  aiiolln  r  indi- 
vidual— the  maternal  oi^anism — it  should  be  classed  with  the  teratomas. 
Inasmuch  as  it  grows  rapidly,  infiltrates,  and  forms  metastases  in  distant 
parts,  it  is  of  malignant  character. 

The  tumor  only  develops  after  pregnancy.  It  may  occur  a  flu  normal 
parturition,  after  abortion,  after  the  expulsion  of  a  hydatidif' n"  mole, 
and  in  extra-uterine  gestation.  The  growth  may  remain  laimt  for  a 
considerable  time  after  delivery.  It  usually  begins  in  the  diorium 
frondrosum,  but  may  arise  from  any  part  of  the  uterus  to  which  liorionic 
villi  are  attached.    It  is  said  by  Schmorl  that  chorionic  villi  may  be 


CHORIO-EPITHELIOMA  MALIONUM 


87S 


detached  and  carried  to  distant  parts  where  the  celk  may  proliferate 
and  form  a  primary  chorio-epithelioma  extra-uterine  in  situation. 

Chorio-epithelioma  tends  to  form  polypoid  or  fungating  growths  pro- 
jecting into  the  uterine  cavitv.  but  eventually  invades  the  muscle  beneath 
the  endometrium  and  may  infiltrate  more  or  less  deeply.  The  mass  is 
of  reddish  color,  frequently  hemorrhagic,  and  b  of  a  soft,  friable,  and 
sponf;y  nature. 

Microscopically,  according  to  Webster,'  three  types  are  to  be  differen- 
tiated: .1)  Where  the  primary  growth  and  metastases  are  of  sarco- 
matous or  carcinomatous  tj-pe,  or  both;  (2)  where,  in  addition,  to  the 
appearances  just  mentioned,  syncytial  or  plasmodial  masses  may  be 
recognized;  and  (3)  where  in  addition  to  the  structures  of  the  second 
;^*oup,  there  are  cell-masses  resembling  placental  villi. 

Fio.  227 


dSc 


Cliorii>-epithelioma  growiig  within  uterus:  V,  wall  of  uterine  sinua;  Ss/n-,  multinucleate 
cells  of  syncytial  type;  L.c,  cells  of  Langhans'  type.     (Teacher.) 

The  growth  is  seen  to  originate  in  the  proliferation  of  the  syncytium 
and  Langhans'  layer  of  the  chorionic  villi.  The  normal  relationships 
are  disturbed,  the  syncytium  is  thickened,  and  the  cells  of  the  Langhans' 
layer  tend  to  extend  through  to  the  surface.  The  superficial  area  is 
generally  necrotic  and  is  covered  with  a  deposit  of  fibrin.  The  deeper 
parts  present  an  alveolar  structure,  the  spaces  possessing  no  epithelial 
lining  and  containing  blood  and  fibrin.  The  resulting  tumor  has  no 
stroma  and  no  bloodvessels. 

The  so-called  syncytial  elements,  when  present,  are  lai^e,  irregular, 
or  elongated  plasmodial  masses,  containing  numerous  deeply-staining 
nuclei.  The  protoplasm  is  finely  granular  and  may  contain  vacuoles. 
The  Plasmodia  are  well  defined  but  their  protoplasm  may,  in  certain 
parts,  pass  imperceptibly  into  that  of  the  surrounding  tissue.    It  must 

>  Canadian  PrMtitioner,  22  :  1897  :  714. 


w 

r 

1 

; 

1  \ 

.  1 

1 

■ 

'  '■\m 

1 

; 

1  n\ 

■  1  ?U- 


874 


THE  PUERPERAL  UTERUS 


Iw  admittwl  that  these  plastnodial  cells  are  not  necessarily  of  .s\  iic; 
origin,  for  ideiiticul  appearances  are  to  l)e  found  in  other  ni!ili;;i 
growtlis,  notably  sarcomas,  originating  in  other  parts  of  the  body. 

The  cells  derivetl  from  Langhans'  layer  form  groups  of  varying;  . 
They  are  irn-gular  in  shajn-,  long,  spindle,  o  spherical,  with  pale  |.r 
plasm.  When  not  pressed  \ipon,  they  hav^,  an  epithelial  appcani 
The  nuclei  often  show  mitosis.  In  many  cases  the  cells  of  Laii);l 
aie  grouped  about  the  plasmodial  nias.ses,  but  in  other  cases  tlic  la 
are  in  excess  and  arrangetl  in  more  or  less  pa  ..llel  rows  with  tluir  1 
axes  at  right  angles  to  the  base  of  the  tumor.  At  the  jwripluTv  of 
growth,  the  new-formed  cells  dissect  their  way  betwee'-  (he  iKivcii 

Fio.  228 


^  -i    i 

!'■■; 


('h<>ri<>-i'|iitlieliiima  nmliKnum.     Zeiss  obj.  DD.  without  ooular. 
the  Montreal  Genaral  Hospital.) 


(From  the  f<li*i  li'-n  ' 


and  the  wall  of  the  blootlvessels,  compressing  the  luniina,  : 
i'lvading  the  whole  thickness  of  the  vessel.     As  a  conse<iU(iu 
iieniorrhage  into  the  growth  and  necrosis  are  common.    This  ii 
of  the  ves.sels  explains  the  great  tendency  of  the  tumor  to  form  lu 
which  may  be  found  in  the  vagina,  lungs,  and  occasionally  in  ih 
liver,  and  spleen.     The  mo.st  frequent  site  for  the  secondan 
the  vagina  which  is  involve<l  in  half  the  cases.     The  lining  ut 
in  the  neighborhood  of  the  growth  takes  the  form  of  a  decidual 
or  a  normal  or  more  or  less  inflamed  endometrium. 

With  regard  to  the  ultimate  causation  of  ihis  extraordiiia 
tumor,  it  may  be  mentioned  that  Leo  Loeb,  on  the  basis 
mental  work,  holds  that  the  stimulus  to  the  formation  of  l>'< 


mil  II 
V  of  1 
ililtni 
fla-tii 

I-  llVlll 

.•|iii«il 
ilf  ult 
ifinlir 

fora 
if  e\7i 
1  detii 


HEMORRHAOE 


875 


anil  ilcciduomata  comes  from  a  certain  internal  '/ecretion  of  the  ovary, 
ix)»ilily  in  connection  with  the  corpus  luteuri.' 


dinaiv  form  of 


THE  PRODU0T8  OF  OOXOCPTIOir. 

Ai)iirt  from  the  decidua  that  lias  just  lieen  referred  to,  these  are  the 
nlucriila,  the  curd,  tlie  amnion,  the  amniotic  fluid,  and  the  fwtus. 

The  PUcenta. 

\ii  iilmormally  large  placenta  is  found  when  the  child  is  large.  The 
pliu  tiitii  may  Im;  unusually  thin,  although  the  villi  may  be  hj-pertrophied. 
I  placenta  membr«uee«).  Instead  of  one  placenta,  from  one  to  seven 
have  l«'«'ii  obser\ed,  even  in  the  case  of  only  one  child  (p.  dnplez, 
triplex,  »'tc.).  When,  in  addition  to  a  large  placenta,  several  subsidiary 
uiit>  arc  met  with,  the  smaller  are  called  placenta  laceentoiiata. 

All  otherwise  normal  placenta  when  in  an  abnormal  position,  that  is 
in  till'  lower  uterine  segment,  is  called  pUcenU  pravia.  Sieveral  varieties 
of  thi-  may  \w  rec-ognized.  Placenta  prwvia  centralis  is  the  form  in  which 
ihf  ciiiirt'  of  tlie  placenta  lies  over  the  internal  os.  In  partial  placenta 
pr;f\  ia  tlie  internal  os  is  covered,  but  the  margins  of  the  placenta  are  not 
dliiidi'tant  from  the  central  axis.  In  lateral  placenta  praevia  the  edge 
of  the  placenta  reaches  nearly  to  the  internal  os.  \Mien  the  placenta 
proitcts  slightly  over  and  into  the  internal  os  it  is  termed  placenta  prai'la 
maniiiKiHn.  The  condition  is  not  common,  and  is  especially  rare  in 
priiiiiparii'.  Various  theories  have  been  advanced  to  account  for  the 
coiiditioii,  such  as  fructification  of  the  ovum  when  in  a  false  position, 
and  irrfi.'ular  growth  and  vascularization  of  certain  parts  of  the  decidua, 
with  atrophy  of  others  (Hofmeier,'  Kaltenbach'). 

Till-  predisposing  cause  seems  to  be  endometritis.  Not  infrecjuently, 
inyotiliromas  of  the  uterus  are  present  and  the  placenta  usually  presents 
<i>uw  aliiiormality  also. 

ischemia.— Ischemia  is  produced  by  the  obstruction  of  the  circu- 
latimi  in  the  umbilical  arteries,  and  in  those  cases  where  at  birth  the 
uiniiili'al  vessels  have  been  severed  without  tying  them. 

Hyperemia. — Torsion,  looping,  compression  of  the  cord,  and  thick- 
eiiiiii:  iif  the  umbilical  vein  lead  to  hyperemia. 

Hemorrhage. — By  far  the  most  important  circulatory  disturbance 
ii  liniMirliage,  inasmuch  as  it  is  one  of  the  most  important  causes  of 
alMiniiiri.  Hemorrhage  may  occur  in  the  decidua  serofina,  or  in  the 
placiiita  and  membranes  and  leads  to  more  or  less  complete  separation 
of  till-  maternal  and  foetal  organisms. 

Ilciiiiirrliage  into  the  placenta  takes  the  form  of  dark  red  nodules  of 

11'    I'rmluction  of  Deciduomata,  Journ.  Amer.  Med.  Assoc.,  50  :  1908  :  1897, 


p.  ivc 
=  !i 
'z.: 


ischl.  Placenta,  1890. 

ir.  f.  Geb.  u.  Gyniik.,  18: 1890: 1. 


if 


1  ! 

i 


876 


THE  PLACENTA 


coagulated  blood  in  the  intervillous  spaces  and  blood  sinuses.    It  cot 
on  suddenly  and  leads  to  compression  of  the  villi,  with  some  destnut 
of  tissue.    The  pigment  is  gradually  absorbi'd,  leaving  a  pale,  limwn 
ur  brownish-yellow  area  which  tinally  undergoes  organizutiori.  with 
formation  of  a  fibrous  patch  {placental  infarct). 

(IddOUk. — (Edema  of  the  placenta  is  found  in  cases  of  hydninir 
and  in  hydremia.  The  placenta  is  large,  pale,  juicy,  and  sunun 
friable. 

Syphilif. — Syphilis  of  the  placenta  usually  takes  the  form  of  aiM-n' 
or  peri-arteritis,  or  a  cellular  inHltrutiun  of  the  villi.  Wide.spn'iid  en 
matous  degeneration  is  unknown.  The  endarteritis  leads  to  ohstnid 
of  the  circulation  with  infarction  and  fibrin  deposit  in  the  inttnilli 
spaces.  The  lesion  resembles  that  of  simple  infarction,  with  the  luldit 
that  there  is  thickening  of  the  villi  with  cellular  infiltration. 

Dflgenflrations. — Hjraline  Deganeration  and  KeaoiU.— Hyalint-  dc^ 
eration  and  necrosis  occur  in  the  chorionic  villi  as  a  result  of  gn 
circulatory  disturbances,  such  as  infarct. 

7att7  Degeneration. — Fatty  degeneration  is  also  largely  due  to  lir 
lutory  disturbances. 

Oalciflcation. — Calcification  often  follows  fatty  degeneration,  ami 
found  in  the  villi.     It  is  met  with  early  in  syphilitic  embryos. 

H]rp6rtrophy. — Hj'pertrophy  of  the  chorionic  villi  nmy  oci  ur  a 
rtvsult  of  increased  demands  of  function,  or  in  association  with  inlla 
mation.     It  is  possible  that  in  cases  of  extensive  destruction  of 

chorion  certain  villi  under>;o  conij.. 
f'o-  229  satory  overgrowth.     A  form  of  livp 

trophy,  or  rather  hyperplasia,  is  fmi 
in  cases  of  abortion,  and  al^)  af 
normal  labor,  where  portions  nf  i 
placenta  or  chorion  are  retainnl  a 
take  on  overgrowth,  leadini;  to  i 
formation  of  the  .so-called  placen 
jKjIyps.  Malignant  tran>fiiriMati 
may  take  place  in  such  cases  (liur 
epithelioma  malignum). 

A  peculiar  and  strikinj;  niaiiiffs 
tion  allied  to  hypertrophy  is  i!ir  cys 
or  hydatidiform  mole  (myxoma  <  horii 
Virchow).  Here,  in  addition  Vi  h.vf> 
trophy  of  the  villi,  there  i~  i}." 
metamorphoses.  The  villi  lie.  <nne  i 
traordinarily  lengthened  and  l>r  inch( 
and  are  converted  into  iiir:i!>er^ 
round,  oval,  or  elongatei!  ve?!', 
containing  a  clear,  viscid,  or  -lit'h 
blcHxl-stained  fluid.  The  aiu'iarar 
all  portion  of  »n  hyduidifonn  molt;  produccd  bcars  a  general  re--,  mi'lai: 
DMuni  liie.  to  a  bunch  of  grapes.    The  conditi 


11  iil  L 


PLACENTAL  MOLES 


877 


is  (111*-  to  the  infiltration  of  the  enlarged  chorionic  viHi  with  abundant 
gi-latiiious  fluid  not  unliitc  the  Wliarton's  jelly.  Thr  i-m  nt  of  the  change 
varifi.  In  very  young  embrycw  the  wholechorion  i.  '•  lie  affected,  but 
it  is  more  common  for  the  placenta  alone  to  be  involveil.  On  lilK-rating 
thf  tliiitl,  a  delicate  mcshwiirk  or  supporting  .stnima  is  dis<losed. 

Mil msi'opically,  one  finds  a  delicate,  connective-tissue  framcAork 
wiili  liii.  .*ew  cells,  covcre<l  by  an  epithelial  layer.  Sometimes  the 
(rrdwiii  is  very  vascular. 

Ii  is  an  important  practical  [Miint  that  these  moles  tM-casionully  take  on 
iiiaiiL'iiiiiit  action  and  invade  the  wall  of  the  uterus.  Xeumunn'  has 
reiiiirtcd  eight  ca-ses  of  hydatidiform  mole  in  three  of  which  chorio- 
f]iitliili(>ma  subsetjuently  dcvclope<l.  Pestalozza'  has  also  met  with  a 
{a~c  where  one  of  these  njoles  eroded  into  the  vessels  ami  gave  rise  to 
numtToiis  metastases. 

Apart  from  the  ordinary  mole  of  tin  jiliif  ■  ta  just  descrilnfl,  Virchow 
ri'di^'iiizisl  a  fonn  in  which  the  iioduli  pn-scnt  a  conncctiv<-tissuc 
(liira('er,  ratlici  'han  the  usual  myxomatous  a|>[M'arancc  (nujjtomn 
tihrii.'iim).  Incri'ast  in  the  embryonic  connwtive  tissue  that  normally 
i-  |irts(iit  between  the  chorion  anil  tl'e  amnion  gives  rise  to  the  so- 
lalliij  i/Z/f/wc  mifjrornfi  of  the  chorion. 

Tamors.  —  Fibroma,  flbromyoma  (Alin),  and  angioma  have  been 
(Ir-rritied.  The  occurrence  of  true  sarcoma  is  not  proved.  The  sar- 
<(imas  (if  the  ])lacenta  describe*!  by  llyrti  and  Waideyer  are  probably 
to  lie  cliissiHcfl  as  chorio-«'pitheliomas. 

.^iiial!  cysts  of  doubtful  o.igin  are  occasionally  seen  in  the  placenta. 

The  Cord. 

riif  (ord  may  l)e  abnormally  long  or  short.  In  the  first  case  it  may 
Ik-  cm  ircied  about  the  neck  of  the  foetus  and  cause  strangulation;  in  the 
latter  it  may  l)e  a  hindrance  to  birth  and  \>e  torn  off  violently. 

TIk'  ((ird  may  be  inserted  eccentrically  in  the  placenta  (insertio 
marpnalis),  or  tiie  umbilical  vessels  pass  first  to  the  membranes  lieforc 
ivadiii.i;  tlie  placenta  (insertio  velamentosa).  The  cord  may  also  divide 
into  Mveral  trunks.  The  omphalomesenteric  duct  at  the  attachment 
nf  tlif  ( nrd  may  be  imperfectly  closed  leading  to  hernial  protrusion  of 
the  iiit'stines  or  other  organs  (hernia  of  the  cord). 

Till-  ( ord  may  lie  twisted  or  looped  about  the  neck,  trunk,  ext.emities, 
or  liriii  h  of  the  foetus  (Fig.  2.30).  In  the  earlier  stages  of  the  develop- 
nifiir  ;r  may  cause  amputation  of  certain  parts. 

Thrombosis  of  the  umbilical  vein  and  hemorrhage  into  the  coni  has 
\)n-n  iji'viribed. 

Fatt..  uegenention  and  calcification  are  occasionally  obser\-ed. 

'  r..'r.er  Blasenmjle  lu  malignes  Deciduom.  Verhandl.  d.  deutschen  Gesellsch.  f. 
CivTijk  .  .si)7:304. 
=  n  M  rgagni,  Octolier,  1891. 


1 

1 

ii 

, 

[ 

:il 

1  ■ 

»l 

: 

'  '     ; 

■: 

ji  j- 

. 

ill 

ill 

Mil 

i 

.sM 

\n 

i     ■ 

illl 

*      .11 


878 


Fra.  aao 


THE  FOITUS 

l«ptle  infflCtioB  of  the  fd-tal  fml 
the  c<m\  is  sonu-tiine.H  met  willi,  lit 
tnfi  to  arteritis  uiul  phlcliiiis. 

PwUitwitlB   uiul    radartaritii,   u 
rellulur  infiltration  anil    tilir<Mj> 
duration,  may  ottur.     Tlw  iiii)>f  fi 
quent  cause  is  nyphilh. 

Chorionic-  ami  iilluntoi<'  cyits  » 
found  at  both  the  fu'tal  and  pliK ,  n 
ends  of  the  cord. 

Myxoma  ami  tnglonuk  are  met  wii 
but  rarely. 

The  Amnion. 

The  amnion  may  \w  iin|)<rfwi 
fonneil  and  fuse  with  the  futiis 
certain  n-ffions.  It  may  iIiih  for 
Imiids  and  adiu-sions.  'riiix'  it 
important,  inasmuch  as  thcv  m; 
prtKJuce  arrest  of  tievclopiiinit  ai 
malformation  in  the  atFtc  itil  |Mri 
or  aj;ain,  by  obstruclin;;  tlic  <  in  iil 
tion  may  produce  j;iant  j;r()\\ili.' 

Little    is    known    with    rciranl 
the    inflammatory    affi'<ti<iii>    i.i    il 
amnion.      Anmionilis     (Alillidii) 
mentioned,    as    well    as    |M'ri:irifrii 
anil  etr  vrteritis. 

The  Anmiotic  Fluid. 


Girl,  aged  ten  years.  Kh>winK  ricatricial 
Kr<N)vea  due  tii  CDnxtrirliori  of  umbilical 
cord.  At  birtli.  an-onliriK  tn  the  motlier, 
the  KrfH)ve!i  in  the  abdominal  wall  and 
left  thinh  were  occupied  by  the  cord. 
(Hawthorne  ) 


The  amniotic  fluid  is  xmiriiini 
increased  in  umouiit  ibydramnio 
polybydranmios),  or  it  m.\\  l>(  il 
minished  (oligohydramnios  Inn 
contamination  with  niceoninni  i 
putrefactive  jferins,  the  fluid  may  l)econie  fi>iil,  cloudy,  discdlun d.  an 
full  of  bubbles  of  gas.  The  amniotic  fluid  also  l>ecom('s  altind  in  ra-t 
of  maceration  of  the  foetus,  although  generally  without  i)iitic  I.k  lim 
Various  drugs  administered  to  the  mother  may  appear  in  the  llniJ. 

The  Foetus. 

Death  of  the  fcetiLs  may  ari.se  from  a  variety  of  cause's  iwA  h:i'!-  • 
.several  curious  results.     If  it  W  not  discharged  prematurely   .■'n.rfam 

'  Klaussner,   Ueber   Missbildungcn  der   menschlichen  Gliedmas.seii,   ^^  .  -!iai!>i 
Bergman,  1905. 


ECTOPIC  OESTATION 


879 


ire  met  with, 


it  niiiv  lie  retuiiUHi  within  the  uteriiM  fur  wm-Iu  or  tiioiiilis,  leudiiiK  to 
atnipliv  uml  nwroti*-  ihaitfti'.s  in  the  variuu.s  striKtim's.  In  .sonw  cu.st'.H 
(hf  I'ii'iiLH  btHomes  nuewttad  ur  inKlfr^ot'H  a  furin  of  mamBlflcktlan. 
Slioiil'l  jiressure  Im?  exerted  ujwn  it,  it  niuy  U-  (iuttened  out  to  the  thiii- 
fiess  iif  |>aper  (fatal  pkpynecai).  Han-ly,  <-alrificntion  takes  phue 
Uthopadion).  In  the  event  of  niicro6rf(anisnu  gaining  ucce.ts  to  tlie 
nttriis,  |)  'refaetion  of  its  coritent.s  and  sepsis  may  (K-jiir. 

i'lif  IV  potent  cause  of  death  of  the  fd-tus  is  svpliilis,  either 
liy  priHJdeinf^  a  generalized  weaknes.H  of  the  system,  or  i)y  cutting  off 
the  IiIimhI  supply  through  endarteritis  of  the  unihilical  vessels.  In  a 
iniiitnilisl  fiEtits  it  is  often  possible  to  fin<l  evidences  of  syphilis  at  the 
r[)i|)liv^es  of  the  hones  and  in  the  vi.s<'era.  Other  causes  that  shouhl 
ttf  tnt'iiti(irK-d  arc  pathological  changes  in  the  membranes,  placenta, 
or  conl,  and  constitutional  disease  in  the  mother  (Bright's  disease; 
f(latii|«-iii). 

Malfonnationa.  Malformations,  apart  from  developmental  anoni- 
i  "ies,  limy  arise  frc«».i  li/fhanical  causes.     .Such  an-:  too  small  an  amount 

tlif  .iinniotic  fluid,  adhesion  of  the  niernhntiies,  and  the  pressure 
if  liaiiils  traversing  the  amniotic  .sa^-      (See  vol.  i,  p.  1!).'}  et  se<|.) 

The  licvelopmeiital  anomalies  are  of  gnat  interest.  .Such  conditions 
ii«  .irtjirfism.  gigantism,  chondrodysiropliia,  micromelia,  osteopsathv- 
rosis  iirc  (iix'iisscd  clsewhert'  (y.  l(JU')  et  se<|.). 

Ectopic  Gestation.- -When  the  embryo  develops  in  an  abnormal 
■iitiiatioii,  the  con<lition  is  calUnl  j-ctopie  gestation.  Of  this  then-  are 
-fvcnil  viirictics. 

Intra-uterine  letopic  Oestttion.  —  Gestation  may  occur  within  the 
lavity  of  the  uterus  but  in  an  abnormal  position  (intra-uterine  ectopic 
LfMatioiii.  Tiius,  the  embryo  may  lie  in  a  rudimentary  horn  of  the 
iiitrii>  or  ill  a  diverticulum  from  its  wall.  The  embryo  has  also  l»e«'n 
foiiiiil  in  the  lower  uterine  segment,  in  the  cen-ical  canal,  and  even  in 
the  vaijiiia.  Tlie  latter  cases  are,  however,  mon-  corre<'tly  to  Im'  regarded 
u^  1  .iMi>  of  abortion  than  of  ectopic  gestation. 

Interstitial  Ectopic  Oeitation. — A  second  form  is  interstitial  ectopic 
L'fMatiipi  Here  in  most  cases  pregnancy  o<rurs  in  the  uterine  portion 
i)f  ;i  I'alldpian  tiil)e  (intemtitial  tubal  grsUition). 

Eitra-uterine  Cteitation. — The  third,  and  most  frecpient  form,  is  e.xtra- 
iieriiii'  i,'c>tation.  This  takes  place  in  the  free  portion  of  the  IiiIh', 
as  a  rule  about  the  middle.  In  these  cases  it  generally  happens  that 
>oiin'  tiiiif  iK'twi-en  the  second  and  fifth  month  the  tul)e  ruptun-s  and  the 
fiitih  is  extruded  into  the  peritoneal  cavity.  Very  rarely,  tubal  preg- 
iiaiK  V  may  go  on  to  full  term.  This  occurs  most  commonly  when  the 
tiiilir\(p  irrows  out  between  the  layers  of  the  broad  ligament  (hitralifiu- 
mi-ntiii:.  tubal  grxlation).  Occasionally,  pregnancy  occurs  in  the  in- 
fimililiiiimn,  and  the  embryo  may  project  into  the  alxlominal  cavity 
'■'■"--■ '■■miiinl  gestation).  In  this  ca.sc  discharge  of  the  fa-tus  into  the 
alKli)iniii,,l  cavity  readily  takes  place  (tubal  abortion).  In  those  cases 
«here  i'ik  fimbriae  closely  embrace  the  ovary,  so  that  it  lies  in  close  coii- 
laet  w  i'l,  ihe  abdominal  opening  of  the  tube,  or  where  a  tuboovarian  cyst 


It 


if 


I 


i  I 


i  i 

i      "    !  ■ 

I  _  i 


Iv 


880 


THE  P(BTVS 


has  exbted  into  which  a  ripe  follicle  has  ruptured,  we  may  speak  of ; 
tubo&varian  gettation. 

Flo.  iS\ 


Tubal  ectopic  gentrtion.  The  uterus  and  vagina  are  opened  from  the  front.  Thr  rich 
Fallopian  tube  is  greatly  distended  and  is  ruptured.  The  fcetus  and  cord  are  also  ^own 
(From  the  Gynecological  Clinic  of  the  Montreal  General  Hospital.) 

Orarian  Q«8tation.- -Ovarian  gestation  is  excessively  rare,  but  undoubt 
ediy  occurs.  The  first  case  was  reported  by  Katherine  van  Tiis.st'nl)roecl 
at  the  Tliird  International  Congress  of  Gynecology  and  Olwtttrics  ai 
Amsterdam  (1S90).  Others  have  been  described  since  by  Thonipsor 
and  Clarence  Webster.'  True  ovarian  gestation  may  occur,  or  tlit-  ovario 
abdominal  form. 

Abdominal  Oestation. — ^The  last  variety  of  extra-uterine  gestation  i.s  the 
abdominal.  It  is  open  to  question  whether  a  pure  form  of  alMiominal 
gestation  exists,  that  is,  where  an  ovum  has  been  discharged  into  the 
abdominal  cavity  and  has  been  fertilized,  either  while  within  the  ovan 
or  after  its  liberation.  Possibly,  a  more  critical  analysis  of  tlio  cases 
reported  would  show  that  they  were  primarily  tubal  or  uvarian. 
Gutierrez'  has,  however,  recently  reported  a  case  that  is  alnio>t  con- 
vincing. He  found,  in  a  woman  aged  thirty-four  years,  a  nialnrc  firtus 
in  a  sac  within  the  abdomen  attached  to  the  great  onuniuin  and 
parietal  peritoneum.    The  placenta  was  inserted  on  the  grt-ut  imientum. 

'  Amer.  Journ.  of  Obstetrici,  50: 1004:28. 

'  Rivista  Ibero-Am«ricAna  de  (Seneia«,Medioa«,  March,  100  i. 


ECTOPIC  GESTATION 


881 


Cases  of  what  may  be  termed  tecondary  abdominal  pregnancy  occur, 
where  through  rupture  of  the  sac  the  foetus  is  discharged  into  the 
abdominal  cavity.  So  long  as  the  placenta  remains  in  situ  and  com- 
munication is  kept  up  with  the  mother,  development  is  possible. 

In  ectopic  gestation  the  uterus  undergoes  changes  in  kind,  although 
not  in  degree,  strictly  comparable  to  those  occurring  under  normal  condi- 
tions. The  muscle  hypertrophies,  a  decidual  membrane  is  forme<l,  and 
the  cervix  may  partially  dilate.    The  decidua  in  time  may  l)e  cast  off. 

Apart  from  those  rare  cases  of  interstitial  pregnancy  where  delivery 
takes  place  per  vias  naturales,  the  foetus  invariably  dies.  When  small, 
the  products  of  conception  may  be  completely  absorlied,  but  usually 
thb  is  not  possible,  and  the  foetus,  when  discharged  into  the  alxlomiual 
cavity,  becomes  encapsulated  and  degenerates.  Mummification,  macer- 
ation, or  calcareous  infiltration  may  occur.  Occasionally,  the  meinbr.mes 
alone  become  cJcified  (lithokelyphos).  With  regani  to  the  effects 
upon  the  mother,  tubal  gestation  is  the  most  dangerous,  as  rupture  of 
the  tube  almost  invariably  takes  place  after  the  earlier  months,  and  may 
lead  to  sudden  and  fatal  hemorrhage.  Blood  may  lie  effused  freely  into 
the  alnlominal  cavity  (hematocele)  or  may  l)ecome  more  or  less  eiicajxsti- 
lated  owing  to  reactive  peritonitis  (hematoma). 

The  causes  of  extra-uterine  gestation  are  various.  The  most  potent 
ate  all  conditions  that  interfere  with  the  natural  passage  of  the  ovum 
down  the  Fallopian  tube  to  the  uterus.  Fructification  may  (x-ciir  in  a 
tul)e  and  the  ovum  l)e  retained  owing  to  salpingitis,  kinks,  tubal  polyps, 
compression,  diverticula,  or  defects  in  the  ciliated  epithelium.  Aniong 
inflammatory  causes,  gonorrhoeal  salpingitis  plays  an  important  part. 


56 


i  ,1 

1 


!     ■ 


^      i 


CHAPTER    XL. 

THE  MAMMARY  GLAND. 

From  the  point  of  view  of  development  and  anatomical  structii 
there  is  no  essential  difference  between  the  male  and  female  Iwa 
In  the  male,  however,  with  rare  exceptions,  the  organ  remains  nulime 
tary  and,  therefore,  functionless  throughout  life.  In  the  female,  with  t 
onset  of  puberty,  certain  developmental  forces  are  set  in  motii)n,  look! 
toward  the  preparation  of  the  breast  for  its  important  function  of  lad 
tion,  that  result  in  a  peculiarity  of  type  which,  among  other  things,  d 
ferentiates  the  one  sex  from  the  other.  The  breast  in  the  case  of  Ih 
sexes  is  susceptible  to  the  same  diseases,  with  the  qualification  that  owl 
to  the  greater  functional  activity  in  the  female  the  organ  is  much  mi 
frequently  involved  than  in  the  male.  Particularly  is  this  true  of  i 
flammation. 

The  breast  is  formed  by  a  downward  proliferation  of  the  epiilerni 
according  to  Minot,  from  the  sudoriparous  glands;  acconling  to  othe 
from  the  sebaceous  glands.  At  birth  the  oi^an  is  at  most  2  cm.  acn 
bv  1  cm.  thick.  The  glandular  portion  consists  in  from  ten  to  ;\vei 
(lucts,  arranged  radially,  which  discharge  in  a  small  depression  in  t 
nipple.  These  ducts  are  lined  by  cylindrical  epithelium  or  stratifi 
pavement  cells,  and  end  in  club-like  enlargements.  During  the  Krst  t 
weeks  after  birth  the  proliferative  activity  may  be  so  great  that  I 
ducts  become  distended  with  masses  of  epithelial  cells  and  frramil 
detritus.  The  breast  becomes  enlarged  and  possibly  somewhat  painf 
Fre<|uently  a  milk-like  fluid  can  be  expressed,  to  which,  in  some  coiintrii 
the  popular  name  of  "witch's  milk"  is  given.  The  dilatation  m 
in  some  cases  be  so  extreme  that  a  cavernous  structure  is  \>t(m[w 
(KoUiker).  In  both  sexes  up  to  the  age  of  puberty  there  is  only  a  .«lij 
further  development. 

As  puberty  is  approached,  the  various  ducts  produce  a  few  si 
branches,  which  to  some  extent  bifurcate  and  form  in  turn  (lnl)-li 
terminations.  In  the  male,  complete  development,  so  far  as  it  fioes, 
reacheil  about  the  twentieth  year,  when  the  breast  measnirs  from 
to  5  cm.  in  breadth.  Only  rarely  does  it  develop  further,  a>  in  psriu 
hermaphrcMlitismus  masculinns.  In  the  female,  however,  the  forii 
tion  of  side  branches  and  end  bulbs  is  more  extensive,  espe.  iailv  in  t 
deeper  parts  of  the  organ,  although  the  transition  to  a  perfect  acino 
gland  is  still  incomplete.  The  glandular  elements  are  eoiii|H>^e(l  of 
structureless  basement  membrane  lined  by  short  cylindricil  eelis,  a: 
are  surrounded  by  a  zone  of  firm,  almost  hyaline,  coiin<<  tive  tissi 
Besides  the  regular  ducts,  in  the  lobules  are  to  be  seen  soli.l  masses 


il  l. 


ANOMALIES  OF  DEVELOPMENT 


883 


epitlielial  c-elis  bounded  by  a  basement  membrane.  These  various  parts 
are  held  together  by  a  firm  connective-tissue  stroma  containing  elastic 
fibrils  and  fat;  about  the  larger  ducts  in  the  nipple  fibers  of  unstriped 
muscle  are  present.  The  changes  incident  to  the  onset  of  puberty  may  be 
so  marked,  both  in  boys  and  girls,  that  the  breasts  become  swollen  and 
tender  and  a  milk-like  secretion  is  produced. 

It  is  only,  however,  at  the  onset  of  lactation  that  the  breast  attains  its 
full  development.  Numerous  side  branches  and  end  bulbs  are  pro- 
duced, so  that  regular  acini  are  formed,  which  now  present  a  definite 
lumen.  The  lining  epithelium  is  a  single  layer  of  cylintlrical  cells  more 
or  less  flattened  from  the  accumulation  of  secretion.  The  basement 
niemhraiie  is  composed  of  subepithelial  flat  cells,  that  about  the  end 
bulbs  assume  a  stellate  appearance,  but  about  the  ducts  are  more 
spindle-like,  with  their  long  axes  the  way  of  the  ducts.  Outside  the 
memltnine  is  the  hyaline  zone,  and  then  a  kind  of  adventitia  composed 
of  a  cellular  and  vascular  connective  tissue.  The  stroma,  as  a  whole,  is 
softer,  more  juicy,  and  congested.  After  the  cessation  of  lactation  the 
(jland-tuhules  collapse  and  diminish  somewhat  in  size,  while  the  con- 
nective-tissue stroma  is  again  relatively  increased.  It  never  again, 
how?ver,  attains  its  former  firmness  and  consistency. 

.\fter  the  menopause  the  acini  :..rophy  and  the  tubules  collapse,  while 
the  epithelium  shows  degenerative  changes.  The  tubules  gra«luallv 
revert  to  the  infantile  condition.  It  is  not  uncommon  to  find  cystic 
dilatation  of  the  ducts  with  accumulation  of  a  brownish  or  grayish,  thin, 
or  mucoid  fluid.  Ultimately,  the  acini  entirely  disappear  and  only  the 
ducts  remain. 


JNOMALIES  OF  DEVELOPMENT. 

.\bseiice  of  the  breasts  (amutia)  is  a  rare  condition  and  only  found  in 
association  with  grave  developmental  defects.  Sometimes  only  one  organ 
is  defe(  live,  usually  the  right.  The  ovary  on  the  same  side  inay  also  be 
absent  in  such  cases.  Abnormal  smallness,  either  of  the  gland  as  a  whole 
(micromutia)  or  of  the  nipple  (microthelia),  is  more  common.  Micro- 
mastia,  like  amastia,  is  more  frequent  on  the  right  side  and  l>ecomes  in 
evidence  first  at  puberty. 

Of  more  importance  is  an  increase  in  the  numWr  of  nipples  (poly- 
theUa^  or  of  the  glands  themselves  (polymastia).  The  supernumerary 
organs  may  be  found  on  both  sides  or  only  on  one,  usually  the  left. 
The  redundant  nipples  are  often  u.^fective  in'size  or  abnormally  forme<l, 
and  mav  Ih-  situated  on  one  and  the  same  gland  or  may  be  connected  with 
awessorv  j;lands.  As  a  rule,  in  polymastia  there  are  only  one  or  two 
supernumerary  breasts,  but  as  many  as  ten  have  been  obser\ed.  The 
additioMiil  organ  is  usually  below  and  to  the  inner  side  of  the  normal 
breast,  rarely  above  and  external.  Exceptionally,  breasts  have  been 
found  ou  the  acromion,  the  thigh,  or  the  labium.  As  a  rule,  these 
supernumerary  structures  are  imperfectly  developetl,  l>ut  occasionally 
nave  be<  u  known  to  functionate.    The  condition  is  met  with  iu  males 


fhW 


It !         I 


!l 


('■ 


% 
II  - 


!  5 


II 


f 


i    ! 


t      % 


884 


THE  MAMMARY  GLAND 


as  well  as  in  females,  and  has  been  explained  as  a  reversion  to  an  ancesti 
condition.  Many  cases,  however,  are  due  to  the  separation  in  the  coui 
of  growth  of  portions  of  the  original  gland  substance,  which  become  d 
located  to  some  distant  part. 

OntOULATORT  DUTXTSBAKOU. 

Hyperemia.— Hyperemia  of  a  physiological  character  is  met  w 
during  menstruation,  the  breast  becoming  swollen  and  tender.  T 
condition  may,  however,  go  on  to  hemorrhage,  which  may  take  place  ii 
the  skin,  the  interstitial  substance,  or,  rarely,  into  the  ducts.  In  the  1 
event,  which  is  more  liable  to  occur  in  cases  of  dysmenorrhea  « 
amen'orrhoBa,  the  blood  mav  be  discharged  through  the  nipple  {vican 
menstruation).  The  blood'is,  as  a  rule,  absorbed,  but  may  form  turn 
like  nodules  of  a  yellowish-red,  fibrinous  substance  or  a  chocolate-l 
debris.  It  is  possible  that  such  areas  may  soften  and  be  converted  i 
cysLs.  Hemorrhage  from  the  nipple  may  also  be  due  to  the  ('  vtlopm 
of  a  papilloma  within  the  ducts. 

A  remarkable  affection  is  one  sometimes  met  with  in  hysterical  wom 
where  there  are  single  or  multiple  nodules  the  size  of  a  hen's  etrg,  t 
on  palpation  give  the  sensation  of  tumors.  They  are  nothing  more  tl 
local  areas  of  oedema  of  neuropathic  origin  (angioneurotic  (Bdenu,  hys 
ical  or  blue  oedema — Charcot).' 


INTLAMBIATIONS 

Inflammation  of  the  breast  may  l)egin  in  the  skin,  the  siiperfi 
eonnec-tive  tissue,  the  nipple  or  areola,  or  in  the  substance  of  the  pi 
itself.     It  is  acute  or  chronic. 

Acute  inflammation  of  the  areola  Iwgins  in  the  sebaceous  plamls 
mav  lead  to  local  abscess-formation  or  a  diffuse  phlegmon  involvmg 
skin  and  sulwutaneous  tissue.  The  appearances  do  not  differ  iiiaten 
from  those  of  ordinarv  erysipelas  of  the  skin  elsewhere. 

Inflammation  of  the  connective  tissue  behind  the  breast  is  of  n 
importance  (pmmuuititii).  It  is  rather  a  rare  condition,  and  ma; 
caused  by  exteasion  of  inflammation  from  the  substance  of  tlie  Im 
bv  carious  ribs,  bv  the  bursting  of  an  empyema  through  tlie  (jliest  v 
or  bv  an  axillarv'abscess.  Fever  and  constitutional  (listiirbance 
marked.  The  breast  is  pushed  forward,  but  retains  its  normal  shap 
tense,  and  feels  as  if  it  were  resting  on  an  clastic  cushion,  ram  k  ><■ 
and  increased  by  the  movements  of  the  arm  and  chest.  <  ■•iierall: 
abscess  forms  (retromammary  abwew),  which  may  burst  int,.  tiie  thoi 
cavity  or  dissect  through  the  breast,  forming  numerous  siniiv-  orexte 
fistul'se.     Orth'  records  an  extraordinary  ca.se  where  the  ( niire  bi 


'  See  Fowler,  Medical  Record,  1  :  1890  :  179  and  191.       '  Lehrl, 


,  1S93:<> 


MASTITIS 


885 


became  sequestrated  owing  to  the  dissection  of  an  abscess  in  the  con- 
nectivf  t'sue  suiroundin';  it. 

Thelitis. — Inflammation  of  the  nipple  (thelitis)  is  not  uncommon  in 
nursiiij;  women,  and  originates  in  small  cracks  or  fissures  caused  by  the 
irritation  of  the  mechanical  act  of  sucking  and  the  macerating  action  of 
the  milk  and  saliva.  In  such  cases  infection  readily  takes  place,  espe- 
cially with  the  staphylococcus,  less  commonly  the  streptococcus,  or  the 
thrush  fungus.  The  process  readily  spread's  to  the  substance  of  the 
gland  by  means  of  the  lymphatic  channels  or  along  the  galactophorous 
ducts. 

Mastitis. — Acute  Blastitis. — Acute  inflammation  of  the  breast  proper 
—acute  mastitis — occurs  at  all  ages.  It  is  found  in  the  first  few  days 
of  infancy,  where,  as  has  Xieen  before  remarked,  swelling  and  inflam- 
mation of  the  breasts  is  not  uncommon.  This  would  rarely,  however, 
cause  much  trouble  were  it  not  for  the  metldlesonie  practice  among  nurses 
of  "rubbing  out  the  milk."  It  is  also  seen  in  girls  al)oiit  the  time  of 
the  first  nieastruation,  particularly  in  those  of  a  strumous  disposition, 
and  is  met  with  as  a  complication  of  the  infectious  fevers.  These 
forms  rarely  go  on  to  suppuration.  Acute  mastitis  is,  however,  by  far 
the  most  frequently  found  during  the  first  month  after  deliverj-,'  and 
especially  in  primipane.  Here  the  process  is  in  immediate  relationship 
to  the  function  of  lactation.  Traumatism,  as,  for  instance,  erosions  or 
fissures  of  the  nipple,  is  the  direct  exciting  cause,  as  it  leads  to  the  infec- 
tion of  the  breast  with  microorganisms.  The  old  view  that  retention  or 
oversecretion  of  milk  is  the  cause  is,  of  course,  incorrect,  except  in  so  far 
as  these  conditions  predispose  to  the  occurrence  of  infective  processes. 

Puerperal  Mutitia. — In  puerperal  mastitis  the  inflammation  is  of  the 
exudative  t}-pe,  and  may  either  be  uniformly  disseminated  throughout 
the  breast  (diffuse  maatitis)  or,  as  is  most  fre<juently  the  case,  affects 
a  circumscril)ed  area,  usually  the  lower  and  outer  portion  of  the  organ. 
.Sometimes  multiple  isolated  foci  are  produced.  The  inflammatory 
process  in  most  cases  originates  in  theconnective  tissue  l)et ween  the  lobules 
\interli)hular  mastitis),  yi\{\c\\  is  hyperemic,  infiltrated  with  iiiflammatory 
prorjurts  and  round  cells.  The'  epithelium  of  the  acini  shows  merely 
secondar  degenerative  changes.  The  process  may  resolve  or  go  on  to 
abscess-formation.  Multiple  foci  of  suppuration  "are  produced,  which 
often  eoiiiesce  to  form  large  pus  cavities.  The  pus  frefjuently  burrows 
around  and  between  the  lobules,  until  the  breast  is  practically  disorgan- 
ized. Perforation  may  take  place,  usually  through  the  skin,  or  into 
a  milk  cliut,  or,  again,  into  the  pleural  cavity.  When  the  abscess  is  large 
we  get  a  cavity  with  irregular  nodular  walls,  unless  in  the  case  where 
the  pus  is  contained  within  a  dilated  milk  duct,  when  the  wall  is  smooth, 
ire  often  formed  externally,  which  may,  in  some  cases,  com- 


Fistida- 


municaif  with  the  milk  ducts  {milk  fistula).  Occasionally  the  abscess 
does  not  {)erforate,  the  pus  becomes  more  or  less  absorbed,  and  only  a 
tatty.  cr:uiular,  and  calcareous  detritus  rei.-'ains.  In  other  cases  the 
process  M-^sumes  a  chronic  course  with  the  formation  of  contracting 
scar  tissiK  and  dischai^ing  sinuses. 


}  r    .  ;  : 

1  M- 

.1:    •■ 

f              1          i 

1        \    I 

i      11 

r//B  MAMMARY  GLAND 

Acute  a«UetopboiitU. — Acute  galactuphoritis,  or  inflammation  of  the 
milk  duets,  is  found,  as  a  rule,  a  considerable  time  after  the  puer|)triiim, 
usually  in  anemic  patients.  It  apparently  originates  in  a  catarrh  of  the 
larger' ducts,  and  is  again  the  result  of  infection.  Occasioimllv  it  is 
secondary  to  interstitial  or  interlobular  mastitis.  There  is  spoiiiaiiwMis 
pain  in  the  breast,  increaseil  during  the  active  function  of  tiu-  jilaml, 
tenderness  on  pressure  over  the  duct,  and  during  the  quiescent  jH-riod 
pus  mav  be  expressed  from  the  nipple. 

According  to  Orth,  the  staphylococcus  is  the  most  common  offender  in 
this  affec-tion,  and  the  streptoc<KTUs  in  interstitial  mastitis. 

Obronic  MMtitla.— Chronic  mastitis,  as  has  just  been  innlni.  may 
follow  the  acute  fonn,  and  abscesses  may  remain  more  or  less  latent  for 
a  long  time.  accompanie<l  by  hx-al  fibrosis.  Besides  this,  however,  we 
have  "to  recognize  a  chronic '/>rorf Mrf/iv  inflammation  in  which  the  over- 
growth of  fibrous  tissue  is  much  the  most  prominent  feature.  .\.s  in 
the  case  of  the  acute  forms,  here  again,  we  have  a  diffuse  and  a  local 
varietv. 

The  diffuse  form  {cirrhosis  mamma,  Wemher)  is  very  ran'.  Hecin- 
ning  with  pain  and  other  signs  of  inflammation,  the  breast  at  first  swells, 
but  later  gradually  shrinks  in  size,  owing  to  the  formation  of  conlraeting 
scar  tissue.  The"  skin  l)ecomes  attached  to  the  deeper  structures,  with 
some  dimpling,  anil  the  nipple  is  often  drawn  in  so  that  the  reseinlilan.'e 
to  certain  forms  of  scirrhus  is  striking.  Only  a  careful  examination  will 
suffice  to  difTerentiate,  and  not  always  then.  The  axillary  ;:laiiils  are 
swollen  and  tender,  but  in  mastitis  the  enlargement  is  not  perniaiieiit. 
Sometimes  a  compens«tt)ry  overgrowth  of  the  surrounding  fatty  tissue 
of  the  breast  occurs,  .so  that  the  total  volume  of  the  breast  need  not  lie 
diminished. 

Microscopically,  together  with  the  formation  of  scar  tissue,  the  anni 
are  atrophic  and  the  ducts  dilated  into  cysts. 

The  local  form  of  productive  mastitis  is  much  more  conimon  Thi> 
gives  ri.se  to  the  formation  of  multiple  hard  nodules,  sonieiinu-  ni  Iwih 
breasts. 

Microscopically,  the  appearances  do  not  differ  from  tiie  former  tyi». 
except  that  the  condition  is  circumscribed  and  not  diffuse.  In  spite  i>f 
the  fact  that  atrophy  of  the  acini  is  the  rule,  carcinomatous  transforma- 
tion has  been  knowri  to  occur  {mastitis  carcinomatosa  of  some  aMihor« '^ 
Tuberculosis.— This  affection  of  the  mammary  gland  (« <  urs  at  a! 
ages  and  in  both  sexes.  The  occurrence  of  pregnancy  and  the  piieriiera 
state  favor  the  extension  of  the  disease.  The  lesions  may  l.e  iunlater.il 
or  bilateral.  The  disease  was  first  described  by  Sir  Asth  .  ( •oo()er  in 
1S3(>.  ami  since  his  time  several  careful  studies  have  appearc .!. 
Primary  tul)erculasis,  so  far  as  we  know,  does  not  cHmr,  hut  the 


'  .s;ee  Hifliis,  .Mutudie  cvbtique  des  mamellcs,  Rev.  d.  Chir.,  ISi'." 
des  Hop.,  1887:  t>73;  also  Kdnig,  Centralbl.  f.  Chir.,  3  :  1893  :  4>.l. 

'Diseases  of  the  Breast,  1836.  .See  also  .Sabrazes  and  Biniiii' 
raWecine,  18it»>,  for  the  pathological  anatomy. 


f.vA  Gi' 


\roh.  p'M-  <i' 


SYPHILIS 


887 


affection  o-iginates  in  the  extension  of  infection  from  other  parts,  most 
frequently  by  retrograde  metastases  from  the  axillary  glands  or  thoracic 
cavity,  from  a  carious  rib,  or  occasionally  through  the  blood  stream. 

Tliree  forms  may  be  differentiated — the  aent*  miliarjr,  the  diicrete, 
and  lilt*  eonflMnt. 

The  first  type  is  similar  to  the  miliary  affection  elsewhere  and  does  not 
call  ft)r  an  extended  description.     It  is,  of  course,  hematogenic. 

In  the  discrete  form  one  or  more  nodules  are  to  l)e  found,  varying  in 
size  from  a  hemp-seed  to  an  almond.  When  a  single  mass  is  present 
it  is  luually  in  the  upper  and  outer  portion  of  the  breast.  The  multiple 
nodules  are  disseminated  throughout  the  oi^n.  The  breast  is  not,  as 
a  rule,  enlarged,  the  skin  is  intact,  and  the  nodules  are  firm,  distinct, 
and  usually  immovable.  On  section  the  lesions  are  composed  of  a 
central,  jjrayish  or  whitish  caseous  material,  or  sometimes  contain  a  puri- 
forra  fluid,  and  are  surrounded  by  a  more  reddish-gray,  semitranslucent 
zone.  There  is  also  often  a  certain  amount  of  fibrosis  in  the  immediate 
neighlMjrhoiKl. 

In  the  confluent  form,  which  originates  in  the  condition  just  described 
hy  the  coalescence  of  neighboring  foci,  the  breast  is  often  considerably 
eniarfp-d.  and  asually  asymmetrically  so.  The  organ  is  firm  and  appears 
to  contain  a  solid  ma.ss.  On  section,  the  affected  area  is  made  up  of 
cavities  irregularly  spherical  with  lateral  pouches.  In  the  adjacent  parts 
may  Ite  seen  apparently  separate  cavities,  which,  however,  are  found  to 
communicate  with  the  main  abscess  by  small  channels.  The  whole, 
&  -efore.  frequently  has  an  areolar  appearance.  The  cavities  are  lined 
a  soft,  pyogenic  membrane  presenting  yellowish  points.  Radiating 
from  the  ce!itral  area  of  softening  are  dense,  fibrous  bands,  and  in  the 
immediate  vicinity  can  be  seen  small  secondary  tubercles.  The  larger 
cavities  fre(|uently  communicate  with  the  exterior  by  fungous-looking 
sinuses.  .\s  a  rule,  one  breast  only  is  affected.  The  process  begins  in 
the  connective  tissue  surrounding  the  lobules  and  acini,  but  it  may 
spread  into  the  ducts. 

Microscopically,  the  tubercles  have  the  ordinary  composition  of  epi- 
thelioid, round,  and  giant  cells,  with  central  caseation,  and  peripheral 
fihrosis.  A  point  worthy  of  note,  however,  is  that  tubercle  bacilli  are 
r*markiil)iy  scanty. 

.\  rare  variety  of  the  confluent  form  is  the  cold  abscess.  It  is  essen- 
tially ciiron!-  and  insidious  in  its  development,  and  is  found  only  in  the 
adult,  and  generally  after  pregnancy.  The  cavity  is  sharply  dcfine<l, 
lined  li\  a  fungous  pyogenic  membrane  of  a  reddish-purple  color,  and 
contains  tliin  pus  and  grumous  material. 

Syphilis.— Se<ondary  syphilitic  manifestations  in  the  skin  of  the  breast 
are  of  ( i.urse  common  and  need  only  be  mentioned.  The  most  impor- 
tant le^iiMi  is  the  primary  cfeanrrc  or  sclerosis,  which  is  found  starting  in 
the  fiiiij.!<.,  hut  may  lead  to  destruction  of  this  organ,  and  extend  to  the 
skin  of  the  breast.  The  lesion  is  ordinarily  due  to  suckling  a  syphilitic 
'hild.  I'he  ulcer  is  of  the  characteristic  type,  chronic  anil  indurated, 
and  accompanied  by  indolent  bubo  of  the  axillary  glands.     Gummas 


>l 


I  [ 


1 

'    W- 

^'' 

1 

y  1 

n '-  H 

1 

!W 

U    ! 


hi 

(; 

I 


h 


if 


i  I: 

i  i 

i  i 

!  i 


THE  MAMMARY  QLAND 


are  rare.    They  have  been  met   .ith  both  in  the  male  anil  the  U'\mV 
breast.     More  common  is  said  lo  be  diffuse  mastitU. 

Actinomycosis.  Actinomycosis  is  excessively  rare.  It  may  he  dui 
to  the  extension  of  pulmonary  actinomycosis  through  the  lh(traci( 
wall.  One  or  two  cases  have  occurred  superficially  which  were  attril)Utet 
to  the  application  of  poultices. 

RETBOORIUIVI  MXTAMORPHOSU. 

Atrophy. — It  is  debatable  whether  retrogressive  changes  properh 
so-called  are  ever  met  within  the  mamma.  Simple  atrophy  of  tlu'  ulami 
ular  elements  is  found  aa  an  involution  process  after  the  menopiiiisc.  mv 
occiisionally,  although  by  no  means  invariably,  after  removal  of  t)i( 
ovaries.  The  atrophy  is  often  masked  by  an  excessive  overjjrowih  oi 
fat.  Atrophy  is  also  said  to  follow  the  pn)longe<l  use  of  icxiiiie  or  it; 
derivatives.  Bollinger  and  others  have  descril)ed  a  curious  atrophy  fron 
inactivity  among  the  people  of  Upper  Bavaria  that  appears  to  l)e  a  farail\ 
vitium. 

Cysts.  -Cysts,  usually  multiple  and  of  small  size,  filled  with  greenish 
or  brownish  fluid,  are  not  uncommon  in  the  breast  during  the  involiitioi 
{H'riotl.  They  are  due  to  the  obstruction  of  the  ducts,  and  from  theii 
si/e  and  hardness  may  simulate  scirrhus. 

PROORESSIVE  MET1M0RPH08ES. 

It  is  perhaps  a  little  difficult  to  know  exactly  what  conditions  oiiglil 
to  \w  disi  ^l  under  this  section.  As  is  well  recognized,  tiure  is  a 
physiological  rtiationship  l)etween  the  breasts  and  the  genital  organs 
and  this  interdependence  is  still  to  be  observed  in  various  putliological 
conditions,  of  which,  indeed,  it  may  he  a  cause.  There  an-  also  itrtaiii 
states  of  ovei-growth  and  functional  overactivity  that  are  perfectly  natural 
in  certain  individuals  at  certain  times,  which  in  other  persons,  at  otliei 
times  and  under  different  circumstances,  must  be  regarded  as  alinornial. 
Thus,  the  active  and  excessive  growth  associated  with  lactatio!i,  if  found 
in  the  non-pregnant  or  non-parturient  woman,  before  the  age  of  pulx-ilv 
or  after  tiie  menopause,  or,  again,  in  the  male,  must  be  repinkil  as  dis- 
tinctly pathological.  We  shall  not  perhaps  greatly  err  if  ut  refer  to 
sm-li  conditions  in  this  place. 

H]rpertrophy. — An  hypertrophy  of  the  breasts,  simulating  that  found 
in  pregnancy,  is  found  associated  with  tumors  of  the  uterus  or  ovaries. 
Uej)eated  stimulation,  as  from  the  application  of  a  child  to  tiif  Im  ast,  lias 
sometimes  establislied  the  function  of  lactation  in  virgins  and  in  old 
women.  Occasionally,  in  males,  the  breasts  assume  the  fcinale  tvpe 
(gynecomastia),  and  milk  may  even  be  secreted.  The  condition  is  often 
assiK'iated  with  atrophy  of  the  testicles. 

k  j>eculiar  form  of  hypertrophy  is  that  not  infrequently  foiii;(l  in  tuber- 
culous individuals. 


HYPERTROPHY 


889 


OonpenMtaiy  Bypwtrophjr. — Compensatory  hypertrophy  of  one  breast 
after  the  removal  of  the  other  may  be  produced  in  experimental  animals, 
as  Kibbert  has  shown,  but  it  is  doubtful  if  it  occurs  in  the  human  subject 
under  ordinary  conditions. 

A  vicariout  overgroiiih  of  the  fatty  tissue  of  the  breast  has  been  ob- 
sen'e<i  in  cases  of  atrophy  and  contraction,  as  in  some  forms  of  scirrhua 
(cancer  atrophicans),  wherel)y  the  total  volume  of  the  breast  is  not 
altered  mater.^Uy.  An  overgrowth  of  fat  is  also  common  in  simple 
cases  of  obesity. 

Exceptionally,  after  the  menopause,  and  therefore  after  the  nonnal 
stimuli  are  removed,  the  breasts  may  not  involute,  but  remain  large  and 
mav  even  continue  to  secrete. 


Fl<i.  232 


Hypertrophy  of  the  breasln.     (Jamrs  Beira  cue.) 

Diffuse  Hypertrophy. — Of  more  iniportuncc  are  the  cases  of  diifuise 
hvpertnipliy  of  the  breast,  of  which  a  numl)er  of  instances  are  now  on 
reeonl.  The  affection  is  usually  met  with  in  young  girls  at  or  shortly 
after  tlie  time  of  the  first  menstruation.  The  growth  may,  for  a  time, 
remain  latent,  being  lighted  up  again  only  with  the  occurrence  of  preg- 
nanev,  or  may  be  continuous  from  the  first.  Both  breasts  are  involved 
in  a  uniform  enlargement  of  the  tissues,  in  which,  however,  the  nipple 
does  not  participate,  but  is  gradually  flattened  out  over  the  mass.     Large 


RSO 


THE  MAMMARY  OLASD 


li  f 


veins  are  f^nerally  to  Ite  seen  beneath  the  stkin,  and  necrosiii  from  proxurr 
or  interferent-e  with  the  circulation  may  result.  The  breasts  liavp  a 
soft,  IwKKy  f^l.  «»>■  nmy  contain  hard,  mom  tumor-like  masses,  us  in  a 
cttse  rec  -tied  by  James  Bell.'  The  enlargiHl  organ  has  l)een  known  to 
attain  the  weif^ht  of  from  four  to  seven  kilos  or  more.  Durslon-  and 
Williams  have  each  reconle<l  a  case  in  which  a  breast  reached  X\w  fiior- 
mous  size  of  sixty-four  pounds.  1  )iiTerent  pathological  condil  ions  ii|)|H-ur 
to  l)e  included  under  the  term  "diffuse  hypertrophy."  In  sonii-  chm's 
there  is  what  is  practically  a  diffuse  fibromatosis,  in  others  the  ^lamliilar 
elements  may  \>e  increased  as  well,  and  in  still  others  true  adcnomaious 
masses  may  lie  found  throughout  the  organ.  The  condition  sitins  to 
be  as.sociated  with  .some  disorder  of  the  genital  functions. 

(^are  should  be  taken  not  to  mistake  a  retnimammary  li{M>mu  fur  {\\\i 
condition. 

Tumors. — Much  difficulty  is  experienced  in  distinguishing;  l»'twe«ii 
the  various  conditions  that  lead  to  the  formation  of  new  tissiit-  in  tlie 
breast.  As  all  clinicians  are  aware,  retention  cysts  ami  the  li\  pcrjilasia 
incident  to  chronic  mastitis  may  at  times  clo.sely  resemble  tlic  true 
neoplasms  so  that  diagnosis  is  rpt  to  be  difficult.  And  pathi>l<>}.'i('ally 
s{)eaking  the  same  difficulty  confronts  us  in  differentiating  IxiwcfM 
what  is  true  tumor-formation  and  that  neoplastic  overgrowth  wliicli  is 
.so  often  secondary  to  inflammatory  irritation.  In  the  bn-ast  we  liave 
Ixith  fibrous  and  glandular  elements,  and  it  is  usually  easy  to  say  wlittlier 
the  latter  are  in  excess  of  the  normal  amount  for  the  individual  or  iiol. 
but  the  further  question  whether  this  overgrowth  is  primary,  '•artive." 
an<l  independent,  or  secondary  and  what  might  l)e  termed  "passive," 
must  .sometimes  remain  in  doubt.  This  passive  hy|)eri)lasia  is  at  one 
time  the  result  of  inflammatory  or  mechanical  irritation  and  at  aimtlifr 
a  .secondary  manifestation  concomitant  with  tlio  development  of  a  iiiMKir 
in  the  related  tissues.  The  appearances  are  still  further  coiniilicateil 
when  cysts  are  produced.  ,  .  some  cases  the  newly-formed  (.'liimlular 
striK  iures  l)ecome  dilated  i  rtly  it  is  probable  from  obstnaiioii,  lint 
also  from  excessive  .seer  >n  (cystadenoma),  while  in  others  tin  re  is 
merely  a  retention  of  s  retion  within  the  normal  or  approxiiiialely 
normal  acini  (retention  or  simple  cyst). 

The  breast  being  in  the  main  composeil  of  three  distinct  types  of  tissue, 
the  integument,  the  glandular  elements,  ami  the  fibrous  stroma,  wr  have, 
corresponding  with  these,  epithelial,  adenomatous,  and  cumicctive- 
tissue  tumors.  With  the  exception  of  the  epithelial  new-growtiis,  these 
are  not  always  pure  in  type,  for,  as  a  rule,  both  fibrous  ami  l:1  mdiilar 
elements  partake  in  the  proliferation,  and  fnini  modification-  of  their 
structure  give  rise  to  a  considerable  variety  of  forms.  The  Intast,  in 
fact,  is  a  common  site  for  the  development  of  mixed  growllis.  .\s  an 
illustration  of  this  we  may  take  the  ca.se  of  the  adenoma,  whic  !i  is  rather 
a  rare  tumor,  while  various  combinations  with  fibroma  (adtiKiiilrn'ma; 


Montreal  Med.  Jour.,  28:  1899:  772. 
'  Quoted  liy  Labarraque,  Th^se  de  Paris,  1875. 


■}m%Sj^: 


m    -I  ii 


TUMORS 


Wl 


filiriHulenoma)  or  modified  connective  tissue  (adenomyxoma;  wdeno- 
sanuina;  myxoa<lenoma,  sarcoadenuma)  are  much  more  common. 

Tlif  exact  point  of  ori({in  for  manv  of  the  breast  tumors  is  still  in  doubt. 
With  re((ard  to  the  fibromas  ami  sarcomas,  Dreyfuss'  ami  Billnith' 
l)elieve(l  that  they  took  their  rise  in  the  hyaline  connective  tissue  sur- 
roiiixling  the  acini,  but  this  undoubtedly  does  not  explain  all  forms. 
A^rain,  in  the  case  of  the  adenomatous  and  carcinomatous  new-)(rowths, 
it  \\m  usually  lieen  taught  that  they  develop  from  the  epithelial  cells 
of  llie  acini,  but  Creighton'  has  publish^  an  elal)orutf  study  in 
which  he  promulgates  the  view,  which,  indeed,  appears  to  lie  su|i- 
portiMJ  l>y  many  facts,  that  the  majority  of  the  glandular  tumors  originate 
ni>l  ill  the  acini  of  the  breast  proper,  but  in  sudoriparous  glands  which 
irp  to  lie  fouml  deep  down  in  many  nonnal  breasts  in  a  more  or  less 
pt-rffct  state.  Some  of  them  are  possibly  to  be  explained  as  originating 
in  a  reversion  to  the  more  embrjonic  condition.  This  work  of  Creigh- 
lon's,  while  most  suggestive,  as  yet  lacks  conKrmation,  and,  like  other 
theories,  cannot  explain  all  cases.  However,  this  may  lie,  the  ultimate 
raiLses  of  tumor-gniwth  in  the  breast  are  as  obscure  as  they  are  in  the 
case  of  neoplasms  of  other  regions. 

It  is  a  well-known  fact  that  the  breast  is  one  of  the  most  frequent  sites 
for  tiiiiKir-formation.  This  is  perhaps  to  be  explained  in  view  of  the  fact 
that  the  breast,  like  the  uterus,  where  new-growths  are  also  common,  is 
ill  tlie  majority  of  individuals  for  a  prolongetl  period  in  a  state  of  both 
physiological  and  anatomical  unrest.  The  truth  of  this  is  obvious 
when  we  asi<ler  the  various  vicissitudes  to  w'  '-h  it  is  liable  in  the  course 
of  |)iil)es(t..ce,  gestation,  lactation,  and  senilu^.  Normally,  then,  we 
must  conrlude  there  is  a  pre<lisposition  to  rapid  proliferation  of  tissue, 
whith  a  great  variety  of  apparently  trifling  stimuli  are  competent  to 
hrinjr  alMiut.  Besi<les  this,  inflammatory  changes  of  all  grades,  with 
their  assiK-iatetl  irritation  and  morphological  changes,  are  particularly 
(omnioii  in  the  breast,  so  that  it  is  not  extraordinary  that  the  natural 
balance  of  things  should  fre<juently  lie  upset.  Many  writers  lay  stress 
ii|)<)n  hcreilitary  influences,  triuma,  race,  and  sex.  Hereditary  pre- 
disposition is  found  only  in  the  case  of  malignant  growths,  and  has  been 
varioiisly  estimated  as  lieing  present  in  from  9  to  21  per  cent.  The  in- 
fluence of  trauma  is  still  a  matter  for  debate.  A  history  of  injury  or 
inflainination  is  given  in  from  12  to  40  per  cent,  of  cases  of  carcinoma, 
wliih'  in  san-oma  the  influence  of  trauma  is  said  to  be  much  greater. 
Whether  this  is  of  etiological  importance  or  is  a  mere  coincidence,  we 
are  not  as  yet  in  a  position  to  say.  With  regarti  to  race,  it  is  a 
remarkable  fact  that  fibrous  tumors  of  the  l>reast  are  rare  in  negresses, 
while,  on  the  other  hand,  fibroids  of  the  uterus  are  particularly  common. 
With  n-gard  to  sex,  practically  all  the  tumors  found  in  the  female 
breast  may  be  met  with  in  the  male,  but  with  much  less  fretjuency,  a 
fail  « iiich  goes  a  long  way  to  support  the  view  just  enunciated  that  dis- 

'  Vir.li.  Archiv,  113: 1888:  .535.  '  Virch.  Archiv,  18:  1860:  .51. 

'C.iiK.  rs  and  Other  Tumors  of  the  Breast,  Williams  &  Norgate,  London,  1902. 


;  it   ^\  ■ 


803 


T««  MAMMAKr  OLASO 


I 

IK  ! 
ji 


t        * 


U  1 


turiuiiM-e  of  functiuiml  ami  Ntnictural  rcjuiiibnum  is  an  importttiii  rtio- 
|ii((iful  factor. 

Tunmrs  of  tlie  lircKtt  iiiuy  Ite  i-onveniently  (livitkd  into  lifnij;!!  uimI 
malignant  fomu*.  Apart  from  i»laiii  cvhIs,  among  the  foniKT  we 
may  recogniase  ftbroau,  adraoiM,  ftbroMtonoiu,  tdMoflbnaM,  e;ittd«- 
iwau,  Upeou,  ajnioiu,  myoau,  ancioau,  «tf«o«wi,  cbondreaM;  biuom);  ihr 
latter,  •ptthaUonu  and  various  t,v|><-s  of  etnlMBk  aral  unoaM.  Mhiiv 
of  thf  c-yst.H  art*  nitrely  "retention"  cvmIs  aw\,  therefore,  pnnKrly  ikx 
tumor.<*,  while  some  arv  either  iienign  or  malignant  eystMlMwmu,  ejrttk 
fibnmM,  or  aucoiBM.  An  overwhr!  tning  prtip«>rtioii  of  mammary  growths, 
variously  f.4imate<l  l»y  Whitp,  NNilliam.s,  (ir«>s.s,  ami  S«*nn  at  frmn  M) 
to  !>.">  }»er  eent.,  are  can-inoniiis.  An  aimly-tis  <»f  i'a.seH  from  the  rcconls 
of  the  Hovnl  Viitoria  HoHpiial  gi\«'s  ih.    foll4>wiug  proportioii.s  f(ir  tin- 

ri.        oniLs:    Total  uuiiiIkt  of  i-ases,  1.S4;  fihnima,  I;  lulenoiiiu    II; 

ii>r<M*itetH>nia,  1 1 ;  <  ystaiieiMH  tia,  I :  sarc<mia,:{;  epithelioma,.');  carcii a, 

l."{2.  These  figures  agree  fairly  w«'ll  with  those  of  Williams,'  who  r«[M(rt> 
24;H>  eases  (liviihtl  as  follows:  fibnuulenoin i,  l'«..'{  jiereent.;  tiiwotna. 
i).  Hi;  sarcoma,  :M>;  t-aniiionia,  77.'>.  The  great  preponderanee  of  iiiiiiit:- 
11,1  nt  forms  reu<lers  it  imperative  that  all  mammary  tumors  slimiM  In 
riMnovwl  early.  Even  the  fibroadenoma  ha.s  l)een  known  to  j;i\.  ri>» 
to  ineta-stases  n<rt  wilhstaialing  the  fact  that  the  histologic!!  |)i(tiirt>  ha< 
Im-cm  that  of  a  mm-malignant  growth.  Hanseman'has  reionidl  ,i  him 
of  this  tyjw.  and  nwuiy  (icrman  pathologists,  therefcire,  sj  luk  of  •car- 
cinoma in  the  guise  jif  adenofihroma."  In  any  ca.se,  \\fioxv  giviiij:  an 
opinion  it  is  nwe.ssary  to  examine  every  {Hirtioii  «»f  the  tufiior.  aii'l  cvhii 
tlu'ii  one  may  l»e  decfived.  ,\n  adenofibnmiii  is  rarely  niistukiii  fi>ra 
(  aninoma,  hut  m;  doubt  the  reverse  fr  (juently  occurs. 

Fibroin*.  Tiic  most  common  of  the  lienign  new-j^rowih^  i>  the 
fibrous  tumor.  This  is  composeil  of  more  or  le.ss  dense,  fil)roU'«  tisMir 
in  which' are  enil>eildcd  glaiulular  elements,  differing  but  !'•!»■  fmiii 
those  of  the  normal  gland  (fibroiM),  although  in  sonu>  cumv  while 
there  is  an  overgrowth  of  the  connective-tissue  dements,  tlitn  i-  a 
pre|)onderance  of  glandular  structur»'s  (fitooadenoma).  .\11  |>i>>sible 
variaticms  iH-twccn  the  two  extreme  typ«'>  may  iH<-ur  (adanofibroiui. 
In  this  connection  it  sliouhl  \w  remarked  tli  it  C(msi(lerable  ioiifii>i(pii  in 
the  nomenclature  has  arisen  from  l!'<'  loose  way  in  which  thesf  varii)u.« 
growths  have  been  regardeil.  In  otlier  .vords,  authorities  have  h  r  l>een 
clear  as  to  what  con.stituted  an  ;i«lenoma  and  wliiit  a  fibnuui  \ 
little  thought  wouhl  have  avoided  ilie  difficulty  A  fibroma  i  mnuir 
composed  of  fibrous  tissue.  In  the  conrs**  of  its  formation  it  >  uirall.v 
may  include  certain  duels  and  acini  of  the  breast.  The  Hiaiiiliiliir 
structures  may  further  1h>  considerably  altered  ^-om  tra<'tioii  or  pre-nre, 
and  frequently  present  proliferative  or  ilegei.  .  itive  changes,  wint  tc 
the  irritation  produced  i)y  nu'chani<al  or  inflammatory  cause- 
changes  are,  however,  obvi<Hisly  se< mulary  ami  in  iw  re.spe<'t  ti 

'  Hrit.  Med.  Jour  .  2:  1WV2:  ">7ti 

'  I >ie  iiiikruHkopixehe  I)w(5iK>.>ie  iler  bosartij^ii  GcschwuLstt. 


niii- 


riBROMA 


803 


^iilrred  as  fvidpiw^es  of  iiHl«*|)eii<lt>nt  Kniwth.  Such  a  tumor  can  only 
\w  It  tihroina,  not  a  fibrowlenoinu.  It,  of  courts,  takpH  <-uaHi)ii'ralili> 
pni<  ik'^  to  (Wi(i«  whrthrr  the  );lan<liilar  chanitfs  in  any  ^iren  rase  arr 
■trciHulary  or  are  rrally  an  atienotnatouH  new-formation,  hut  an  attempt 
ihoiild  he  iraule  in  every  ca.<te  to  .settle  the  iMiint.  An  aiienoma,  on  the 
(itlMT  hand,  is  a  tumc»r  rom|Mi.s«Hl  chiefly  of  ((lamiular  elements  derived 
fnitn  die  acini  or  ducts  .lut  vuryin^  notahly  from  those  characteristic  of 
iIh-  iiormal  gland.  The  epithelial  cells  forinin^;  the  acini  and  du<-t.s 
have  proliferated  consiilerahly,  s<i  that  solid  epithelial-cell  masses  an* 
|)ri)(lm'ed  or  lumina  cwlased  hy  several  layers  of  cells,  in  contradiHtiiic- 
(Hiii  to  the  normal  acJtni,  where,  at  least  in  the  active  condition,  the 
a«iiii  are  compase<l  of  ii  single  row  of  fJls.  Farther,  in  udciioniu,  utid 
it  Ih  this  that  constitutes  the  main  difference  l)etween  the  tumor  and 
ihn^t'  secondary  changes  which  have  just  l>een  mcritiont'd,  the  ducts 
aii<l  u'ini  iire  not  groupe<i  into  lohules,  nor  are  they  mere  i>!f.slnM»ts 
from  the  lohules,  hut  are  arranged  in  an  erratic  way  differing  ni'  or 
less  widely  fwnn  the  orderly  arraiigcmeni  of  'ho  normal  gland.  The 
(iiffiise  enlargement  of  the  ''reasts,  pcferrei.  lo  ^«l)ove  under  the  name  of 
"iliffii  hyper  uphy,"  is  nt  some  cases  «■-  K'iated  with  great  increuse 
of  the  glandular  element-  and  hence  has  U  tii  calh'd  hy  s.  ne  "diffuse 
udetioina."  It  i-.  in  no  s*  fise,  htiwever,  a  tumor,  hut  u  form  of  hy|)er- 
(ilasia.  A  tnie  adenoma  i>  nilateral,  circumscrilH'd,  nnd  •  ncapsulatcil. 
Mich  a  tinnor  may  Ije  a.s.si«<iate<l  with  fihrotnutous  ovr firrowth  (flbro- 
idenonu,  adenoflbrom*),  or  the  fihnxis  tissue  may  unde  z»  mucoid  or 
sinouiatous  transformation  (adraoiBTZonu,  adanoMnom.  etc.).  It  is 
tlie  imperfect  apprehension  of  these  considerations  that  nas  led  to  the 
nmitiplicity  of  natnes  that  have  l)een  propo.se<l  for  these  tiirnors,  stich  as 
aiienoid,  fihroadenoma,  and  aci^^nocele. 

i'lire  fihromas  without  any  admixt'iri  vith  glandular  sti  ictures  are 
rare,  .\.s  a  rule,  certain  ilucts  and  -.m.  '•  liecome  entai  rd  in  tite 
filimiis  ov'Tirowth  and  apiiearji    (ompD^Mil  and  atrophied  remnants. 

me  cases  the  dilatation 
can  differentiate  solid 


-  a  nile,  in  early  adult 
.ses  have  heen  met  with 
cystic  forms  are  found 
The  tun  or  usually  first  comes  in  cvi- 
ptierperium,  <>^  iug  to  the  discomfort 


(ir.  Hirain,  iiecome  distorted  and  dated.  In 
amoiwtts  to  cyst-formation,  so  th.  '  c'liiiieally 
aii'l  (v«fic  tihrernas.  Fihromas  iire  i!  't  witi 
tif-  fmm  the  age  of  sixteen  to  thirt  a  iiougt 
a>  .irly  .i^  velve  and  as  late  .is  fi-  ».six.  Th 
somewhat  later  than  tl  others 
deiiri'  during  meastruatH  -i  or 

it  cau-e-  at  such  time-  The  iwth,  as  a  rule,  forms  a  circumscrihed, 
PMi!!' !<•<!,  •<!  '1  nodi-'.ar  m;  -.,  fi  i  and  elastic,  projt-ctiiig  under  the  skin. 
i  ?'.!'  most  fnipient  site  is  f  f)  ■■  perijiiiery  of  the  hreast  almve  the  nipple, 
altr  ..;i;.'h  the  intra^niialici  siir  variety  is  apt  to  l»e  more  deeply  situated. 
Wh'  ,  <  yst.s  are  pre  they  ifiay  often  l»e  recognize*!  as  fluctuating  bosses. 
.\  t-:;j:,iile  ii  usu.";;y  f;:nnr!:  :;;  -h:it  the  gniwth  is  fn-cly  movable.  Fi- 
hnwia^  are  generally  -■>liti  ry,  hut  luitv  l>e  multiple,  or  even  affect  both 
main^n:p.  The  Vr  ■'  of  gr«>wth  i>  slow  and  the  tumor  rarely  attains  a 
lari'-'  'v.  Cystit  lorms  te  1  to  enlarge  more  rapitlly.  (\vsts  ar»  more 
!ike|-     .  Ije  found  in  ti"-  ot.  r  .        nts.     After  removal  local  re*  .  rcnce 


894 


THE  MAMMARY  GLAND 


has  been  observed  in  some  few  cases,  but  there  is  no  tendency  to  iiifiltra- 
tion.    Besides  the  nodular  form  just  described,  there  is  a  diffuse  variety 


Fio.  233 


Pericanalicular  fibroma  of  the  mammary  (land.  The  glandular  acini  and  duct?*  are  \>Tnmitm\t 
and  show  some  irresular  ovencrowth  of  the  epithelium,  but  the  main  feature  it*  the  dfveloitment 
of  connective  tissue  both  periacinous  and  inten*titial,  the  latter  not  »«harply  delintil-    iHibliert.) 


Fia.  234 


[i  t 


Intracanalioular  fibroma  or  intracystic  papilloma  of  breast.     (Ort'j  > 

in  which  the  whole  breast  is  liable  to  be  involved.  Here.  I'n'  tibroas 
ti.^ue  forms  cylindrical  sheaths  along  the  ducts  and  acini,  th'  siMalled 
plexiform  fibroma  of  Nordmann. 


FIBROMA 


sas 


On  section,  fibromas  are  firm,  fasciculated,  and  of  a  grayish  or  grayish- 
red  color,  and,  if  of  the  pericanalicular  variety,  made  up  of  an  agglomer- 
ation of  hard  nodules.  Should  there  be  dilatation  of  the  ducts  this  is 
evidenced  by  the  presence  of  numerous  minute  fissures,  or  even  cysts. 

Histologically,  we  may  differentiate  two  main  types,  the  periciinnlicular 
or  ptriglandidar  and  the  intracanalicular. 

Ill  the  former  there  is  proliferation  and  often  hyaline  transformation 
of  the  adventitial  connective  tissue  about  the  gland-tubes,  which  are 
usually  altered  by  mechanical  pressure.  The  newly  formed  fibroas 
tissue  surrounds  the  glandular  elements  as  a  well-defined  sheath.  This 
protliices  on  section  the  appearance  of  a  nodular  or  granular  surface. 
The  condition  of  the  interlobular  connective  tissue  varies,  at  one  time 
paHaking  but  little  or  not  at  all  in  the  hyperplasia,  while  at  othere  it  is 
increased  and  merges  almost  imperceptibly  into  the  adventitial  sheaths, 
thus  giving  rise  to  a  more  diffuse  fibrous  growth.  The  glandular 
tissue  preserves  more  or  less  completely  the  ordinary  arrangement  into 
lobules.  Should  the  various  ducts  become  obstructed,  as  not  infre- 
quently happens,  irregular  fissures  or  actual  cysts  are  produced  (fibroma 
cjiiiUciim).  The  fibrous  tissue  may  be  dense  or  cellular,  giving  rise  to 
hanl  and  soft  fibromas. 

In  tiie  intracanalicular  form  there  is  a  remarkable  overgrowth  either 
of  the  jHTiglandular  adventitia  or  of  both  this  and  the  interstitial  stroma 
into  the  lumina  of  the  duets  and  acini,  so  that  a  kind  of  cystic  tumor 
is  produced,  the  cavities  of  which  are  filled  with  conical,  nodular,  or 
leaf-like  ]  ojections,  giving  the  tumor  a  warty,  papillomatous,  or  cauli- 
flower appearance.  These  papillae  are  covered  with  epithelium  similar 
to  that  of  the  normal  glands. 

Fibroadenoma  and  Adenofibroma.— Here  we  have  a  combination  in 
varvinj;  proportions  of  hyperplastic  connective  tissue  and  adenomatous 
nevy-foriiiation.  Shouhl  the  glandular  elements  predominate,  we  have 
a  fihroadenoma;  if  the  fibrous  tissue  is  more  develope<l,  then  we  have 
an  adenofibroma.  The  glandular  structures  recall  in  appearance  both 
the  acini  and  the  ducts,  but  differ  considerably  from  those  of  the 
iiDrnial  gland,  being  more  numerous,  wider,  and  irregular,  with  pro- 
hferaliiiii  of  their  epithelial  lining.  With  this  there  is  a  more  or  less 
marked  increase  of  the  fibrous  elements. 

Takuig  the  intracanalicular  fibroma  as  a  prototype,  we  have  a  ri/xt- 
(idniojihroma  intracanaliculare  corresponding  to  it.  "in  this  the  papillary 
exm'scciKPs  are  present  as  l)efore.  but  the  fibrous  tissue  is  much 
minced,  forming  merely  a  delicate  central  core,  while  the  epithelial  cells 
have  a<lively  proliferated  and  are  heaped  up  into  masses.  In  other 
cases  adenomatous  structures  are  found  within  the  substance  of  the 
fibrous  outgrowths  (ntirnocele,  Virchow).  Owing  to  the  rapid  develop- 
ment ..f  the  papillary  processes,  the  cavities  of  the  gland  become 
frreat!;.  dilated,  so  that  cyst.s  would  be  produced  were  it  not  for  the  fact 
(hat  the  spaces  are  practically  filled  up  with  cauliflower-like  ma.sses, 
reduciiif;  the  cavities  to  fine,  collapsed,  and  ramifying  fissures.  The 
growth  may  be  so  exuberant  that  papillomatous  excrescences  appear  at 


896 


THE  MAMMARY  OLAND 


the  nipple  externally  or  burst  through  the  skin.     When  this  wciirs  the 
cyst-walls  are  perforated,  and,  owing  to  the  dislocation  of  the  out- 


Fio.  236 


Fibroatlenoma  «{  the  mamma  of  the  aciDoiu  type.     Winokel  obj.  Nu.  3,  wiili.mt  ocul«r. 
(From  the  oollectinn  of  Dr.  A.  G.  Nicholls.) 


Km.  230 


rt 


•<'•  r- 


ym'^ 


^. 


x^mjfi 


AdenoBbroma  uf  nwmnia.     Zeiss  obj.  DD.  without  ocular.     (From  tlie  i.  II.     ion  u(  Ibf 
Royal  Victoria  Huapilal.) 


CHONDROMA  AND  OSTEOMA 


807 


|Trowths  from  their  original  position,  their  place  is  left  free,  and  distinct 
cystic  cavities  make  their  appearance.  The  resemblance  to  the  papil- 
larj'  cystadenoma  of  the  ovary  is  striking.  The  cysts  when  present  art- 
filled  with  a  serous,  mucinous,  and  viscid  fluid,  often  stained  with 
hl(xxl,  and  sometimes  containing  fat-globules  and  cholcsterin.  Rarely, 
keratinizal  epithelial  masses  (cholesteatoma)  are  found.  Both  the 
fihroinas  and  the  fibroadenomas  are  liable  to  undergo  secondary  nuicoid 
or  even  sarcomatous  change,  while  hemorrhagic  infiltration  and  (edema 
are  also  common.  This  gives  the  tumors  on  section  a  very  varialilc 
appearance,  here  firm  and  fibrous,  there  soft,  grayish,  gelatinous,  and 
transparent. 

The  adenomatous  mixed  tumors  are  found  at  all  peritNls  of  life,  i>ut 
are  most  common  about  the  third  and  fourth  decade.  They  may  be 
quite  small  or  may  attain  a  considerable  size.  A  weight  of  twenty  kilos 
has  t)een  recorded.  The  rate  of  growth  is  sometimes  slow,  sometimes 
rapid.  The  growths  are  hemispherical,  definitely  lobulated,  and  some- 
what warty  on  the  surface.  At  first  they  are  freely  movable,  but  latiT 
l)ecoine  attached  to  the  skin.  While  they  tend  to  grow  rapidly  and 
orodiue  considerable  disturbance  in  the  neighborhood,  they  are  in  general 
to  Ik;  regarde<l  as  l)enign  growths,  as  when  removetl  they  do  not  tend  to 
recur  and  do  not  form  metastases.  When  they  do  return,  it  is  gt-ner- 
ally  l)e(ause  of  the  subsequent  development  of  a  small,  indejxMidcnt 
^niwtii  that  has  lieen  overlooked.  This  statement  is  not  without  ex- 
ceptions, however.  A  suspicious  feature  is  when  the  tinnor  masses  arc 
multiple  or  when  both  breasts  are  affected. 

Adenoma. — Pure  adenoma  is  a  relatively  rare  tumor  in  the  brt-ast. 
It  consists  of  a  fibrous  stroma  in  which  are  emlwdded  glandular  elements 
of  tile  type  of  acini  or  of  ducts  lined  by  cylindrical  epithelium.  Thus, 
»e  can  recognize  two  forms,  the  adenoma  acltiosum  and  the  ndciinmii 
lull  'i\  In  the  first  form  there  is  a  great  numerical  increase  of  the 
acir.;,  which  deviate  considerably  from  the  nonnal  in  that  they  are  not 
arraii^rcil  into  lobules.  In  the  tubular  variety  the  duct-like  striicturt-s 
are  evenly  scattered  throughout  the  tumor  or  are  aggregated  into  ^'r()U|)s. 
In  hotli  forms  the  interstitial  fibrous  stroma  is  looser  and  more  cellular 
than  tliiit  of  the  normal  breast.  The  tumor  i.s  usually  small,  circinn- 
sirilieii,  and  encapsulated.  It  occurs  in  young  women,  and  starts  as 
a  small  nodule  in  the  upper  and  outer  quadrant  of  the  mamma.  As  it 
enlarjres  it  In-comes  round  or  oval.  On  .section  it  is  firm,  s!n(K)tli,  rnd 
(.'rayisji-wliite  in  color,  and  a  milk-like  fluid  may  sometimes  Ik-  expressed. 

Lipoma.— Lipoma  does  not  occur  in  the  breast  proper,  but  in  the  con- 
nective tissue  behind  or  above  it. 

Myxoma. — ^The  niy.\oma  is  rare  as  a  pure  tiiinor  without  adinixtnir 
with  jriandiilar  elements,  but  mucinous  transformation  of  fibn)inas  and 
sarcoiiiiis  is  not  uncommon. 

Myoma.  Myomas  are  also  rare.  They  start  from  the  iinstri|ied  innsflc 
in  the  skin  or  almut  the  nipple. 

Chondroma  and  Osteoma. — Chondromas  and  osteomas,  either  as 
pure  uniwtlis  or  a.s.sociate<l  with  .san-oma  or  carcinoma,  an*  decidediv 


TT 


SOS . 


THE  MAMMARY  GLAND 


I. 


iincominoti.  ClioiMlromtis  are  more  frequent  in  dogs.  Cure  slioiild  I* 
taken  not  to  mistake  cysts  with  calcified  walls  for  these  growths. 

Angioma. — Angioma  is  .so  rare  as  only  to  nee<l  mention. 

Sarconu.  San-oma  of  the  breast  is  a  companitively  rare  affectidii 
forming  scarcely  4  jht  «ent.  of  the  tum«)rs  found  in  this  siiualioi 
(Minically,  ns  in  the  ca.se  of  the  fibromas,  we  may  have  solid  anil  i-ijtii 

Fio.  237 


niiimlrniim  fn.m  niuimiia  of  hitch.     .\t  one  iHiint  the  upwimen  »ho»»  a  iali:ii.   m 
Wjiiikel  iibj-  .N".  »,  without  mular.     (Fnim  llie  collp.>tiiin  of  \.  '!.  Ni.  Ij.ill 


,U.|..,-it 


:i  ; 


!    '■ 


forms,  ("vstic  .sarcoma  is  .sjiid  to  l)e  pe<'uliar  to  the  brea.st.  Siircoiiii 
form.wiien  pure,  unilateral,  circum.scrilml,  and  movuliic  imkIuIo,  iii 
occur  by  preference  in  girls  and  youngi.sh  women,  being  nmly  foui 
after  tlie  menopau.se.  In  this  re.s[)ect  they  differ  from  ciin  iiiciiui 
Occasionally,  they  form  diffu.se  nm.s.ses  and  are  found  in  botli  Iwasi 
Sarcomatous  tninsformation  is  not  uncommon  in  fibromas  ami  Iti  tihroi 
and  adenomatous  mi.\e<l  tumors. 

Histologically,  the  .solid  .sarcomas  are  couipo.sed  of  niixiil  '  i H-^.  >"" 
of  them  giant  cells,  round  or  spindle  cells.  Myxomatous  dm. mniiio 
hemorrhage,  nei-rosis,  t alcification,  are  not  infnHjuent  (..mpli.atioii 
Sometimes  the  ctmijMHient  cells  a.ssume  an  alveolar  arrangtim  in 

AiiifliMdrriunn  (jierithelioma  malignum')  has  l)een  dcsi  ril««l.  siiirtii 
from  the  ailventitia  of  the  vessels.  As  curio.sities,  may  !m  inenti"iit 
inrltiiiolif  siirromn  and  rovnH-relhff  mn-nnw  containing  >'■•    '"'  "'"•"■' 

Cystic  sarcomas  are  strictly  comparable  to  the  cysi.il.  iinHlmiii 
intracanaliculare  l)efo«-  n-ferretl  to,  which  they  greatly  ns(  n  '  .l>-.  1 1'*" 
tumors  arc  found  in  early  atliilt  life,  and  form  large  !»>  ■     Mi.nilei 


ill.  a 


CARCINOMA 


fm 


pi>wtlis  imperfwtly  encapsulated.  On  section  thev  present  irregular 
clefts  or  spat-es  filled  with  niucoid  or  hlo«l-staineil  fluid,  into  which 
|)n)j<(  t  numerous  villi  or  papillary  excrescences  {cyiitwMrcomu  phulMeg) 
Mi(  roscopically,  these  papilla-  have  a  c-entral  core,  not  of  onlinarv 
fihn.iis  tissue,  hut  of  a  highly  cellular  and  vascular  tissue  conipo.se«l  of 
rouii.l  and  spirulle  cells.  Myxomatous  and  degenerative  changes  mav 
lie  foiind. 

Involvement  ,i  the  chest  wall  and  the  skin  is  much  less  ftwiuent 
than  in  the  case  of  carcinoma,  although  the  pectoralis  major  is  .x-casion- 
ally  infiltratwl.  Lymphatic  enlargement  is  rare  in  sanoma,  and  when 
It  .Kcurs  IS  due  usually  to  inflammatory  or  other  irritaiion  and  not  to 
sarcomatous  invasion.  The  metastases  arise  through  the  Mood  stream 
ami  the  lungs  are  early  affected. 

Cucinonu.— The  breast  is  one  of  the  most  freipient  sites  for caninoma 
4(1  per  cent,  of  all  ca.ses  of  carcinoma  l)eingfouml  in  this  region  (Williams)' 
The  average  age  at  which  it  is  first  di.sc-overwl  is  fortv-eight,  most  cases 
Imua  nut  with  shortly  More  the  .nenopau.se.  It  is  ra're  liefore  the  age  of 
thirtv-Hve  and  in  advanced  life.  Instances  have,  however,  l)een  reconled 
uiuler  twenty  (Boussereau)  and  as  late  as  ninetv-four  (C'olev').  When 
not  .)|»  rate<l  upon  the  average  duration  of  the" disea.se  is  27.1  months 
((m)s>  .  Some  ca.ses  have  l)een  known,  however,  to  run  a  chronic 
crnrse  ..f  from  five,  ten,  fifteen,  or  more  years.  One  authentic  case  is 
rwonied  where  the  di.sease  laste<l  more  than  tliirtv  vears.  The  scirrhous 
ivpe  IS  the  one  most  likely  to  run  a  prolonge<l  course. 

(•aninoma  may  commence  in  any  part  of  the  l.reast,  lieiiig  found 
ileeplv  seated  or  imme«liately  under  or  alMHit  the  nipple.  A  favorite 
imsition  IS  ,n  the  lateral  portions  of  the  gland.  It  .xrurs  both  as  a 
.iminiscrihed  n.Klule  or  as  a  diflFuse  infiltrating  gmwth  Clinically 
we  re(o;:mze  suj>Prficial  and  deep-.seatd  forms.  In  the  former  cla.;s 
an- UK  .Kleil  epithelioma  and  miliary  carcinosis  (sciuirrhe  disseminee)- 
n  the  latter,  hanl  and  soft  forms,  such  as  scirrhus,  car.  medullare 
ilfn(Har(in()ma,  car.  gelatinosiim. 

.\  ran-  fonn  of  can-inoma  is  it(iuamou.s  rpithellomii  ( Paget 's  disease  of 
the  nipple;  malignant  papillary  dermatitis;  superficial  carcinoma  of 
ttiesknii  ihis  affection  at  first  assumes  the  appearance  .f  .  chroiii,- 
«zeiiiH  of  the  nipple.  In  time  the  nipple  is  .lestrove.1  an.l  e  disease 
-prt-ads  oyer  the  surface  of  the  breast  an.l  eventuallv  invade,  le  deeper 
parts^  he  ii  cer  prinliK-ed  is  slightly  rai.se<l,  with' sham  clges.  and  is 
"I  a  Ijnd.t  re<l,  raw  appearance.  Secretion  is  scantv.  At  fiiNt  there  is 
Lfil!  ■'""*•'  i  !  ^  «'P't»ielium  of  the  nipple.  f„||nwe,l  l.v  an  inflammatorv 
WtniiiuM  of  the  sulK-pithelial  layeiN.  After  a  longtime  the  pn.lifer- 
tini:  epithe  lal  cells  reach  the  galactophoroiis  ducts  an.l  form  a  more 

n«f  •  l'."';i    "*i ';""'"'  "^  •''^  "'"•''  ^l"""'""-^  type,  with  epithelial  cell 

nws  1 1  trlkiigeln).  ' 

Allot!,,  r  rare  variety  is  the  acute  milian,  rnrri,„K„\  „r  .lissemiimted 

'  Itefer.  Haiiilli.  .Med.  Soi..  1>:  liKIl :  (>2<». 
'St.  Unrtholonuw's  Hosp.  |{,.|,,^  IS7J.S7. 


900 


Tim  MAMMAHY  GLAND 


t\\ie 


stirrhus.  In  170  cases  ivconle.1  by  Williams  only  2  wer^  ..f  tin  ,. 
It  iH-Kins  supertitiullv  ami  apF""  t»  spread  by  nieaiw  of  the  lymi.  latio 
Tlie  .leeper  forms" of  cait- moma  are  conveniently  divMletl  acconlin^- 1, 
the  am.)unt  of  connective  tissue  they  contain  into  scirrhoas  <art  iiu.ma 
c  simplex,  an.l  c.  me<lullare.  The  clinicians  are  in  the  habit  of ,  lass.fv 
inu  them  into  hanl  ..r  scirrhous  an.l  soft  forms.  It  shoul.l  l»e  rvinarke,! 
however,  that  many  tumors  that  have  all  the  characters  of  scirrlniso 
uhvsical  examination,  when  examine.1  micrtxscopically  are  realiv  simpl 
cancers.  In  fait,  a  pure  scirrhus,  histologically  consuleretl,  is  one  , 
the  less  common  types  of  carcinoma.  Consequently,  there  is  a  l.al.il.t 
for  some  confusion  to  arise  in  the  use  of  the  term.  A  further  p..int . 
considemble  importance  is  that  any  Kiven  carcinonia  is  rarely  of  .me  ivi 
thn.ui!hout.  It  may  be  scirrhous  in  one  part  ami  simple  can'ii.oma  i 
another.  pn)ving  the  necessity  .>f  a  careful  examination  of  all  parts , 

the  growth.  _  ,  »    ^i    . 

The  forms  just  mentioned  conform  more  or  less  perfe<tly  to  an  a<'in..i 
type  of  growth,  but  there  are  other  forms  in  which  the  ep.tlulial  eel 
are  arranged  in  a  tubular  fashion  somewhat  resembling  ducts  ,./,/,. 
carcinoma),  ami  still  others  that  are  cifntic.  .....  . 

Scirrhous  carcinoma  l)egins  as  a  small  nodule  within  the  breast  It 
not  so  .sharply  defined  .vs  a  fibroadenoma,  as  it  is  not  em■apsulat.^l,  a. 
s.K.n  becomes  more  or  less  immovable.  It  is  knotty  on  the  surface  ai 
somewhat  flattened,  with  roimded  outgrowths  from  the  inarirm. 
consistency,  it  is  extremely  hanl,  without  much  elastinty.  a.ui  ...nve 
t,.  the  examining  hand  a  suggestion  of  weight  rather  than  size.  I.;it. 
fixation  to  the  skin  inrcurs,  which  Inn-omes  immovably  adherent  «: 
some  .limpling.  C^nly  when  advanced  does  the  tuin.)r  project  a  u, 
the  Keneral  level  of  the  breiust.  In  many  ca.ses,  where  the  larirer .  ii, 
pre  implicatetl.  it  is  impossible  to  draw  the  nipple  for^var,l.  an.l  h. 
on  the  nipple  is  actually  retracted.  In  cases  that  are  ncs;lnte,l  i 
tumor  becomes  attached  to  the  chest  wall  aiul  mav  ulc.raf  on  i 
surface.  The  breast,  as  a  whole,  is  often  flattened  an.l  it^  v.'lni 
diminislml.  When  cut  into,  the  growth  is  hard,  no<liilar,  an.l  tilmi 
often  showing  radiating  bands  of  cnnective  tissue  an.l  yell..wwl.  patch 
In  el.lerlv  people  it  is  not  uncommon  to  fiml  small  inv.>lutu.ii  .v.ts  hll 
with  a  velLwish-green  flui.l ,  resembling  pus  or  colostrui... 

Hist.')logicallv,  the  careinoma  cells  proper  are  small.  inon.Muule 
aiul  atr.)phic  Im.king,  arrange.1  in  small  islets  or  elougatnl  row-  i 
fibrous  tissue  is  relatively  greatly  increase.  ,  .s..  that  the  c,mhclml  o 
have  the  appearance  ..f  iR-ing  .•oinpresse«l.  I  ml..ubl.'.il^  liierv  .• 
proliferation  ..f  the  interstitial  stn.ma  as  well  At  the  ,.,  riphen 
type  of  gr.)wtli  is  apt  to  l)e  softer  ami  more  cellular  than  m  the  cent 
ronseciuently.  in  s<irrlius  the  metastases  are  frcpiently  ..t  lit.  -nnplex 
medullarv  ts'p*'-  'l'*!''  amount  of  fibrous  tissue  may,  in  -  -; 
so  great  "that  at  first  sight  the  new.gr.)Wth  re.sembles  scar  w 
than  a  tumor.  In  the  most  a.lvance.1  forms  of  this  tyjK'  i,;.^ 
cells  are  largely  .legenerate.1  ami  reiluml  to  .lebris,  w  • 
arouiKl  is  atrophic  and  sclerosed  {canrrr  atrophican.'<}. 


c:t-e«. 

■lie  rut 
.■anijKi 
the  li'^ 


ti 


CARCINOMA 


901 


ducts  Kliiiini- 


Iri  rarcitwma  limpUx  the  rlinit-al  features  are  practitally  the  same  as 
in  thi'  case  of  stirrhus,  except  tliat  the  gruwth  is  more  rapid.  The 
tumor  is  rounded,  nwiular,  very  hard,  and  is  apt  to  be  much  larger 
than  in  the  scirrhus,  causing  marked  pniniinence  of  the  l)reast. 

MI(  roscopically,  however,  tlie  appearances  ciiffer  consideral)ly.  The 
epithelial  cells  are  larger,  more  rounded,  and  with  relatively  more 
pn)t«>|.lasrn.  They  are  also  much  more  ahunilant,  both  aetuallv  and 
relatively,  so  that  cells  and  stroma  are  about  e<jual  in  amount.  '  As  a 
rule,  the  growth  tends  to  a.ssume  an  alveolar  type. 

The  mediUlary  or  encephaloid  carcitumn  is  much  more  rapid  in  its 
development  than  the  scirrhous  form,  an<l  may  attain  a  large  size.  It 
is  soft,  va.scular,  rounded  in  form,  and  cammt'lie  <lifferentiate<l  on  pal- 
pation from  the  breast  substance.  It  offers  to  the  hand  a  sensation  of 
fluetuation.     Hetraction  of  the  nipple  does  not  owur. 

Histol«)gically,  the  epitlielial  elements  are  abun«lant  and  the  stroma 
is  re<liice<l  to  fine  delicate  fibrilla?.  In  all  the  softer  <aRinomH.s  the 
interstitial  tissue  is  looser  and  more  cellular  than  in  the  scirrhous  form. 
It  is  rommon,  therefore,  to  find  a  markeil  cellular  infiltration  at  the 
periphery  of  the  growth  an<l  round  alniiit  it.  These  c-ells  do  not  suggest 
the  ( haracter  of  exudate  cells  or  leukocytes,  but  are  of  the  granulation 
t\pe.  with  a  single  round  nucleus. 

Ma< r(xs<opically,  the  .softer,  more  acinous,  careinomas  are  somewhat 
noilular  on  .section  and  of  a  grayish-re«l  color.  A  milkv  juice  mav  be 
.)l)tai(ie«i  on  scraping.  The  conneitive  tissue  l.etween'  the  can(cn)us 
masses  appears  as  grayish,  glistening  bands.  The  mcdullarv  form,  how- 
ever, is  pulpy  and  brain-like. 

Ocrasionally,  the  caninf»ma  simplex  undergties  a  colloid  or  gelatinous 
-lejseneration  (c.  gelutinoaum).  This  occurs  chieflv  in  the  older  portions 
"i  the  ^Towth,  while  the  periphery  pre.sents  the'  onlinary  features  of 
larcinoina.     Here,  too,  there  are  no«lular  and  diffuse  forms. 

In  the  larger  masses  of  epithelial  cells  it  is  not  unusual  to  find  fattv 
cla-eii.  ration  ami  even  extensive  necrosis  of  the  central  portions.  Hya- 
Ime  (lenenenttion  of  the  fibnius  stroma  and  calcification  are  rare. 

U  mMiirclmmii. —'iWs  is  a  term  applied  to  a  growth  having  a  special 
histol-vK-al  structure.  The  general  resemblance  to  the  acinous  and 
lohiilar  arrangement  of  the  normal  gland  mav  be  fairlv  well  preserve«l. 
rhe  eiMthelial  cells,  however,  have  proliferate«l  into  the  lumen  of  the 
liKLs  an, I  into  the  lymphatic  spaces.  The  appearances  varv  in  different 
portion,  of  the  tumor.  In  one  part  there  may  be  normal  gland-tissue; 
inanotlur,  numencal  increase  of  the  ducts  with  enlargement  and  dila- 
tation an.l  some  proliferation  of  the  connective  tissue.  The  amount  of 
t-aninMinatous  invasion  of  the  .stroma  varies  considerablv  in  different 

TTi  1^'  ''""^'^  '***'*  '""'^'  '"^  ■'«'a""fl.v  an^-  I"  other  cases  the  epi- 
Wial .  l.-.nents  extend  into  the  lymph-phanriels  and  form  .small  clu.sters. 
}^  -?r  :.,a  i.s  never  so  den.se  and  fibrillar  as  in  the  case  of  the  scirrhus. 
Ihe  epitlielial  cells  are  similar  to  those  of  the  normal  acini,  but  are,  as 
a  rule.  !ar>:er  and  polymorphous. 


\yo2 


THE  MAMMARY  GLAND 


riiiiically,  the  gn>wth  is  rather  hanl,  and  a  sen>iw  «listharf?e  from  th 

nipple  is  not  uncommon.  ,      , ,  ,  .•       i     i.i      , 

One  or  two  cvstic  forms  of  caninoma  should  be  mentionwl.  ultlidunl 
they  are  rare.  In  the  first  variety,  there  is  a  single  main  cyst  with  siihk.i! 
wails,  varying  in  size  from  that  of  a  walnut  to  that  of  an  appl.-.  A 
one  point  of  its  surface  there  crops  out  a  grape-hke  or  papillci.mtou 
mass  sometimes  pit)vide<l  with  a  pedicle.  The  warty  excres<eiu rs  ma 
\^  .edematoas  and  juicy  and  on  microscopic  examinatmn  pn.v,-  to  , 
carcinomatoiLs.  In'ing  composed  largely  of  columnar  cells.  ( )rtli  think 
that  the  growth  originates  in  a  milk-duct,  which  then  Incomes  .lilate 
and  finally  hypertrophie.1.  In  other  cases  we  have  a  carcinoiiiatoii 
growth  combine.1  with  numerous  small  cysts  of  the  proliferation  typ 
{cyntadenocarnnoma).  .        ,      ■..    i- 

There  can  lie  little  doubt  that,  with  the  exception  of  epithelioma  an 
the  columnar-celletl  variety,  carcinoma  of  the  breast  in  many  mstancj 
originates  in  the  lobules  of  the  glaml.  for  in  the  older  p<>rti.>i.s  of  tl 
growth  the  acinous  arrangement  can  still  often  lie  recognize.!. 

The  epithelial  cells  proliferate,  filling  up  the  lumina  and  hiulmp 

ililatation  of  the  spaces.    The  hyaline  membrane  of  the  tunica  so* 

.lisappears.  although  the  .spindle-celled  layer  is  longer  preserv  !,  a. 

finallvthe  glandular  elements  break  through  the  membrane  an.  appe 

in  the  stroma,  when  extension  continues  along  the  lymphatics.   ( )n.f  ii 

pnx-ess  is  well  established  it  soon  extemls  into  the  neighboring  l.)l)uh 

which  thus  liecome  infiltrated  with  careinoma.     While  only  a  portmii 

the  lobules  are  likely  to  be  involved  in  the  cancerous  overgrowth,  it 

usual  for  l>oth  the  glandular  and  the  interstitial  structures  <.f  the  n 

of  the  mamma  to  proliferate.  •  <;  ^' 

Careinoma  of  the  breast,  if  left  alone,  does  not  remain  conhned 

the  glandular  substance,  but  gradually  extends  to  the  n.^.f:hl.on 

struc-tures.    The  skin  becomes  involved  and  is  found  to  be  hxe.l  to  t 

tumor  ma.ss.     It  is  reildenetl,  inflamed,  and  in  time  the  growth  l.tir 

thn>ugh,  forming  a  foul,  excavated,  and  suppurating  ulcer.    N-"i,.  a 

n<Khiles  form  also  in  the  pectoralis  fascia,  the  pectoralis  itself  a.ul 

time  inva«le  the  thoraoic  wall  and  even  the  pleural  cavity  aii.l  the  Im 

Thus  the  tumor  liecomes  attached  firmly  to  the  thoracic  wa.l.    n 

extension  takes  place  by  means  of  the  lymphatics,  ami  distant  m.^tasia. 

are  produced  al.so  through  the  dissemination  of  .small  niass.s  of  .a,  - 

cells    through    the    .same    channels.     Occasionally,    smnlu     .r<>nrt| 

noduies  form  in  the  skin  and  sulx-utaneous  tissues  f,)llow..l  hv  .hit. 

c-areinomatous  infiltration,  whereby  the  anterior  thoru.u'  wall  U.^n 

converte.1  into  a  .stiff,  .swollen,  sclercedematous  m^j  (c,wr<  r  n.  ,;nm 

Panzerkreb.s),  which,  in  tiin  .   my  -show  superficial  "l*'''j'"""-  J 

is  rare,  l>eing  only  ob.serve.1  .  .  two  ca.ses  of  our  «"»'•''•    .^'"."V" 

have  taught  that  the  condition  :.  here  confined  to  the  skin.  I.ut  tl..> 

undoubte.llynottheca.se.  ..„.,,        u    i      il-wlns 

The  distant  meta.sta.ses  are  met  with  first  in  the  lyinph-ghm'l^  "<•« 

anatomical  relation.ship  with  the  part  of  the  breast  atfecte.1.    .Vs  a  n 

the  axillarv,  infraclavicular,  and  supraclavicular  glands  .r.  moi^ 


PLATE  X 


Neglected   Carcinoma   of    Bieast.     (Brewer,  j 


w 


*  1 
il  ! 


CYSTS 


WKt 


in  iIh-  kt  niven,  aiiti  lir<-«jine  hani  ami  shitty.  It  should  Ik-  iuiIciI, 
howivcr,  that  the  eniarf^ement  is  not  invariably  diie  tc»  inetustati*-  il^ixisit! 
for,  ill  the  early  stages  at  least,  it  may  Ik-  causeil  by  influniniation  or  M.nie 
()th«T  uH  yet  unileterniined  irritation.  We  have  more  than  onir  Mfii 
(Hseoiis  tulierculiwis  of  the  axillary  glands  in  association  with  cttninonia 
of  tlif  breast.  When  the  growth  originates  in  the  inner  jMmion  of  the 
hnust  the  glands  of  the  anterior  mediastinum  are  liable  to  l»e  involve«l, 
.>r«'v»'!i  those  of  the  opposite  axilla.  In  the  former  case  exteasion  to  the 
liver  iiiiiy  follow.  The  eareinoinatotw  invasion  l)egins  at  the  |)eripher)- 
of  thf  mules,  which  may  Itecome  !mm\  together,  and  may.  in  time, 
fxteiKl  to  the  neighlnmng  tissues.  The  t.vpe  of  growth  pn»d'iK-e.l  in  the 
irfaniU  is  not  necessarily  identical  with  that  of  the  origiiiMl  tumor.  Vis- 
(f  nil  im>tHsia.ses  rarely  arise  until  after  the  involvement  of  the  Ivmphatic 
){laii(ls  is  well  markeil.  They  occur  asually  in  the  lungs,  liver,  and 
l.r.1111.  mid  are  most  prolmbly  hematogenic 'in  origin.  Metastatk-  in- 
volvement (rfthe  Inmesalso  is  hematogenic,  and  is  relati\ely  morecimimon 
in  iIh  siirrhous  or  .s<ler(»sing  cancer.  The  In.nes  affecte<l  are  the  hea«l 
of  thf  humerus  t)n  the  same  side  as  the  origina!  tumor,  the  vertebrie, 
the  steniiim,  and  the  upper  eml  of  the  femur.  The  growth  liegins  iii 
the  medulla,  but  the  .shaft  may  in  time  lie  enxl  \l,  m  that  spontuiieous 
fractures  or  compression  <)f  the  spinal  c«)nl  sometii.^.es  occur. 

it  iiiifiht  further  l)e  remarked,  as  a  matter  of  interest,  that  the  mamiiuc 
are  not  iiifrwjuent  sites  for  multiple  independent  growtlis.  We  have 
twiee  (iliserved  simple  carcinoma  attacking  both  breasts  simultaneouslv. 
ITiese  multiple  grf)Wths  are  not  always  of  the  same  type,  however;  cpi- 
ihenomii  has  lieen  oKserved  in  one  breast  ami  glamliilar  carcinoma  in  the 
other.  Two  ca.ses  also  have  l>een  reported  of  carcinoma  in  one  breast 
and  aii^oosaif  oma  in  the  other. 

("as«<>us  tiiljenulosis,  with  epithelioid,  giant  cells,  and  tuliercle  bacilli, 
has  Ihsii  fcuind  in  mamnuiry  carcinomas  (Warthin'). 

Cysts.— The  simple  cv^ts  found  so  often  in  the  involution  peritMl  of 
the  lireast  ami  the  cysts  associated  with  sarconin  ami  carcinoma  have 
alreadv  JHri,  referretl  to.  Besides  the.se,  we  have  as  rarities  Echinoci>ccm, 
Cj/fturrniM,  and  Dermoid  cysts. 

Of  more  importance  are  those  dilatations  of  the  milk  ducts  and  acini 
that  .ontam  milk  (galactocele).  These  occur,  of  course,  onlv  in  the 
fuiictmiiiii};  breast.  \NTien  obstruction  takes  place  in  a  large  <luct  lu-ar 
the  nipple,  a  conl-like  sw.lling  can  Ire  felt  l)eneath  the  areola  wliicli 
Uradiwilv  extends  towanl  the  periphery  of  the  breast.  In  the  event  of 
olwtriuiioii  in  the  lobules  the  enlargement  is  more  deep-seated.  Then' 
IS  no  iMlhnnnmtion  ami  but  little  pain.  The  increase  at  first  is  rapid. 
Imt  iliiniiiiition  in  size  may  occur  after  lactation  has  ceased.  In  sonie 
<ast>s  siii^dc  large  cysts  are  produced  having  an  oval  shajM?  an.!  smcnrth 
"iilhne.  Occasionally,  if  the  wall  of  the  cvst  has  j;iveii  wjiy  .it  some 
part  aii.l  its  contents  have  escape«l  into  tlie  surrotmding  ti-ssues,  the 
cyst  Ls  more  lobulated.     .Scarpa   has  recorded  a  well-known  ca.se  in 

'  Amer.  Jour.  Med.  .Sci.,  118  :  1890  ;  25. 


fNI4 


THE  MAMMARY  QLASD 


I- 


wliifh  thp  I'y.xt  fontainetl  ten  pounds  of  milk.  After  a  time  »\m\ 
of  thf  motv  ttiiiii  parti  of  the  milk  may  oct-ur,  aiwl  the  cv.tt  is  foi 
coiitnin  a  i-rean-  >r  ^uder-like  substance.  Oec-a.>«ionaliy  the.M- 
supnumtt'  or  hei  or  \\»^  <jrcurs  into  the  cavity. 

1  he  male  breas  s  liable  to  the  same  affections  as  the  female,  I 
rourw,  nitieh  less  frequently,  having  reganl  to  its  unlinarily  nHliim 
condition.  Chronic  mastitis  and  many  forms  of  tum<>rs  havr 
met  with. 

In  relative  frequency  as  compared  with  those  of  the  female  brea« 
are  as  '.\  to  1(X).  The  nuut  common  tumor  is  carcinoma,  ((eixritltv 
simple  (yj»e.' 

'  I  sani  with  regard  to  the  varii>«w  forms  of  ii 

.ill  readily  In;  gathered  that  there  mu-st  ofi 
<r  nir  u  differential  diagnosis  l)etween  llie  v 
.'  Ity  is  not  so  great  for  the  morbiil  uitstoniis 
>i,  and  in  any  ca.<)e  will  have  the  mi('nMco()('  ( 
che  most  careful  investigation  is  in  all  cases  iic<v 
and  even  then  in  many  ca.ses  the  clinician  will  often  ))e  at  find 
view  of  the  importance  (»f  the  subject  we  give  the  ac-companyii^ 
for  differential  diagnonis,  which  presents  the  chief  anatoniii-a 
clinical  features  of  the  comlitions  most  likelv  to  be  confused. 


Fntm  w^hat  has 
mation  and  tumo 
great  difficulty 
conditioas.    'I , 
will  rarely  \w  ii 
him,  but  duriu) 


'  Wnrfii'lil.  Carcinoma  of  the  Male   Breaat,  John*  Hopkinii   lIoHpital   It 
12  :  lilUI  :  na. 


time  altsorpiii 
■  cv.tt  is  found  t« 
ally  thes4- 


v\sU 


e  (emair,  hut,  of 
trily  nNliniciitan 
iii«>rs  huvi-  liprn 

■mal**  biviist  ihfv 
,  ({eiwrttll\  of  tlir 

forms  of  iiiflam- 
re  must  often  bf 
vtrn  tlir  variiiii- 

I  Hitiitoinist,  wh. 
k'n»<ico|)t'  Id  lifli 

II  ca-sfs  iH-ces^sjir 
l)e  at  fiiiill.  In 
smpanyiiii;  talilr 
anatoniiial  ainl 
'use<l. 

Himpital   KiiUnin 


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SECTION    VIII. 
THE  TEdUMENTARY  SYSTEM. 


CHAPTER    XLI. 

THE  SKIN  AND  ASSOCIATED  STIUCTl'RES. 

THE  SKIN. 

Thk  skin  is  a  somewhat  complicatefl  stniPture,  composed,  as  it  is,  of 
an  outer  e|)i<lermal  layer  of  flattened  and  horny  cells  restinjj  upon  a 
siilHiitaiieous  cushion  of  fat  and  fit  rous  tissue,  in  the  deeper  layers  of 
wliicli  lire  the  hloodves; els,  nerves,  tactile  corpuscle;;,  hair-follicles, 
sU(lori|iar(>us  and  sebaceous  jjlamls. 

In  accordance  with  its  stri:.-ture,  the  skin  performs  numerous  and 
important  functions.  It  is  the  or);an  of  tactile,  painful,  and  thennic 
sensation.  It  acts  as  an  external  protective  covering,  regulates  the 
iMxIily  heat,  and  to  some  extent  exercises  excretory  and  respiratory  func- 
tions. 

.Vs  one  would  expect  from  its  structure  and  expasetl  position,  as  well 
as  from  the  fact  that  it  is  in  close  physiological  relationship  with  many 
of  the  internal  organs,  sue''  as  the  heart,  kidneys,  nenous  .system,  an<l, 
indirectly,  the  liver  and  .se.«:ual  apparatus,  the  .skin  is  su.sceptihle  to  a 
great  variety  of  disturbing  influences,  and  its  disonlers  are  con.sefjuently 
nmneroiis. 

OONOENITAL  ANOMALIES. 

\  remarkable  and  rare  congenital  affection  is  ichthyosis  congenita, 
a  (ondilion  characterized  by  overgrowth  of  the  epidermis  with  a  marke<i 
tendeiK  y  to  cornification  of  the  superficial  layers  (keratosis).  The  dis- 
ease usually  involves  the  whole  or  the  greater  part  of  the  btxiy,  but  may 
lie  l(M  ali/tHl.  In  the  mildest  form,  there  are  merely  small,  papular  eleva- 
tions iiliDut  the  hairs,  due  to  proliferation  and  keratosis  of  the  cells 
at  the  mouths  of  the  follicles  (jvrai/.»,  xertMlermii),  and  all  inter\-ening 
grades  limy  Im>  found  up  to  the  pnMltution  of  large,  flattened  plaques 
and  sciies  of  horny  texture,  .so  that  the  skin  resembles  that  of  a  fish 
urallii;  itor  (irhthy(mn  murodrnmi).  As  the  growth  of  the  Ixxly  goes 
on.  the  t  scales  l)ecome  separate*!  more  and  more  one  from  the  other,  and 


90S 


THE  SKIS 


the  skin  becomes  lined  with  fissures  and  furrows,  while  the  sc-alcs  turn 
itp  somewhat  at  the  edges.  The  fine  hairs  are  implicated  in  the  over- 
growth.    The   fingers  and   toes  may  be  so  affecteii  that  they  remain 

Microscopically,  the  epidermis  is  greatly  thickened,  the  plaques  \wmfi 
compttseil  of  dense,  laminated,  keratinous  material,  which  exteiuis  to  the 
papilla?  and  even  into  the  dilatetl  hair-follicles.  The  cells  in  the  deeper 
layers  of  the  cutis  are  shrunken  looking.  Fragmentary  and  atrophied 
hairs  may  be  found  eml)edded  in  the  horny  sulstance. 

Absence  of  the  normal  pigment  of  the  skin  is  a  not  unconinioii  con- 
genital peculiarity,  known  as  lenkodenu  or  lenkopathia  congenita  or 
albiniim,  as  oppwieil  t(  leokopathia  aeqniuU  or  vltiUco. 

Fio.  238 


Piumenled  nfvus.     (Hyde.) 

All)inism  mav  affect  the  pigmentetl  structures  of  the  body  as  a  whole, 
skill,  hair,  iris,  and  choroid.  The  affected  persons,  called  ail)irH).s 
have  clear,  white  or  rosv  transparent  skins,  white  or  yellowish-tthite 
silkv  iiair,  and  pink  eves.  In  partial  albinism  there  may  l.e  wiiitbh 
streaks  on  the  skin  in  various  parts  of  the  body.  The  condition  is  said 
to  l)e  hereditary.  .  . 

An  excess  of  pigment  is  found  in  certain  of  thenevi  orl.irtlimark.' 
(ntBvi  pigmentosi).    '1  iicv  vary  in  color  from  pale  brown  to  lilink. 

Congenital  hypertro^ihy  of  the  nails  (hyperonychia)  is  fouii.i  :i^sociate.l 


CIRCULATORY  DISTVRBAXCES 


909 


with  ichthyosis.  Absane*  or  imperfeet  development  of  the  nails  is  also 
met  with. 

The  hair  may  be  abnormally  scanty  or,  rarely,  completely  al>sent 
(ilopecU  congenita  nnivenalis).  This  is  often  accompanied  by  imperfect 
development  of  the  teeth  and  nails. 

Excess  of  hair,  hypertrichoiii  (hirsuties,  polytrichia),  may  be  local  or 
involve  the  body  as  a  whole.  Universal  hypertrichosis  is  usually  inherited 
and  affects  several  imlividuals  in  the  same  family.  The  whole  body, 
except  perhaps  the  palms  of  the  hands  and  the  soles  of  the  feet,  may 
I*  covered  with  long  hair,  giving  the  individual  a  striking  resemblance 
towrtain  of  the  lower  animals  (hairj-  men,  dog-face<l  or  baboon  men). 
Local  h\-pertrichosis  is  met  with  in  the  naviut  piloum,  an<l  on  the  sacrum 
in  a-'^iK-iation  with  concealed  spina  bifida. 

Fiu.  238 


KxleiiMve  verruci>He  anil  "|Hirt-wine"  nevut*:  inacn>dactyly  and  microdactyly. 
(Dr.  .\.  K.  Vipond'H  ca'W.) 

.\  common  anomaly  of  the  .skin  is  the  .s(>-calle<l  "birthmark"  or  nevtis, 
which  is  met  with  in  the  form  of  large  or  small,  well-<lefine<l,  re<ldish  or 
puq)lc  patches  {ikbvu^  iHisculo.tu,H,  port-wine  stain),  soft,  nodular  e.vcre.s- 
(•ences  or  warts  {iiwvus  verrucoxua),  or  local  diffuse  thickenings  of  the  skin 
[dtph(inViasis).  In  all  these  there  is  a  local  anomaly  in  the  arrangement 
Kill!  development  of  the  bloodve.s.sels.  Some  nevi,  again,  are  level  with 
tlie  skin  ( navm  spllus) ;  others  hairy  (jiavus  piloxim). 

Ssborrhon,  or  excessive  se<'retion  of  the  .sebaceous  follicles,  is  occasion- 
ally met  with  at  birth  and  afterwanl.  Here,  the  vernix  caseosa  or 
sinejiina,  which  is  normally  present  on  the  .skin  of  the  newborn  infant, 
persists  into  later  life. 


OIKOULATORT  DISTURBANCES. 

The  amount  of  blood  in  the  skin  varies,  of  course,  widely  at  different 
tunes,  even  under  physiological  conditions,  as,  for  instance,  under  the 
mfliieiK  »■  of  exerci.se,  heat,  cold,  and  emotion.  Pathological  hyperemia 
iieeurs  as  a  diffu.se  blush  over  an  extended  area,  or  in  small  spots  and 
patches. 


910 


THE  SKIN 


Hypcrania. — Aetire  H]rp«reini». — Active  hyperemia  is  fntiiul  in  thi 
first  staj?e  of  inflammation,  in  vasomotor  disturbances,  expasure  t()  cmts 
sive  heat  or  cold  (erythema  pernio),  and  as  a  result  of  slight  injuries 
such  as  are  caused  by  mechanical  or  chemical  irritation.  I^rp-  patche 
of  hyperemia  are  termetl  erythema;  small  spots,  roseola.  Tlie  loio 
is  a  pale  rose  pink,  and  disappears  on  pressure,  only  to  return  instantl; 
when  the  pressure  is  removed.  Erythema  is  not  infrequently  assiHiatei 
with  exudation  of  plasma  and  swelling  (inflammatory  owlema),  ami  whe 
long-continued  or  repeated  may  lead  to  pigmentation  of  the  skin,  owin 
to  diapedesis  of  the  retl  cells  and  metamorphosis  of  the  heniofjlohin. 
Puiive  Hypcremi*. — Passive  hyperemia  is  well  seen  in  chronic  valvula 
disea.se  of  the  heart  and  other  conditions  which  favor  blood-stasis,  sue 
as  pneumonia,  toxic  states,  and  sunstroke.  The  lips,  face,  neck,  and  th 
extremities  often  present  a  diffuse  dusky  blue  or  leaden  color  (ciiiiinmn 
A  small  spot  of  cyanosis  or  lividity  is  termed  Uvedo.  After  deatli  th 
blood  stagnates  to'the  dependent  parts  of  the  Inxly  (post mortem  Undliy 
Ixjcal  passive  congestion  of  the  skin  may  be  brought  alnnit  hy  t^ 
pressure  of  tumors  or  inflammatory  products  on  the  efferent  vessels  ( 
a  part. 

Odema.— The  natural  result  of  prolonged  passive  congestion 
ffflema.  This  is  found  more  especially  in  connection  witli  chnni 
stasis  in  the  blood-  or  lymph-systems.  The  skin  and  sulKiitaneoi 
structures  are  infiltratetl  with  plasma,  are  firmer  than  normal,  ami  p 
on  pressure.  The  skin  is  commonly  tease  and  shiny.  In  .severe  cum 
blisters  are  formed,  or  the  skin  may  burst  through  overdistension  and  tl 
fi.ssures  weep  clear,  watery  fluid.  Secondary  infection  and  inflainnii 
tion  are  not  uncommon  seijuels. 

Angioneurotic  Otdema. — Angioneurotic  redema  is  a  vasomotor  disttirl 
ance  of  the  skin  and  sulx-utaneous  ti-ssues  found  in  neurotic  individual 
It  is  notablv  a  here<litary  affection,  reappearing  in  .several  generation 
It  is  characterized  by  the  sudden  oii.set  of  local  swellings,  >;eiienill 
about  the  evelids,  ears,  lips,  or  cheeks,  but  which  may  also  he  found  i 
the  hands,  feet,  breast,  genitalia,  or  back.  The  attack  mav  be  |)refedt 
by  slight  itchiness  ami  redness  of  the  skin.  The  condition  \\va\  siii 
aijout  from  «)ne  place  to  another,  and  usually  pas.ses  off  a.s  suddenly  i 
it  came.     Acconling  to  Osier,  giant  urticaria  is  the  .same  disease. 

Teleangiectasis.— Dilatation  of  capillaries  (teloangiecUsis  i  is  due  i 
obstnu'tion  to  the  free  outflow  of  bloo«l  from  any  part,  as,  for  insiatu 
from  the  pressure  of  tumors  or  contracting  fibrous  ti.ssue  on  (lie  eiferei 
vessels.  _  . 

BoucM,  a  condition  due  to  the  ililatation  of  the  superficial  i  n|)illttnf 
is  met  with  n«)re  esjHHially  in  those  addicte<l  to  alcohol,  or  who  ai 
expose<l  to  wind  and  weather. 

Hemorriiace.  Hemorrhage  into  the  .skin  is  commonly  tin  vsult  i 
traumatism,  or  is  a  sympt«)m  in  certain  of  the  infectious  fr\irs.  .^i 
infrtH|uenUv,  tw),  it  comes  on  .s|K)ntaneously  or  "idiojMithieall}. 

Heinorrhages  vary  greatly  in  size,  are  of  rwldi.sh  or  piir|)li^li-re<l  coin 
and  <lo  not  disappear  on  pressure.    Small,  irregular  spots  alnHii  the  su 


PURPURA 


911 


of  a  pin-head  are  termed  petaebla.  Elongated  streaks  or  branching  lines 
are  calle<l  TibicM.  Large,  irregular  patches  of  considerable  superficial  ex- 
tent are  called  ecehymoMi.  Occasionally,  the  amount  of  blood  effused  is 
suffitietit  to  produce  nodules  (jrarimn  papaloM)  or  actual  tumor  (b«iu- 
tom).  In  some  cases  the  epidermis  is  elevated,  forming  a  blood  blister. 
The  h\ooA  may  also  be  effused  into  the  sweat-glands,  causing  bloody 
perspiration  (henutidroiii).  The  extravasation  takes  place  into  the 
corium  or  papillary  layer. 

In  course  of  time  the  effused  blood,  which  is  at  first  reddish,  is  trans- 
formed, and,  as  in  the  familiar  instance  of  the  "black"  eye,  the  affected 
patch  passes  through  all  stages  of  reddish-brown,  brown,  yellowish- 
jtreen,  and  yellow.  In  many  cases,  the  blood  is  completely' absorbed 
and  the  only  trace  of  its  presence  may  be  a  little  pigmentation  of  the 
skin,  due  to  the  deposit  of  hemosiderin. 


Fio.  240 


Purpura  rheum«lic«.     (From  the  Montreal  Oeneral  Hwpital.) 

Purpura.— Spontaneous  hemorrhage  is  usually  included  under  the 
ffeiifnil  tt-rm  purpura.  By  this  is  meant  a  condition  in  which  there  are 
multipl,.  hemorrhages  in  the  skin,  either  petechial  or  ecchvmotic,  some- 
iimes  :i  MKiate<l  with  bleetling  from  the  various  mucous  .surfaces,  .such 
as  the  nose,  lips,  gums,  stomach,  intestines,  kidneys,  or  uterus. 


912 


THE  SKIN 


Purpura  mav  be  convfiuentlv  (livi<l«J  into  the  following  types:' 
1    Essential' purpura,  including  peli<»siH   rheumatica,  morbus  W, 

hofii    purpura  simplex,  purpura  urticans,  and,  (Hwsihly,  siorl.iitiiv 
"  ' S„mp(onuitir  purfmru,  such  as  is  found  in  the  lnfectloll^  f.vt 

typhus,  variola,  scarlatina,  ineaskw.   hulwnic  plague,  sepsis,  lyph, 

fever,  and  icterus  gravis.  .     „     ,   .    i-  ■     . 

3.  Cachectic  purpura,  iu  pernicious  anemia,  Hnirlit  s  disease,  hiikem 

and  carcinoma.  ,       .       .  -a      i       i 

4.  Toxic  purpura,  as  in  snake  lute  and  jMMswiing  with  plu.^jilK.r 

antipvrine.  copaiba.  , 

■i! 'Multiple  sarcomatmis  of   the   veswels."     lo   which   may  iH-rh; 

{]  Neuropathic  purpura,  as  in  hysterical  "stigmato." 
No  doubt,  "purpura"  ought  to  be  regante,!  merely  as  u  syinpt. 
for  it  mav  lie  prcMluced  bv  a  variety  of  causes.  As  a  rule,  more  than . 
cau.se  is  at  work.  It  is  safe  to  say  that  in  all  ca.ses,  .save  possihly 
neuropathic,  there  is  some  abnormal  condition  of  the  walls  of  tlic  siiia 
vessels  and  capillaries,  such  as  fatty  degeneration,  which  leads  t..  hen 
rhaire  per  diapedesiu  or  per  rhexiu.  Actual  rupture  of  the  vesset 
probably  rare,  but  has  l)een  dmioastrated.  Tlie  imiM.rtaiice  of  .hs«i 
vessels  in  the  prcxluction  of  these  hemorrhages  is  well  seen  in  t-l.l 
persons  with  arterial  sclerosis,  who  .sometimes  develop  purj-iirK  s] 
oil  the  lower  extremities.  In  some  ca.ses  thrombi  and  emboli  have  1, 
found  obstructing  the  vessels.  The  ring-.sha,)e<l  iH-techw,  (Hcasum 
seen  an-  of  this  nature.  ( )r,  again,  as  in  a  case  of  purpura  comphi  a 
acute  eudcK-anlitis.  which  one  of  us  (A.  d.  N.)  studied,  the  .-mil 
is  due  to  hematogenoiLs  infection  (mycotic  infant),  t he  innn.le  v« 
of  the  parts  lieing  filled  with  bacteria  and  surrounded  by  Uiikw 

infiltration.  „    ,  .•         i       i 

The  maioritv  of  cases,  including  all  the  .symptomatic  and  pn.l.i 
some  of  the  eksential  purpuras,  are  the  result  of  infecliye  |.n--ei 
Some  of  the  cachectic-  forms,  notably  those  (K-currii.g  in  n.pl.i 
.■ancer.  an.l  leukemia,  are  possibly  to  be  attributecl  to  tenn.nal  nif.r, 
The  toxic  forms  are  most  likely  .liie  to  profound  changes  m  the  1.1 
which  lead  to  rapid  ilisintegration  of  the  ves.sel  walls,  or  to  sl-.w.r  hyi 
and  fattv  degeneration.  In  many  instances,  however  a  .  oinl.nui 
„f  fa«-tors  is  at  work.  Circulating  toxins,  of  whatever  kind,  may  c 
.legeneration  of  the  vessel  walls,  with  con.seciitiv-  .lilatatmn.  U^ 
with  a  diminution  of  the  coagulating  power  of  the  1)1<kh.  l,.Ha  ..l.sl 
tion  as  fnmi  thromlxisis  or  embolism,  will  tend  to  damap  ilif  v 
walls  and  rai.se  the  IiUkmI  jiressiire  at  that  point,  so  that  .iilaiatioit 
rupture  readily  take  place.  .,        ,    ,  ..  c,,, 

Anemia.- -Anemia  of  the  skin  is  manifested   by  pallor      «.<• 
anemia  is  one  of  the  commonest  pathological  coiuhtions.  bnuj;  i..m 


i'vcr»i 


'  NichoUs  aii.l  l..'urni..iilli.  The  H.'m.>rrhii({ic  Diathosis  iii  ■lM.li..Ml   I  ■ 
l!,.l„ti..nsl.ip  I..  I'lirpuric  (■.■nditi.ms  in  OenPral,  IJincct,  I/m.lni..  1    vm:.m 
'  .Martin  an.l  Hamlllon,  .Imir.  Kx|M'r.  Me.l.,  l;lHt»6:  I. 


DERMATITIS 


913 


chlorosi.'*,  pernicious  anemia,  leukemia,  hemorrhage,  after  fevers,  and  in 
all  cliroiiic  wasting  diseases.  I^-al  anemia  is  due  to  exposure  to  cokl, 
pivs-siin-,  or  may  be  neuropathic,  as  in  neuralgia  and  fainting. 


DtTLAlllCATIOIII. 

An  entirely  satisfactory  classification  of  the  various  forms  of  derma- 
litis,  or  inflammation  of  the  skin,  has  yet  to  be  made.  This  is  accounted 
for  hv  the  fact  that  authorities  have  not  always  agreed  as  to  the  lesions 
present  in  any  given  ca.se,  nor  as  to  the  interpretation  of  the  appearances. 
IiiHaniniations  of  the  skin  are  «»f  the  most  protean  character.  One  and 
the  saine  cttu.sc  may,  on  occasion,  give  ri.se  to  the  most  diverse  clinical 
manifestations,  and,  conversely,  one  «lefinite  clinical  picture  may  lie 
the  result  «)f  widely  differing  etiological  factors.  Again,  inflammation 
may  originate  not  only  in  the  skin,  but  in  its  appendages,  and  in  the  sub- 
I  iitaneoiis  tissues.  In  the  rarer  affections,  moreover,  the  e.xact  sequence 
iif  events  has  not  always  lieen  made  out.  In  manv  cases,  finallv,  the 
raiise  or  ciui.ses  is  ol)scure  or  (juite  unknown.  The  cla.ssificatioii  which 
we  here  present  is  simple  and  convenient,  and,  we  l)elieve.  in  harmonv 
with  the  fiHts  as  they  are  at  present  known. 

Owinj;  lo  its  expose<l  position  and  its  function  as  a  protective  covering, 
lite  skin  is  liable  to  a  great  variety  of  insults,  not  onlv  fn.ni  ine<lmnicai 
iraiinm,  init  from  variations  in  temperature,  the  effects  of  light,  and  the 
irritation  of  chemical  and  other  toxic  substances,  .\gain,  interference 
with  its  action  as  an  excretory  organ  .sometimes  results  in  inflammation. 
The  VKsciiliir  system  conveys  to  it  various  microiirganisms,  microbic  and 
"Iher  toxins.  I^-sions  j»f  the  ner\'ous  system  often  result  in  congestive 
liypt-reinia  and  sometimes  inflammation,  or.  again,  in  disorders  of 
nutrition. 

We  may  divide  dermatitis,  or  inflannnation  of  the  skin,  into  two  main 
vaneiieK!  primary  or  esuntial  dermatitis,  in  which  the  lesions  originate 
in  the  skin  or  its  as.sociated  structures,  and  are  confined  to  it;  and 
Mcondary  or  symptomatic  dermatitis,  in  which  the  cutaneous  niani- 
''""" ^  »«•  simply  one  phase  of  a  gcneniliml  systemic  disonler. 

(lit   Triiumnlir,  fmtn 

1.  .Mechniiiciil  injiirv. 

2.  I'hvuiral  aKciif.s,  .such  as  liRht, 
heat,  rolil,  iiioisturo.  filth, 
cheiiiicnl  and  other  external 
toxic  Kiihstances. 

('i)   Iiifrrlinu.i,  from 

1.  Hactorin,  veasts,  and  moulilH. 

2.  .Animal  )>nra»<itcR. 
((•>  Seuromthir. 
(■/I  Of  xiniinmcn  or  dmMful  etiology. 

(ii)   Kiiinlhrinntouii  irupHimn. 

('•1  Toxic,  from  the  internal  adniiiiiH- 
tration  of  miHlicinal  ami  other  poi- 
sonous HUbstanccs. 


friniiry  or  Essential  Dermatitis 


««cond»ry  or  SymptomaUc  OermatiUs 


58 


914 


THE  SKIS 


The  lesions  pro.luf«l  hv  dermatitw  are  extremely  vanable  .l.pend.ns 

upon  the  nature,  extent,  localization,  and  ehron.c-.ty  of  tl...  .l.sease^ 

I'hecanlinal  features  of  inflammation,  namely,  reclness,  8weUln^^  l,.Hta,Ki 

pain,  are  particularly  well  exemplified  in  the  ease  of  the  .sk.n.      ),«.. 

mlnU  and  swellinK  Ls  termed  erythema.    The  c-olor  .s  hn^ht  ..n.l  v.vkI, 

m^ite  in  eontrast  with  the  dull  lividity  of  passive  congestion.  disu,.,HHnnn 

momentarily  on  pressure.     The  more  cireunwcn UhI  areas  ..f  inhltratmn 

™reknown  as  papules,  wheals,  ncxles.  or  tul>ereleH.     Pap,d,.  are  sndl 

elTvations.  due  to  infiltration  in  the  skin,  which  vary  m  size  fnm.  llmt  of  a 

millet-seed  to  that  of  a  pea.     larger  elevatioas   up  to  a  ha/.elnut  m 

X  are  call«l  mxles,  nJide.,  or  Ud>erde».     Still   arger  ones  an-  some- 

;  m^s  t^r^ed  vhymn.     Wheah  are  bn««l.  flattenecl  elevations  .,u,le  *vll 

lXe<T.Thich  appear  and  disappear  rapidly.    They  are  .lull  m  l.sh  ,„ 

clor.  or,  in  the  c^Tse  .,f  the  larger  ones,  with  wh.t.sh  a,UMnK.-l...k>n, 

r  .tres.    Histologically,  one  finds  in  such  mi  .1  forms  of  dennat.tts  n,  1- 

ration  of  the  ti^ues  with  -serum,  together  with  diapedesis  ,,    l.M.k.*v  es 

and    .KCHMonallv.  of  red  cells.      The  epithelium  is  usuailv  l.nt  Intl. 

affite,!.  although  certain  of  the  cells  may  \^  swollen  and  l.vdn.,..c,  hikI 

there  mav  l»e  slight  proliferation. 

Where' the  sennts  exudation  is  more  intease,  lot-al  collections  of  fl.n,l 
.KTur  which.  pn.vi.l«l  that  the  superficial  epidermis  remain  mta... 
;.  d  to  the  separation  of  the  outer  layers  from  the  un.ler  y,„^.  ,,.,rt.on>. 
hi  forming  elevation,  commonly  known  m  blisters,  WW,.,  or  ,r,,r/,,. 
Such  ve^cles  mav  l,e  single  or  lohulatcl.  They  contain  a  .tear,  tn, ^ 
Imlnt  serum,  ulm.«t  .levoid  of  c-ellular  elements.  In  other  cases  .h. 
H  id  is  slightl V  turhi.l  from  the  a.lmixture  of  leukocytes,  or  nMl.hsh  fn  n 
ex  ra  vatbii"  of  I.UkkI  (blood  blisters).  Not  .nfre«,.iei,t  Iv,  also.  th. 
ex  Stion  is  turbi.l.  whitish,  un.l  purulent,  the  vesicle  then  In-.n,  kno« 
as  a  muitule.     When  the  pustule  dries  it  forms  a  crj«.^or  ^rah. 

InTher  cases,  where  the  <-orium  is  marke,  Iv  infiltratcl  w.,h  Hn,,l, 
the  ex"u lation  sprea.ls  to  the  papillary  layer,  ami  finally  to  tlu-  c,mlenni. 
tL  cells     volve,!  are  swollen,  vacuolated,  and  hy.lropu-.  to  son.e  ex.« 
.limpre  X  an.l  eventually  .liss.K-iated.      \N;hen   c..rn,h..a..on  »  -« 
marKe  fluid  exiules  upon  the  s.irfa.-e.  where  it  mav  ..ufru  .,.■  .r 
Z    Svine  rise  to  .rusts  nv  scabs.     This  exiulate  may  be  HaH."'* 
fi  iiiS  "mi  "l  nith  leukcKyte ,  or  re,l  c.lls.     Superficial  .l..f...s  m  >  e 
e  riennis     fi.'<»ure.   or   exrorlatlo,,..   are   not   unc-om.non    mu  er  >Kh 
l^ZLl.  :.r  even  cracks  or  rka.jades,  extending  thn.ng    ,  .  ^ 
thickness  of  the  skin.     1  n  more  extreme  conditions  cspc<i..ll>  «  Here  I 
Saion  is  ,nu.-h  interfere,!  with,  we  get  actual  uUrrs.  M.:... 

'"Srinflainination.  if  tnil.l.  may  ...lickly  pass  offjeavi,,.  Ijde  or. 
traces  In-hind.     Fre.,uci,tty,  lu.wcver.  even  after  so  *"fl".^;.;;;  ««•"', 
crvthcma    the  sut)erfi.-ial  epi.lennis  is  cast  ..ff  or  de.s.|.unM.u^  .    l  i 
.?:   ,"  ;.uti..U.  may  come  a'way  in  the  f.>rm  of  a  ^r.^  ^^^^-' l"-;^^ 
Lsed  of  minute  dry  scales  ^de..^uamai, o  fnrfurnrea)   or  .^  ^^O 

Im   .lelicatc,  whitish,  silvery  flakes,  or.  -PH'"'  -.,!^' l^;.    f  J  t 
shreds  or  membrane  (^denqmunolio  memhrmmna).      i  I"   -  «'•' 


PRIMARY  OR  KiiHESTIAL  DERMATITIS  flj-, 

the  most  part,  exfoliiile*!,  horny  epitheliuin,  hut  in  munv  instances  it 
is  patholouirally  alteml  u.s  well.  Pigmenlntum  is  also  a  «>mnion  se<iin'I 
of  ilermatitis,  «lue  to  the  deposit  of  bloo«l  coloring;  matter. 

Ill  cases  where  there  has  l)een  a  hxss  of  suljstance,  as,  for  instance,  in 
vesides,  pustules,  or  fis,sure}f,  there  is  a  regeneration  of  the  epithelium 
fnim  the  cells  at  the  periphery  of  the  lesion,  from  any  remnants  of  the 
fpidtTiiiis  that  rf  main,  and  even  fmm  the  epithelium  of  tiie  hair-follicles, 
sweat  ami  selmcejius  glamls.  A  thin,  bluish,  semitranslucent  covering 
Ls  thus  pnMluced,  which  ultimately  is  converted  into  onlinary  horny  epi- 
tlieiiuiii.  Should,  however,  the  papillary  layer  or  the  corium  l)e  dam'agetl, 
regeneration  is  nirt  so  perfect,  and  the  Icxss  of  sulxstance  is  made  gcnxl  hv 
the  pnMluction  of  new  filmms  tissue.  The  papillie  htc  commonly  not 
re|inHluce<l  or  are  stunteil,  while  the  superficial  epithelium  is  smcM»th. 
shiny,  and  largely  or  entirely  rlevoid  of  hair-follicles  and  glands.  \ 
pijtineiited  »mr  is  a  conmion  ri'sult. 

In  (•lin)nic  inflammations  atrophy  and  hy|)ertrophy  may  l)e  coml)ine«l. 
The  fonnution  of  epithelium  may  l)e  in  alleyance.  inade(|uate,  or  exces- 
sive, jiiid  the  normal  prix-ess  of  cornificutio'n  may  l>e  interfered  vitli  in 
various  ways.  The  papilla-  fretpiently  hy|)ertrophy,  iiecoming  elongate«l 
ami  branched,  while  the  corium  and  sulHMitaneous  tissues  are  thickened. 
In  otlu  r  cases  the  papillte  are  atrophic  and  flattenetl,  while  the  coriuni 
is  thiniK  <l. 

Primary  or  lasential  Dermatitis.— TranmAtie  Dermatitii.— 'I'rau- 
matic  dermatitis  in  its  widest  sense,  may  lie  taken  to  inchnle  all  those 
fonns  of  inflammation  of  the  skin  due  to  mechanical  injury,  expcxsure 
t.)  Ii>;ht,  heat,  or  cold,  and  the  action  of  chemical  aixl  other  irritating 
sniistances.  Not  infrwjuently.  several  etiological  factors  are  combine*!. 
Ottiii^r  to  the  exp<xse<l  position  of  the  lesion,  secondary  infection  is  apt 
to  lie  sii|H'mdde<l.  Thus,  for  example,  in  the  moist  condvlomas  found 
SI)  often  about  the  genitals  we  have  the  combine<l  effects'  of  moisture, 
heal,  .lirt,  toxic  irritation,  and  infection.  Dennatitis  is  often  met  with 
ill  contusions,  abrasi(ms,  and  lacerations. 

riiiitr  the  heading  of  dern  atitis  from  the  effects  of  light  may  be  men- 
iioiieil  the  well-known  j-rinj  dermutHii.  In  the  mildest  grades  we  get 
httie  iiiore  than  a  transient  irritation,  \Miich.  in  time,  after  n>peated 
application  of  the  rays,  is  followed  by  pigmentation,  gUxssincss  of  the 
skill,  and  loss  of  hair.  Of  the  frank  inHamniations,  perhaps  the  coin- 
iimiH-t  is  a  simple  erythema,  which  appears  after  a  vari.ible  pcri(Kl 
nmi  a  few  hours  to  some  days.  Vesicular,  bullous,  and  liemorrliagic 
fomis  ill,  more  fre<piently  met  with  than  are  the  papular  aiul  pustular 
vanetio.  ( )c<asionally.  deep  ulcers  or  eschars  are  formed  wlii<  N  are 
exijiiMtcly  painful  and  difficult  to  heal.  Weeks,  or  months  or  -ven 
one  or  tw-  years  may  elapse  before  cicatrization  is  .ompletc.  Among 
"thcr  .irc<is  may  lie  noted,  canities,  ami,  ra«'ly,  leuk.Hleriiia.  Occa- 
Mimallv  il„.  ulcers  liecome  malignant. 

Ili-tMlny;i,ally,  our  knowledge  is  incomplete.  Darier,  in  the  milder 
K'racle^  ,>f  the  affection,  found  narked  thickening  of  the  stratum  cor- 
"fiini:  ilif  stmtum  granulosum  showe<l  both  hypertripliv  and  hyper- 


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010 


THE  SKIS 


n|.Hi«  of  it.H  vi^lU,  whkh  contained  numerous  ele.din  gmnules.    l.,Mf 
Tf  the  stratum  .sinnosum  wrr*  al^.  Iiypen,l««t.e  and  hypertn.pln. , ,,, 

M'tumn  mit..se..  while  the  hair  papilW.  ttr«-.ton«  pilorun..  an.l  m-\ 

fe««iH  cianfls  hail  tli»nj)i>eared. 

The  sinn,Ust  fonn  of  dermatitis  due  to  heat  (dermnUl.n  ..,/.,r,n 

ttiMl   perim  ,s.  to  M>me  extent  al.v.  to  light,  is  the  erythema  .uu... 

;  IW  .1!  the  Mun  (.««6«r«).     H.  n..  the  injury  has  not  been  sulhn. 

„.  destr.  ^   the  tia,ue.  but  has  led  to  taxation  of  the  hi.  .mIv.-ss. 
onp-stiv.-   hvpen-mia,  and  slight  exudation.     After  the  pn.-ss  1 

sul.side.1.  ,le4"»"'««">".  ""^l  '"««'  "'  ''^^^  pigmenta  ion  is  apt  tn  f.  1. 

'Hie  susJeptihilitv  to  "sunbun."  varies  greatly  in  different  .n.hvi.lm 

iH-in.  .!.lH.n.l.-nt' apparently  to  .s...ne  extent  on  the  amount  of  ,..«„., 

..onimlh  in  the  skin      IViple  of  fair  complexions  and  th.xse  wul,  leul 

tlennii  siHTer  more  than  others.  •      •    :.       1 1 

In  all  n-siH^ts  similar  is  the  inflaminatK.n  due  to  burnuuj  m  is  mil.l 

deitroe  (rirnuatith  .,mh„M!oni»  vrythenmUmx  bum  of  t„-  Jint  ,lr,,r 
\Vh.r..  the  injury  lias  Ik^i.  more  severe.  ..wing  to  a  higher  t..,n,K.n.t 
or  a  .n..re  pn.l.mge.!  .ontuct.  considerable  exudation  takes  pla. r  f. 
tlu-  papillary  IkkIU-s  Wneath  the  epidermis,  which  is  thereby  ...-v., 
..'vesicles-  (dermnlUh  a,„hn.s,i.,n!s  bullosa,  burn  of  Ih.  .W  </,-,,r 
Again,  ^yhe^.  then-  is  loss  ,.f  substance  of  the  cutts.  «^  ^jH-ak  of  a  /. 
„///,<■  thir.l  deque,  or  in  the  case  of  .•hamng.  o  a  bun,  of  Ihr  J,h 
L,re,:  Burns  of  the  se.-«nd  degn.-  heal  provide.  infcHtion  .  ..s 
take  phu-e.  with  simple  n-genertili-.n  of  the  epithelium.  I"  t  .;•  .i 
wlu  J  there  is  a.-tual  loss  of  sul^tan.  e.  the  burn  heals  by  granul....on 

the  formation  of  a  .scar.  ,    t,  ^, 

Closdv  allieil  to  dermatitis  calori.a  is  the  .lermatitis  .bie  to  frost- 
, ,K.r«/<..  dermoiUh nmrlatlonU).     Here,  again,  there mav  U-  .n.n.ly 
u-.na.  with  .swelling,  an.l  later  destpiamation   yesicula  k...  i'lmm 
n>«v'V'<^--''*  fc"/''«'0. ''r  even  gangrene  (./.rm,,/,//.  .•o»^7W«/"."- ^ 
^ov/i)      In  the  seyeit-r  form,  the  aff^tcl  part  is  re,   and  IivmI.  lai.r . 
rcl.  aiul  tinallv  InH-omes  surroun.l.-.l  by  a  line  '>' «»«*"«'""';"'l;,    ,  „ 
Inflammation  .,f  the  skin  may.  also,  be  causcl  by  contact  vMtl.  a  f 
variety  of  .•hoini.-al  and  other  toxi.-  agents  Ulermihh^  rmmntu,. 
great -numl^T  of  substances.  .Icrive.!  from  t'.e  vegetal. le    a-mna 
minend  king.U>nis.  may  on  .xrasion  l.e  at  fault.     A  f«'«  "'      '« 
„u-ntionc.l  are  the  poi.sons  ..f  po.son-ivy  an.l  p...son-oak.     »    m 
the  venom  of  .-ertain  reptiles  and  insects,  yarious  dyes.  <a>.>ii.  .Il^ 
and  a.i.ls,  an.l  certain  sub.stan.-es  n.se.1  in  inclual  practi.r.  mk 
,.u,tharid..s,  .-n,!....  oil.  tnr,H.ntine.  mastar.1.  uxloform.  forma  n 
.arboli.-  a<-i.l.     S..me  of  these  substances  may  Ik-  abM..!-!  nit^ 
svstem  and   pro.lu.-e  .lermatitis  elsewhere. 
■  Infectious  DermaUtis  of    B«t«Ul   Origin. -Un.ler  tins  h.  „1„. 
,„„v  .-onveniently  an.l  projM-rly  in.-lude  all  those  '"««''!;''■'•';;'';;; 
skiii  an.l   sulK-utaneous  tissues  >i..e  to  vegetabh-  paras.t.-,     Ijuli 
„.,t    .U.p.-,i.u...t    .m   .-.mstitutional   <lisea.se.     Dermatitis    m,   .ln> 
mav  lie  l.M'al  .>r  diffu.'^i  i  ;„  ,,,, 

A  local  .lerm  .!:*.s    i.ivolying  all  the  elements  .>f  tl..-  >Imm  a" 


ISFKCTIOUS  m:H\tATlTIS  OF  flACTKRIM.  OHUllS  917 

itlainl  structures,  m  cmnmon  as  a  result  of  woumls,  hruises,  lilisten, 
ami  iibiusions,  particularly  when  they  have  betoiiie  iiife^tetl. 

Iliupilal  gangrene,  u  disease  pniliuhly  never  met  with  now,  but  cinn- 
nidit  lUMler  the  unhyjfienic  jomlitioas  of  fonner  «lays  and  liefore  the 
iMlvpiit  of  aniiseptic  surjjei^-,  was  a  fomi  of  Kan^rene  which  was  liable 
to  Bttuck  even  the  most  trifling  wounds.  The  tissues  at  the  eil^e  and 
in  liu-  immediate  neixhlMirliood  of  the  wound  assumeil  a  dirty  yellowish- 
ffnv  color  and  were  converte«l  into  a  foul,  slimy  mass.  The'destruction 
iif  ti>-.iie  was  rapid,  uiul  the  necrotic  material  was  cast  off  in  the  fonn 
iif  uii  olFensive,  shreddy,  serous  di.schar)(e. 

Fro.  241 


Imprtixo  (•■inliwi.isuin.     (llyde* 


huiHliijo,  formerly  divided,  but  erroneoiusly  so,  into  impetigo  nimplix 
ami  niijirtigo  contagiosum,  is  a  pustular  dermatitis,  found'  in  badiv 
iioun.Ud  children  who  live  under  unhvgienic  conditions.  It  is  due 
toinff,  iioii  with  pyogenic  cocci.  The  pitstules  are  found  in  the  derma. 
Iney  ,\„  not  tend  to  infiltrate,  but  the  infection  may  be  carried  from 


MldlOCOPV   RBOUITON   TBT  CH/  'T 

(ANSI  and  ISO  TEST  CHART  No.  21 


1m 

■  2.8 

■  M 

US, 

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■■■ 

Ui 

1^ 

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tii 

Li 

|3^ 

lb 

Ib 

12.0 

1.8 


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4     x^PPLIED  IM/)GE    In 


t65J   Cost   Mam    Street 

Rochesler,   Ne*    tork         1*609       uSA 

(716)   *82  -  0300  -  Phone 

C'I6}  288-  5989  -  Fqh 


9IS 


THE  SKIN 


one  part  to  another  by  scratching.  Uncomphcated  cases  liea  wit 
scarriiiL'.  The  ilisease  may  become  chronic,  and  may  n-siilt  in 
formation  of  vesicles,  pustules,  and  crusts,  with  desciuamatK.n  of 
epidermis.     ltchieflyatTectstheheadandextremit.es. 

ICcth uma  is  a  more  severe  form  of  impetigo.  1  he  pustules  urc  la 
the  infiltration  is  more  extensive.     It  is  rare  to  have  scarring,  I.. it 

mentation  may  result.  i     i      ^  • 

The  .foft  vhuncre  (ulcus  molle,  chancroid,  venereal  ulcer)  is  a 
infectious  inflammation  of  the  skin  and  mucous  surfaces  tran>ni 
from  one  wrson  to  another  by  immediate  contagion,  usually  hy  < . 
Within  twentv-four  hours  of  the  infection  there  appears  on  some 
of  the  genitaUa  a  small  vehicle  or  pustule,  which  rapidly  breaks  , 
into  an  uU-er.  The  base  and  e«lge  are  yellowish,  soft,  an<l  pun 
and  the  ulcer  is  bounde<l  bv  a  reddish  hj-peienuc  zone. 

Microscopically,  one  sees  extensive  infiltration  of  the  tissues  wit 
flaiumatorv  round  cells,  the  more  superficial  of  which  are  ni  va 
stasies  of  degeneration  and  molecular  disintegration. 

Under  suitable  treatment,  soft  chancre  heals  with  the  formation 
small  scar.  Lymphangitis  and  inguinal  lymphadenitis  (biib<»  "r 
infreciuent  complications  of  this  form  of  ulceration,  hyplnlis  .1... 
result  except  in  instances  where  there  is  mixed  i  fection.  In  sucli 
the  .hancroid  d<K-s  not  disappear,  but  in  three  or  four  weeks  is 
verted  into  the  true  chancre  (hanl  chancre,  ulcus  induratuiii). 
chancres  are  apt  to  be  multiple,  and  the  virus  may  be  transpiant.cl 
one  part  to  another.  A  small  bacillus,  described  by  Ducivy  In 
some  been  regarded  as  the  specific  cause  of  the  affection.  I  v, 
(■(K-ci  ar» ,  however,  to  l)e  found  in  the  ulcer  as  well,  and  arc  pi 
exclusively  in  the  buboes.  x  ■     i 

Chancre  (true  chancre,  hard  chancre,  ulcus  induratum)  is  the  \n- 
manifestation  of  syi)hilis  in  the  skin  and  mucous  ineinbranes.  It  ai: 
usually  from  ten  to  thirtv  days  after  infection,  and  may  assinn.-  s( 
forms."  In  some  cases  a  harply  defined,  firm  area  of  inhltration  is 
beneath  the  superficial  epithelium,  composed  of  an  accuiimlaii 
small  round  cells,  and  sometimes  large  epithelioid  and  giant  ( .  1  ■ 
other  instances,  the  lesion  begins  as  a  papule,  the  siw-  ot  a  >l 
larger,  of  dark  bluish  or  pale  red  appearance.  At  first  it  is 
snlierical,  but  tends  gradually  to  .spread  laterally,  ^^llen  on  pa 
the  bcMly  that  are  kept  dry  the  superficial  epidermis  is  heap.,  In 
<les(|uainates,  wiiilc  the  surface  may  be  covered  with  a  s,  al. 
moist  situations  the  chancre  is  .soft  and  moist  also.  Owinir  t"  I 
substance  an  ulcer  mav  result.  When  healing  takes  p 
whitish  flecks  and  scars  are  left  l)ehiiid,  or  firm  fibrous  papi 
typical  hanl  chancre  In-gins  as  a  papule  or  vesicle.  \  cry 
superficial  epithelium  is  cast  off  ami  a  .shallow  erosion  is  i  .<■ 
Tiie  ulcer  extends  into  the  corium,  is  .shari)ly  defined,  with  x 
base  and  clean-cut  edges.  Infiltration  is  usually  marke.l  aii.l  s 
when  the  ulcer  is  palpated  laterally,  it  feels  as  if  then-  w.i.  a 
parchment  in  the  base.    The  ulc-er  is  <iuite  iiuh)lent.  aial  '!"< 


ai't' 
ilrs. 
-(Id 


INFECTIOUS  DERMATITIS  OF  BACTERIAL  ORIGIX  fllft 


lend  to  spread.  It  is  single,  and  the  virus  cannot  \ie  inoculated  in  any 
other  i)art  of  the  Ixxly.  'I'he  secretion  is  scanty,  consisting  of  thin  pus. 
Uarely,  granulation  tissue  forms  in  abundance  and  .  inall  papi..ary 
excrescences  are  found  on  the  base.  Occasionally,  when  the  ulcer  is 
infected  secondarily  witli  pus  ccx-ci,  it  resembles  closely  the  soft  chancre, 
l)Ut  tlie  course  of  the  affection  and  the  se(jueliB  will  distinguish.  The 
hard  cliancre  heals  with  the  formation  of  a  .scar,  but  induration  persists 
for  a  long  time.  Recently,  the  .specific  organism  of  .syphilis,  the  Spiro- 
cha-ta  |>allida,  has  l)een  detected  repeate<lly  in  scrapings  from  chancres 
and  ill  the  tissues  about  them  (Schaudinn,  Hoffmann,  I^vaditi,  Bu.schke 
ami  F'scher,  Burent  and  Vincent). 

Tithcrnilimiii  of  the  skin  is  primary  and  secondary.  Primary  tulier- 
culosis  includes  the  "postmortem  wart"  (verruca'  tul)erculo.sa)  and 
lupus  vulgaris.  The  .secondary  forms  are  the  so-called  .scrofuloderma 
(if  the  older  writers,  and  certain  ulcers  of  the  ,kin  and  mucous  surfaces 
iilxHit  the  various  orifices  of  the  Ixxly,  found  sometimes  in  tul)ereulous 
subjects. 

Tlie  rrrrmv  tuberculosa,  or  anatomist's  wart,  is  o( casionally  found 
ill  those  who  are  brought  into  close  contact  with  the  IxmHcs  of  individuals 
affected  with  tul)erculosis,  such  as  morbid  anatomists,  surgeons,  and 
luitehers.  Washerwomen  have  also  been  known  to  become  infectefl 
fnim  'aiidling  infected  linen.  Iluman  l)eings  are  usually  infected 
with  l)ii(illi  of  human  derivation,  but,  as  Havenel  has  showi'i  recentlv, 
biitehers  may  l)e  infected  from  bovine  tubercle.  The  bacilli  enter 
ilirmijtii  punctures  and  incised  wounds,  or  through  abrasions.  The 
»art  api>ears  as  a  small,  rough,  elevated  papule,  of  purplish  color,  which 
is  extremely  indolent  in  its  (levelopment. 

Microscopically,  there  is  overgrowth  of  the  papillip,  with  hypertrophy 
ami  des(|iiamation  of  the  epidermis.  Tubercles  are  found  in  the  rete 
aiui  in  tlic  sul)epitheiial  ti.ssues.     Bacilli  are  particularly  scanty. 

.Should  infection  with  pyogenic  c(Kci  take  place  at  anv  time',  a  deeper, 
more  widely-spreading,  ulceration  takes  place,  with,  possibly,  a  Ivm- 
[>liaiit;itis.  Systemic  infection  with  death  from  disseminated'  tubercu- 
losis lias  l)cen  known  to  occur.  The  skin,  however,  appears  to  l>e  a 
partieiihirly  unfavorable  .soil  for  the  growth  of  the  tuben-le  bacillus,  .so 
that  the  resulting  lesion  remains  for  a  long  time  strictly  hx'alized. 

/.M/)H.v  niUjiirh  has  now  been  <lemonstrated  beyond  (pie.stion  to  l)e 
a  chronic  tiibercidosis  of  the  skin  and  subcutaneous  tissues.  Two 
pwssc,  are  at  work,  one  of  destruction  of  tissue,  and  one  of  hyper- 
plasia, and  the  di.sea.se  assumes  several  clitiical  forms  acconling  to  the 
flative  predominance  of  one  or  the  other.  The  affection  usually 
iftrms  in  early  childhcxxi  and  may  last  for  many  vears.  Thf>  lesioli 
j''  single,  more  rarely  multiple,  and  is  commotdy  found  on  the  face, 
less  fiie(|ii(iitly  on  the  extremities  and  trunk. 

The  prcHcss  begins  in  the  lower  layers  of  the  corimn  with  the  forma- 
tion of  I'  pical  tul)erc-ulous  granulomas.  Tlie.se  in  time  undergo  necrosis 
aiiil  mav  i„.,.„ine  ab.sorbed,  but  ccmunonly  extend  tluoui;h  to  the  surface, 
*ii  that  open  ulcers  discharging  pus  and  covered  with  crusts  are  pro^ 


f. 
^^1 


920 


THE  SKIS 


diu-ed.  The  older  foei  show  central  caseation,  and  the  prtxess  - 
hv  the  coalescence  of  neighboring  granulomas  and  the  fonim 
new  ones  at  the  periphery.  Some  of  the  granulomas  may  he  iil. 
while  others,  after  the  discharge  of  the  necrotic  material,  heal  w 
formation  of  dense  fibrous  scars.  Thas.  the  picture  is  prest-i 
scarring  and  more  or  less  distortion  of  the  parts  at  the  centra 
lupus  patch,  while  at  the  margin  the  disease  is  active  and  pro-; 
The  connective-tissue  hyperplasia  may  lie  so  extreme  that  a  i 
elephantiasi-i  results. 

Kio.  242 


1^^^ 


T„l,.r,ul.,„s  «n.n..h.,i„n    >i.sue.     A  no.le  -if   r.,una-..ll.-.l  infiltrati.m   will,   iw" 
An   ™rl.v   »l..Ke       Zei^s  nbj.  A.  wi.luml   ovular.      (From   tl,-  cUectl,...  of  .he  H„! 

Hnvpilal.) 


Microscopicallv,  there  is  marked  infiltration  with  round  ccll-i 
cells  arc  fairlv  numerous,  but  epithelioid  cells  are  scaiitv. 
l)acilli   are  but   few   in   numbers.      The   sebaceous   glands  a 
filled  with  inflammatorv  cells,  and  the  various  glands  aiM 
show  varving  grades  of  atrophy  and  destruction.     Ihe  epitl 
involved  secondarilv,  the  cells  of  the  rete  lieiiig  swollen,  .1.1," 
or  in  other  cases  proliferating.     The  papilla-  are  fretpieiitly 
and    extend    downward,   suggesting    in   appearance   an   ."i.i 
which,  indeed,  in  some  cases  is  superadded.     In  other  parts  tlu- 
laver  is  thinned,  atrophic,  and  even  destroye.1. 

According  to  the  gross  appearance  presented,  several  cliin. 
have  been  recognized.'  In  the  early  stages,  before  there  is  .1- 
of  tissue,  the  tubercles  in  the  cutis  may  be  indicated  by  i. 
yellowish-brown,  smooth  or  scaly  spots  {lupus  maculosu-v. 


INFECTIOUS  1)I-:H.U.\TITIS  of  BACTKRIAL  ORIGIS 


921 


e  process  -prcinU 
the  fonimiioii  of 
may  he  iil)M)rlHHl, 
•ial,  heal  with  the 
■e  is  presented  of 
the  ceiitn'  of  tlie 
•■  and  prni;rcssivf. 
le  that  a  form  of 


m   with   tw"  Bian!  «■» 
111   of   the  llMVal  Vii!' 


several  foci  are  in  dose  proximity,  the  central  portion  of  the  area,  owing 
to  alworption,  l)ecomes  depressed,  and  the  skin  over  it  is  brownish- 
red  or  brownish-yellow,  fissured,  and  des({uamating  (lupus  exfoliativua). 
Wlieii  loss  of  substance  has  taken  place,  '  j  that  an  open  ulcer  secreting 
pus  and  covered  with  crusts  is  pnxluced,  we  speak  of  lupus  exulcerans. 
In  many  cases  the  process  tends  to  heal  at  the  centre,  with  the  formation 
of  smooth,  stellate  scars,  while  it  exteuils  at  the  periphery  (lupus  ser- 
phjimmis).  Or.  under  the  epithelium  and  in  the  base  of  the  ulcer 
papillary  excrescenc-es  may  form  (lupus  frnmbwsloides,  papillaris,  ivrru- 


Fin.  243 


5; 


;t 


llv MihiK  lu|>ti>  nf  the  face.     (From  the  Skiti  ("linie  .if  the  Mnntreal  Cleiieral  Hn.ipital.) 


mim],  or  ncMlules  (lupus  inxlosus,  tubcrosus,  tumldus,  hyprrtropliicus), 
covered  with  crusts  and  epitheliid  scales.  In  the  course  of  time,  the 
ilistax'  extends  to  the  deeper  structures,  even  lu  tiie  hone,  and  the  larger 
part  of  til?  face,  eyes,  and  lips  may  he  destroyed,  while  from  the  extensive 
scarriujr  markeil  deformity  is  produced. 

."vtdiidary  tuberculosis  is  not   unconmion   in   tuberculous  subjects, 
in  parts  of  the  Ixxly  which  are  liable  to  be  contaminated  with  infective 


discil: 


IT! 'OS, 


Sijiall  sui>erficial  ulcers,  of  oval  or  rounded  shape, 


ith 


sli^liily   infiltrated    edges,   and   surrounded    by   minute   granulomas, 


922 


Tut:  sKix 


are  found  usually  about  the  orifices  of  the  ImmIv,  the  lips,  ;r(.||jt. 
iinus,  l)\>t  also  on  the  head  and  other  parts. 

The  soH-alled  m'rofuUxfermii  is  found  in  cases  of  widespread  din 
tul)ereidosis  of  various  orj;ans,  and  is  fouiul  particularly  in  cliiliirtn 
subjects  of  tulien-ulous  lyinpluulenitis.  The  affe<'tion  takes  the  fun 
well-<lefined,  isolatetl,  nmlidar  j^rannlonuis,  usually  in  the  sulKiiliiiK 
tissues.  The  disease  may  burrow  deeply,  or  gra<lually  extend  tn 
surface.  In  this  way  an  excavated  ulcer  is  pnxluced  with  livid  ini 
mined  etlges,  havinjj  its  ba.se  covered  with  jjranulations  and  ptci 
material,  an<l  d,    harginj;  a  thin  yellowish-white  fluid. 


Kl.i.  244 


SerpiKiniuis  lupur  <»i  the  face.      (Frniii   I)r.  Slieplienl'-  Skin  Cliiiif.  Montreal 


(-.■■IMT^ll    II. .-I 


Miliary  iuben-ulosis  of  the  skin  has  been  ol)serve<l  in  cases  tif  L:tiit 
ized  hematogenic  infection. 

Rhiiioxilermnn  (Pfundnase)  is  a  raiv  disease,  whicli  apixar-  li 
practically  confined  to  the  contintnt  of  Kurope.  Its  (listiiiL;iiisl 
feature  is  that  it  is  :in  inflanunatory  granuloma  poss'-ssiiij:  litiN  m 
tendency  to  necrosis.  The  generally  a-cepted  etiological  fiu  inr  is 
Bacillus  rhinoscleromatis  of  v.  Friscli,  which  is  a  short  r;i|i^iili 
bacillus  with  rounded  ends,  not  unlike  the  '.'riedliinder's  iiat  illi. 

The  disease  affects  the  skin  of  the  nose  and  the  nuicoiis  inrinl): 
of  the  throat  and  larynx.  Large  tumor-like  growths,  wliiii,  mil 
grayi.sh-red  in  color,  and  covered  by  relatively  but  little  ii!i  nil 


ISFECTIOUS  OKRMATITlft  OF  BACTERIAL  OHKUS  903 


iiscs  (pf  :;ciipral- 


fheliiiin,  are  pirMJtu-ed.  These,  micmscopically,  consist  of  rellular  coii- 
nwtivc-tissue,  armnged  in  ronnded  masses  or  strands,  enclosing;  cells  of 
varvini.'  appearance.  Some  are  larjje,  swollen,  reticulated,  and  stain 
Iwdlv.  Others  are  colloid  or  hvaline  in  apiK-amnce  and  contain  bacilli, 
which  are  also  to  \w  found  scattered  thron);hout  the  tissues.  Lymphatic 
chanm-ls  are  numerous.  The  di.sease  remains  strictly  hxal  and  extends 
pxtreinely  .slowly. 

/.c/>m.  — Leprasy  is  a  disease,  which,  with  tnl)enMilosis,  syphilis, 
actinoniycasis,  and  rhimxscleroma,  is  classed  amonj;  the  infectious 
(rramilonias.  The  specific  cause  is  the  Bacilliis  lepra-  of  Hansen, 
which  is  found  in  j;reat  numl>ers  in  the  lesions.  The  affection  is  feelilv 
(iintafiious,  l»einj;,  ."o  far  as  is  known,  only  transmitted  by  close  |)ersonal 
(oiitact,  or  incx-ulation  with  infectious  discharges. 

Two  inain  fonns  are  re<-oj;nized,  identical  in  pathogenesis,  and  differ- 
ing only  in  hx'alizatiorc,  namely,  lepra  tuhrriilona,  tiiherimi,  or  lutdom, 
ami  Icpni  anwuthetlco. 

Tuiicrculous  lepmsy  usually  affects  the  face,  the  extensor  surfaces  of 
the  knees  and  elbows,  and  the  extremities.  The  lesion  consists  in  the 
formation  of  granulomas,  similar  to  those  in  tulwrculosis  and  syphilis. 
These  are  composed  of  the  usual  lymphoid  and  epithelioid  cells,  with 
the  addition  of  larj^e  j;ramilarand  vacuolated  cells  known  as  "lepra  ceils." 
(liant  cells  are  also  present.  The  bacilli  are  found  both  in  the  lepra 
(rlls  and  in  the  lymphatics.  A  scraping  from  the  skin  lesions,  stained 
with  (arliol-fuchsin,  as  shown  by  the  late  Wvatt  Johnstcm,  re>eals  the 
^IKH'ific  l)acilli  in  abundance  and  affoni-:  a  ready  Mieans  of  diafjnosis. 
The  process  l>e);ins  in  the  corium  and  gnulually'spreads  throujrh  it  to 
the  siilxiifaneous  tissues  and  to  the  surface.  The  various  j;lan<ls  and 
fdliieies  at  first  show  hyjK-qjIasia  but  eventually  are  destroyed.  Th- 
papilliv  are  gradually  obliterated,  and  the  epidern'iis  is  thinned  or  exfob- 
alinjj.  Ill  the  more  advanced  cases  ulceration  t:.kes  place.  ()b|-  dvelv, 
the  distiise  nianifest.s  itself  at  first  by  reddish  patches  on  the  skin,  which 
may  reirojirade,  leaving;  merely  a  pigmented  spot,  or  are  gradually 
trdiisfornied  into  discolored  ntxlules  or  tumor-like  masses.  The  disease 
may  for  a  long  time  remain  stationary,  but  in  many  cases  the  infiltration 
liecomes  extreme  aiul  the  various  ncxlules  coalesce,  .so  that  the  tissues 
nf  the  face  are  greatly  thickene<l  and  <ieforme<l  (dephtiiitiaiilii  d'aroniin, 
im-ies  konfinu).  Uedne.ss  and  swelling  of  the  skin,  of  ervsipelatoid 
ivpe,  arc  foimd  about  the  lesions,  indicating  the  onset  of  fresii  leprous 
iiifiltralioii. 

hi  tlic  anesthetic  form  the  nixlules  form  upon  the  nerves,  in  tiie  peri- 
and  eiKloiieurium.  The  lesions  affect  at  firsi  the  distal  portions  of 
the  smaller  ner\es  and  .spread  centri|)etally.  As  a  result,  !r(>{>hic 
(haiifps  l)ccome  manifest  in  the  skin  in  the  form  of  whitish  or  brownish 
^'treaks  \l< pm  maculotia.  morphmi  nir/ra  et  nlhn).  Anesthesia  of  the  part 
isi  prominent  symptom,  resulting  from  the  disintegration  of  the  ner\e 
mr^.  As  a  result  of  the  trophic  <iisturbance.  or  of  traumatism,  ulcers 
ivadily  r.irin,  which  penetrate  deeply  and  leml  to  the  '  '-s  of  portions 
of  the  liody,  such  as  the  fingers  ami  voes  {lepra  mutilaw 


II 
It 


I 


i.f 


*  't 

>  1     i  i- 


024 


TIIK'SKIN 


leprosy  has  been  recoverwl  from,  but,  as  a  rule,  the  disousf  re 
stationary  for  years,  or,  at  most,  is  slowly  progressive.  As  a  consciii 
those  affefted' commonly  die,  not  of  leprosy,  but  of  some  inftrci 
disease.    Secondary  septic  infection  of  the  ulcers  may  oc-cur. 


FlO.  345 


Case  iif  nodular  lepniKy  (from  a  piitii-iit  of  Dr.  .hihii  V.  SlioenmkerV  in  tlic  M. 
CVillege,  PhilaJel|)liia).     The  leonine  ex|>rea»i<in  is  well  shown.     (M.l  .i 

.\Hiii()myr().i!.i  of  the  skin  may  he  primary,  but  i.s  u.suallv  m(( 
to  di.sease  of  the  <leej)er  part.s.  In  man  the  affection  most  (iftcn 
.somewiiere  in  the  l)uccal  mucous  membrane,  usually  at  tlic  al 
priKcss,  an<l  extends  to  the  cenical  lymphatic  glands  ami  ilu'  f 
the  face  and  neck.  The  lesion  is  a  chronic  destructivt  '^nm 
the  skin  l)eing  ulcerated  or  penetrated  by  discharging  siiuisis.  N 
fiH'i  with  central  cicatrization  or  diffuse  infiltration  may  iilso 
In  the  necrotic  material  and  the  discharge  the  specific  orL':iiii.>ii 
actinomyces — is  usually  to  be  found.  It  may,  however,  lie  I 
numlHTs  and  difficult  to  detect.  Primary  actinomycosis  of  ilic  siv 
the  mamma  has  been  noted,  <lue  to  the  application  of  a  p()iilii<  c. 

("Iftsely  allied  to  actinomycosis  is  the  Matlura  foot  dixoi''  "I'H 
pedis,  fungous  foot  of  India),  found  in  India  and  other  tropiral  (oii 


INFECTIOUS  DERMATITJ^  uF  BACTERIAL  ORKilS  925 

It  is  nire  in  America,'  only  5  rases  liaviiig  lief-n  retonled  to  date.  The 
disease  usually  l)egiiis  in  tl>e  i)all  of  the  jrreat  toe,  and  is  generally  believed 
to  result  from  trauma,  such  as  the  pricking  of  the  toe  with  a  thorn. 
The  injured  part  l)egins  to  swell,  and  a  firm,  noclular  mass  forms  beneath 
the  skin,  which  assumes  a  purple  color,  and  liecomes  indurated  and 
adherent.  The  progress  of  the  disease  is  exc-essively  slow,  and,  curiously 
eiioiinli.  painless.  Secondary  n(Klules  form  in  other  parts  of  the  foot, 
which  in  the  course  of  a  year  or  so  break  down,  and  finally  ilisc-harge 
externally,  pnxlucing  numeroas  intereommunicating  sinuses.  The 
discharge  is  a  thin  pus  containing  numenms  spherical  grains,  which 
have  lieen  compared  to  salmon  roe.  Two  varieties  of  these  are  de- 
M'n\wi\,  the  first  pale  yellow  or  pinkish  in  color,  the  second  black. 
Eti.dogically,  they  are  different.  The  pale  varietv  is  due  to  the  actino^ 
invtes  Mudune  of  \iiicent;  the  black  or  melano'id,  to  a  hvphomyces.' 
The  f(K)t  may  be  converted  eventually  into  an  enormous  distorted  mass 
full  of  necrotic  material  and  riddled  with  cavities  while  the  skin  on  the 
surface  has  a  somewhat  velvety  appearance. 

Authmx  of  the  skin  (mnliffnant  pwtule)  is  a  local  inflammation  pro- 
(luml  by  the  anthrax  bacillus.  It  is  an  affection  of  sheep,  horses, 
and  cattle  rather  common  in  certain  countries.  Human  l)eings  become 
affected  through  contact  with  infective  discharges,  or  from  handling 
the  hides  or  wool  of  diseased  animals.  The  virus  enters  usuallv  through 
a  scratch  or  abrasion,  or,  occasionally,  from  insect  bites.  The  lesion 
takes  the  form  of  a  pustule  or  carbuncle  at  the  site  of  inoculation.  The 
affectec!  area  is  elevated  above  the  general  surfac-e  of  the  skin,  and  of 
a  reddish  or  yellowish,  often  hemorrhagic  appearance.  On  the  surface 
of  this  are  often  to  be  seen  vesicles,  bulla-,  or  pustules.  Slight  erosion 
iiiav  take  place  with  the  effusion  of  a  small  amount  of  blcKxl  ar  '  •  rum, 
which  dries  into  crusts.  (Consequently,  the  margin  of  the  area  ,.i  gher 
than  the  centre.  The  skin  in  the  neighborhcKxl  is  swollen,  redo  .led, 
ami  (edematous,  and  may  present  small  blebs.  (Jeneral  infection  anci 
|l«ith  often  result,  but  where  this  does  not  oc-c-ur,  a  gangrenous  slough 
IS  formed  which  gradually  .separates.  Occasionallv,  instead  of  a  car- 
huncle  heiiig  formed,  there  is  a  difTu.se  ccdematous  .swellinf^. 

Histologically,  the  papillary  layer  and  the  coriuin  are  infiltrated  with 
uitlamniatory  cells  and  exudate,  together  with  hemorrhagic  extra- 
vasation, and  contain  numlwrs  of  the  specifiL-  bacilli.  The  suiierticia  I 
epidermis  is  in  places  elevated  into  vesicles.  The  deeiM-r  lavers  are 
also  mon-  or  less  infiltrated. 

(iknihrs  is  a  disease,  occasionally  involving  the  skin,  due  to  infec-tion 
«ith  the  bacillus  mallei,  which  enters  through  .some  small  cut  or  abra- 
Mi>n.  The  disease  is  usually  derived  from  horses.  At  the  site  of  incK-ula- 
ijoii  an  area  of  inflammatory  swelling  is  formed,  which  c|uicklv  breaks 
;lown  ml.,  an  ulcer,  secreting  thin  pus,  and  having  ragged  erodwl  edges, 
i  he  ba.  illi  are  apt  to  extend  from  the  primary  lesion  along  the  lymphatics, 

\'lami  and  Kirkpatrick,  Trans.  .Assoc.  .\mer.  I'hvs.,  10:  1H05:  92 
=  »  right,  Jour.  Exper.  Med.,  3:  1898: 421. 


92*1 


Tilt:  SKIN 


I 


Jii 


priMliiciiiK  "lifftise  i-rynipelatokl  inflammation,  or,  a);ain,  sccon 
pustuU's  un«l  iiU-ers.  *Alon>f  the  lymphatics,  and  in  the  niunds,  inf 
nintorv  niMlules  may  l)e  forme<i  (jiircy  buds),  which  break  liown,  gi 
risi>  to  ileep  ulcers.  \Mien  systemic  infection  (xt'iirs,  ttl»H(tssfi 
f.)rni  ill  the  internal  organs,  and,  in  fact,  in  any  part  of  the  IkmIv.  Pi 
lur  areas,  resemhling  the  p<xk.s  of  variola,  or  pemphif{«ml  Udis, 
l»e  forni.-.l  in  the  skin,  which  break  down  and  discharge  a  viscid  li| 
stained  pns,  often  having  an  offensive  oilor. 

(llanders  niav  run  an  acute  coutse  of  from  two  t<»  four  wit-ks 
ajfiiiii.  may  last' for  many  months.  A<'ute  glanders  is  almost  invar 
fatal.  Tlie  «hronic  form  may  l)e  recovereil  from.  It  may  Ik-  ussik' 
with  amvloid  ilegeneration  of  the  viscera.' 

Orlcuhil  fuTUUcle  (tnipical  ulcer,  Aleppo  evil,  Delhi  boil,  \t 
bouton)  is  a  local  inflammation  of  the  skin,  which  is  contiinioiLs 
!)elieve<l  to  l»e  di;c  tn  ;i  microorganism.  The  affection  lM-j;iiis 
papule,  which  soon  Itecomes  a  pustule.  This  breaks  down  int 
ulcer.  Healing  takes  place  with  the  formation  of  a  bluish-wliiic  cici 
Histologi'-allv,  the  lesi»)n  resembles  a  tubercle. 

Tropical  phagedenn  is  a  rapidly  progressing  gangrenous  ulcrnitii 
the  skin  tomid  in  c-ertain  tropical  regions.  The  disease  is  siipf 
to  l)e  due  t  some  ger.n  which  enters  the  .skin  through  a  slij;ii(  w.i 
Frtimhenifi  (Yaws)  is  a  curious  affection,  found  chiefly  anionj;  nc; 
in  some  tn)pical  «'ountries.  The  di.sea.se  is  infectious  anil  has 
iiiialogies  with  svphilis.  It  legins  with  a  local  manifestation  at  tlw 
of  iiKK  Illation,  which  after  a  variable  time  is  followed  by  lesions  (i 
skin,  .s..iiie  cimstitutioiial  disturbance,  and  often  general  cnlar^'e 
of  tlie  glands.  The  disease  may  lie  acute  or  chn»nic.  The  skin  it- 
are  found  in  the  upper  part  of  tlie  cutis,  and  resemble  the  otlicr  iiiffc 
granulomas.  The  later  manifestations  present  the  itpiManim 
fungoid  lUMlules  covere<l  with  a  scab,  which  when  renioynl  Itiu 
warty  surface  resembling  a  rasplierry  or  cauliflower.  Tlic  di 
has  \hhmi  thought  to  \w  due  to  a  bacill..  ">ut  spinxhctcs  have 
discovered  recently  in  the  lesions. 

f,'r//.«//)W((.''.— The  chief  diffuse  dermatitis  is  erysijKias,  an  i 
infectious  and  contagious  disease,  due  to  infection  of  ll-e  >kin  1) 
streptiK-cKTUs  ervsipelatis  of  Fehleisen,  l)elieve<l  to  Ik-  a  variety  o 
stn-pt(K-<K-cus  pyogenes.  The  affection  liegins  suddenly,  with  (hill,  I 
and  considerable  constitutional  disturbance.  It  is  often  i)riniar\ 
inav  complicate  odier  disea.ses.  Previoasly  existing  chronic  ^kin  dis 
an(i  previous  attacks  predispo.se.  The  infection  spn-ad.  aloiiii 
Ivmphatics.  It  is  usual  to  clas.sify  the  di.sea.se  under  tlm-t-  hca.'-,  ai 
iiig  to  the  .severity  of  the  lesions,  namely,  niUinroun  irii.'<lpihi\  re 
rutinieoux  vnixipeUtx,  and  cdlulith.  The  last-mentioiu-.l  Inrin  si 
not,  however,  lie  regarded  as  nece.s.sarily  due  to  the  same  ttiohi 
factor  that  is  at  work  in  the  other  types. 

In  the  first  form  the  skin  is  smooth,  .shiny,  and  of  a  vivid  red  i 


i;ot)iiis.  Stiiilies  from  tht-  HovhI  Victoriii  Hospital,  Moiitrt-; 


:  I'KHi: 


ISFKCTIOUS  DURMATITIS  OF  UACTEHIAL  ORlUIS  927 

the  Mush  .lisappearin^  m..inenturily  on  pmsMiin..  Uter.  the  «,lor 
.•hH,.t;.'s  to  «  .liwkv  bluish-  or  Immnish-iwl.  To  thi-  M  the  uffe<te,l 
p«rt  IS  h.»t  painful  u,„|  l.rawnv.  'n.e  ,p,t.«,lin«  rnarKin  i.s  sharply 
.i«-h,u-.l  ami  more  elevute.1  than  the  remainder  of  the  pateh  The 
amount  of  ixudation  varies  «o,onlinK  ««•  the  intensity  of  the  inflainma- 
tion  an<l  its  situation.  |„  the  rase  of  hn.se  (issue.;  the  •e.hfr  mav 
he  .xtrc-ine.  FriMjuently.  the  ef!iis«l  flui.l  .■..|ie<ts  JK-neath  the  .siiiH-r- 
h<n.l  epulen..,.,,  whith  it  raises  into  I.Hsters  or  l.uli.e  (,n,.lpel„.  veL,^ 

'""";  '■'  '";'/"'■■)•        >^;«-«s' .liy.  the  vesicles  .ontain  .s^m.w  (eru. 

.,iwn.  puMHl,»,„m).  The  exii.luti..M  mav  dry  into  a  «al.  upon  the 
s.irfa.e  (ery^.pelus  ,ruM,^„m).  As  the  inflammation  subsides,  the  skin 
KHoines  less  swollen  an,  iiHlurat.-,l.  the  color  gmcluallv  .lisapiH-ars  and 
(les(|imniati<m  of  the  epidermis  <Krurs.  ' 

HistoloKieally.  one  Hiuls  in  the  roriiim.  and  even  in  the  deeiK-r 
striK  mres  evidences  of  a  cellulofibrinous  exudation.  The  bl.MKlve,s.sHs 
an.l  lyinphatKs  are  congeste.!.  Inflammatory  leukocytes  air  found  in 
.  ...m  about  the  vessels.  The  ,^||s  of  the  epidermis  «„■  sw." lie 
.•I.MK  y.  v«ciiolat«l,  or  may  have  un.!erK..iie  colli,,uation  netmsis.  The 
v.N.les.  if  present,  contain  fibrin,  and  a  few  inflammaf.rv  cells.  Strep- 
.O...VI  are  found  chiefly  in  the  lymphatics,  but  also  to  "some  extent  hi 
the  tissues. 

In  (•ellul.KUtaiieous  erysipelas  the  siik-utaneous  tissues  aiv  involved 
as  well  as  the  skin.        he  parts  are  greatly  swollen.  .e<lemat<n.s.  and 

«H  «ashle«ther.  1  he  skin  may  present  numerous  blebs  or  mav  actually 
slouch.  A  .sceyses  form  in  the  sulKutaneous  struc-tuivs  which  often 
|x.in(  ,nu  discliarjje  externally.  (JauKrenoiis  necrosis  of  certain  parts 
may  result,  ami  the  priKess  sprea.ls  laterally  and  to  the  deeper  parts 
d|.uu.mK  alonp  the  lyiKphatics.  (Jeneral  pyemia  sometimes  follows  ' 
BesKcs  the  forms  of  uermntitis  of  frankly  bacterial  oriKin,  there  ai* 
"(hers  due  to  the  action  of  various  kinds  of  moulds  'I'hese  ar^  itenerallv 
knonn  as  the  dermnfomycm...  Chief  amon^  these  are  the  affectioiw 
dmnltili?'"'"    ""''"'■"""•    I''^^""-^'"'    ".vthrasma.    and    blastomyc-etic 

¥»n,.  (tinc-a  favosa)  is  an  affection  of  the  skin  due  to  the  activity 
j  a  vejrHable  patusite.   the  achorion  Schonleinii.     The  hairv  part^ 
tlu  l„Kly.  notably  the  head  ami  iK-anl.  are  those  usually  affe^-fed. 
'»t  otli.  r  rc-pons  may  In-  attacked,  as.  for  instance,  die  nails.     The 
.tese  ,s  ,„minon  in  certain  of  the  lower  animals,  and  is  readily  trans- 
mittal   o  man  and  from  man  to  man.     The  fungus  takes  the  form  of 
mvjrlium.  composed  of  thre:..ls.  fre,,uently  branc'liing,  which  vary 
n;-l<n.bly  in   length   and    breadth.     Some"  are   thin,  delicate,  anil 
.......Meous;  others  larger,  moniliform,  or  divi.led  into  compartments 

I)  tn,„.     rse  divisions,  ami  c-ontain  spores.     The  spores  also  vary  con- 

po  hclral.  or  ob'  np  They  are  fouml  chiefly  at  the  cmls  of  certain 
'f'h»  Miv.elial  hlK-rs,  but  are  also  free  or  in  little  clumps.  The  organism 
'>  '""n.1  .hiefly  m  the  shaft  and  bulb  of  the  hairs  and  i>,  the  hair-foSl 


1    ,■' 

i  • 


I 


•£■■ 


Ilfi  14 


i 


i 


92K 


TIIK  SKIS' 


It  iiisimmtes  its«.|f  iK-twetM.  thf  hornv  cellM  ol  the  epuU-nnis.  form 
small.  Vfllowish  un-a  jiint  In-iiettth  the  MirfH.r.  |HMietrat«l  l.y  ii 
.\.H  it  Kn»ws.  a  sulnhur-yellow,  concav..  or  «up-hke  .Iwk  (««^//,. 
siTie  ..fa  U  ul  or  larger,  w  pro.hu-e<l.  This  'I!  k  is  tonvex  Ulnv 
lien  in  a  oorrt^iK.n.lin){  excavati.m  in  the  skin.  When  the  ^rov 
re.nove.1  the  underivinR  skin  is  moist  and  re.1.  owin^  to  reactive  ni 
niulion.  In  lonK-stan.linK  eases,  atrophy  of  the  hair-papillw  aii.l  vi 
irlaiuls.  and  of  the  tfte  and  nppr  part  of  the  rormin  results  b 
hair  an.l  .scarring  may  be  pennanent.  When  exiMH«l  to  the  ai 
faviw  eluinp  iH^.-mes  drie«l  into  u  .lirty.  yellowish-vvhite,  .  r.ui 
„ui.ss,  which  is  midily  lm.keii  up.  The  hairs  of  the  atf.Mted  p. 
dry.  lustreless,  and  easily  pulled  oui.  Tiie  fuiiKUs  l.y  suital.le  mi. 
can  \n'  denioiistrateil  in  the  Imir-sheaths. 

Kiii.  24A 


Pcrtion  -f  a  hair  invaded  by  the  triAo|.I«rt"n.  endo«tothrix.  X  SOO  o.  a,  olmi,.- 
in  foou..  b.  a  rhain  -ituaUd  farther  within  the  hair,  and  hence  not  .n  'ecu,.  iH.  .n 
micnxrapli.)     (Hyde.) 

In  favus  of  the  nmU—onifchomifcosls  favosa     the  fungus  gn.w-;  I 

-e  keratinous  lavers  of  the  nail-plate,  which  is  thickeue.1,  l.nli 

.nliltrated  with  yellowish  masses.     Complete  disinteKrHti..n  ct  t 

inav  result. 

iHmiworm  is  a  dermutomycosis  of  which  severn!  forms  arc  :<•(. 
acconliiiu  to  the  nature  of  the  parasite  at  work.  At  least  t«o 
varieties  of  fundus  have  \m-n  demonstrated,  ..ue  with  siniil  s 
inicro^iw.ron  Audouiiii:  the  other  with  larj^re  spores—the  trirho 
In  the  first  case  the  mvcelium  is  .levelope.1  within  the  hai.  .K> 
the  filaments  after  division  terminate  on  the  outer  aspect  "t  t 


f\FKCTlOUS  DKHMATITIS  OF  BMTt.KIAL  OHIC.IS  WJM 

Mx.  ill*"  JtporpH  aif  eritirek  exU-rnal  to  th*-  hair.  In  the  case  cif  the 
tmhi)|>liyton  the  sjHw.i  are  round  in  rows.  paraUel  to  tli.-  loti^r  i'nI^  <»f 
ilic  liiiir.  The  nivfeliuin  is  not  |ir«Nhie«><l  within  the  hair  Three 
^iil.vHriities  of  the  trichophyton  .ire  now  reco^nixetl.  acconhn^;  to  the 
IKMitioM  of  the  spores  within  or  without  the  hair,  viz..  the  endothrix, 
llifHfdtlirix,  and  the  endo-ectothrix. 

Several  forms  of  rinj^wonn  (tinea)  are  nH..^niz»sl  <  hnically,  ac<onlinK 
Id  the  liK'ulisiation  of  the  lesions. 

Twill  timnuraim  (rin«worin  of  the  scalp)  is  due  to  the  pmsence  of  the 
mi(n>H|«iri.n,  h'ss  often  of  th«  endotlmx  within  the  hairs  and  liair- 
fiJlicles.  The  affec-tion  results  in  tiie  nuitlon  of  an  area  of  sli^dit 
iiiHaniiniition  on  the  scalp,  in  which  t.  I.  lirs  an>  l)rittle  an<i  n-adily 
hiMilv  olf.  leayinK  brush-like  stumps  p  .ttinjc  '}»>*t  alK> -e  the  surfa*-": 
iif  the  skin.  This  is  due  to  the  distortion  of  the  l>ull>  and  shaft  of  t! 
hair,  t«v<tlier  with  its  .se|Miration  into  fihrils.  The  di.s«-nse  is  connnot  . 
ill  chihlren  than  in  adults,  is.  of  cours*-,  contajfious.  ami  i.-  lialile  . 
apfrnr  in  epidemics. 

Tifiiii  lircih.:,  is  foinid  on  the  hairless  portions  of  the  ImhIv  and  is 
due  to  tile  pre^,  lie  of  the  trichophyton  in  the  ih-eiH-r  parts  of  tlie  hornv 
Iwr  ami  in  the  upiM-r  parts  of  the  rete.  The  fundus  extends  ceiitrilu"- 
.iiHy,  Um\\\\\)f  the  chamcteristi<-  circinate  lesions  of  riiiffworm.  A 
reactive  inflammation.  marke<l  hy  hyjM'remia,  is  ..Iso  pn-sent.  and  varies 
iiisfverily  according  to  the  amountof  moisture,  warmth,  and  irritation 
(nwlii.li  liie  part  involved  is  sul.j«Hte,|.  In  parts  of  the  hodv  where 
nv(.  surfaces  ruh  upon  one  another,  and  the  epithelium  is  macerate<l 
fnini  retained  and  decomf)osinfr  sweat,  a  .severe  inflaniiiation  with  the 
fiimmtiiHi  of  vesicles  and  .scahs  (rczcmfi  marfflniitiiin)  r»\sults. 

Tiiiai  xijrosh  (l.arl)er's  itch)  is  a  rinffworm  of  the  hairv  parts  of  the 
fiuf.  caused  l>y  the  trichophyton,  usiiullv  the  ectothri.x  varietv,  or 
l«KMl)ly,  th-  endoectofhrix.  '<"  ^  lesion  "is  a  '  "icu'itis  and  wnUA- 
Witis.    The  hairs  l)ecome  l<K..sei.ri  and  fall  .  The  inflammation 

I-  more  intense  than  in  other  forms  of  rinnwo-  The  hair-follicles 
anil  sel>a.e.>us  jflands  are  destroyed,  ard  ^midl  alvscesses  nmv  form  here 
aii'l  there  in  the  deeper  parts.  This  is  ;  -.ssiLly  the  result  of  secondarv 
iiifwtiDii  With  pyoj^ric  micrncirganisms. 

Tim,  nnhrkatn  (Tokeh.:.  .iogworm)  ,  iound  in  tropical  countries 
i'i|l  IS  .Itie  to  a  form  of  tric>  i  yton.  The  fuii^rus  is  fouiul  onlv  in  the 
fpidmiiis  and  the  follicles  are  unaffwte«l. 

Tm;i  nrxlcdm  (pityriasis  versicolor,  dermatomvcosis  furfuracea) 
i<a  nnciiic  disea.se  of  the  skin,  affecting  chieflv  the  coverwl  parts  of 

I  *f  IhxI.v.     The  orjianism  at  work  is  the  micro.s|K)ron  furfur  which  is 
"ii'Kl  "1   llie   upper   portion   of   the  stratum   corieum.     It    pnxliices 

l*M|iwiiiaii..ii.  hut  the  reactive  inflammation  is  practicallv  nil      The 

I  hair.f„|  1,1,.,  ,,^  „„t  i„v„ive,l.     The  affecte«l  part  j.resents  an  irregular. 
;fil»wi.sli.|„„wn,  blotchy  appearance,  with  slight  .les.iuamafion  of  the 

I  fpiileniii,>.  ' 

r.ri,lhr.i.<m„  is  a  .somewhat  similar  affection.  U'lieved  bv  some  to  be 
I'liMo  tlH    inicnxsporon  minuti.ssimum,  although  others  'think  that  it 


'■•*       ;•  t    if^ 


m 

i 


930 


THE  SKIS 


is  pnxljK-ed  l)y  Imi-teria.  The  disease  is  foumi  in  parts  of  ili 
whith  are  warm  ami  moist,  as,  for  instance,  in  the  j,'n)ins  and 
where  two  skin  surfates  come  together.  The  patciies  are  fail 
defined,  and  present  slight  mhiess  and  descpiamation. 

BUinUymyeetk  dermnfith  is  a  curi(»us  and  rare  affection  of  tii 
first  descriWd  l)y  (Jiiciirist,'  dne  to  u  fundus  related  to  the  yeasts, 
fuilv  developed,"  the  lesion  Wars  a  somewhat  close  resemhlanrc 
rncose  tnlierculosis,  and  (Hcasionally  to  snperficial  papillary  epith 
With  care,  however,  differentiation  is  possible.  The  affection 
with  the  formation  of  a  papnle  or  pnstnle,  which  grailualiy 
nntil,  in  the  conrse  of  months  or  years,  considerable  areas  of  s 


Kilanierit»  and  »|...res  "f  tin-  irirhnphytiMi  fnmi  llie  l>panl  nf  a  i.aliciit  affi"  tcI 
tinea  fycfois.     (Hytie.) 


involve<l.  A  warty,  tumor-like  outj;rowth,  presentinf;  <h 
snperficial  ulcerations  covered  with  crusts,  is  the  result.  Tin 
mav  be  extensive  and  an*  apt  to  be  nniltiple. 

Histolofrically,  the  appearances  are  those  of  an  iiiflannnittor 
loma.  Tiie  most  marked  cliunj;es  are  found  in  tlie  rete,  the  <  |) 
of  which  shows  hyperi>lasia  in  the  form  of  exten.sive,  clciiii;.-! 
branching,  downg'rowtiis  of  its  cells,  jinxlnciuf;  fiiif;er-likf  i 
practically  identical  witii  those  seen  in  epithelioma.  l''il,v 
nuclear  leukcxytes  are  fonnil  .scattered  about,  both  betwctii  dw 
tile  cells,  or  in  small  clumps  which  are  really  mimite  absct  ^  i  -. 
accordinfr  to  Montgomery,  are  characteristic  of  the  pr(Mi-.-i. 
disintegration  is  complete,  tin-  ab.scesses  contain  degeneradiiL  Ifi 
red-bloo<l  cells,  epithelial  cells,  jiarticles  of  chromatin  ami  oi 

•  .J.)lm.s  Hopkins  Hosp.  Hop.,  I  :  lH!Wi  :  2()9. 


larts  of  ilic  IhnIv 
i^niins  anil  axillic, 
les  are  fairlv  well 


PLATE    XII 


r 


t  ^i 


iniciit  afffiit-il  witli 


Clinical  Types  of  Cutai 


leouH    Blastomycosis 


liPi 


DIRMATITIS  DUE  TO  ANIMAL  PARASITES  931 

(letrifus,  the  specific  microorganism,  and,  usually,  giant  cells  The 
rrt(-<ells  are  lar)^  and  swollen,  somewhat  dissocia'tetl,  and  the  prickles 
an-  .)urticularly  well  define<l.  Those  in  the  immediate  neiirhhorhood 
ot  (Ik-  alwcesses  are  more  or  less  flattened.  Single  giant  cells  are  occasion- 
ailv  to  he  ol)serv«l,  surrounde<l  by  a  few  leukocytes.  Isolate<l  cells 
oFfrroups  of  cells,  show  pathological  keratinization.'  A  laver  of  columnar 
cells,  (K-(-a.sionally  showing  mitases,  can  usually  he  traced,  more  or 
less  perfectly  l)etween  the  epithelium  and  the  cori'um. 

In  the  corium  inflammatory  infiltration  may  l)e  yery  marked  I^uko- 
ntcs,  endothelial  cells,  and  plasma  cells  ar^  to  lie  ohser^-ed.  Miliary 
al.s..-sses  may  occur  here  also.  Mast-c-elLs  and  giant  cells  may  he 
found  m  yarymg  numl)ers. 

The  )rny  layer  of  the  skin  varies  much  in  thickness.  In  some 
places  It  IS  erode*  ,  m  others  thickened,  penetrating  downwanl  l)etween 
the  papillip,  which  are  thereby  dislocate<i  and  distorted.  On  the  sur- 
face can  Ik-  seen  scal)-like  masses  of  fined  secretion,  composed  of  pus, 
hliHHJ,  des(|uamated  epithelium,  and  bacteria. 

The  specific  organism  can  readily  l)e  demonstrated  by  placing  portions 
..f  tissue  or  pus  in  a  strong  solution  of  caustic  potash.  In  stained 
se<ti..i>s  the  parasite  is  a  round,  oyal,  or  slightly  irregular  bo<lv,  possess- 
inj:  a  highly  refractile,  <loubly  contournl,  homogeneous  cap.sule  The 
pn.tophisiu  IS  somewhat  granular,  and  separated  from  the  capsule 
hy  a  space  of  yarymg  wi.lth.  In  the  cell-body,  a  clear  vacuole  can 
often  Ik-  made  out.  I  he  parasite  lies  .singly  or  in  pairs,  ami  biid.ling 
onns  in  all  stages  can  usually  be  .seen.  It  is  found  in  the  ahsce.sses, 
iHtwc-ii  the  epithelial  cells,  and  in  the  giant  cells 

.''"'"'  •"•>J«"i^"'  •"'■'^  '•«'"  successfully  cultivated,  although  it  grows 
with  some  difticulty.  ami  when  in.K-ulated  into  the  lower  animals  has 
pn«  nce.l  abscesses  or  inflammatory  granulomas.  It  seems  fairly  well 
.^tahhshcl  now  that  the  parasite  is  specific,  although  it  is  possible  that 
thei-e  may  l)e  .several  subvarieties.'  "  f 

1.1  all  of  these  mycotic  disea.ses  the  specific  organisms  can  usually 
y  .Icnonstratcl  by  placing  the  affected  hairs  or  scales  in  a  o  to  10 
IH;r  c,,,t.  solution  of  caustic  pota.sh  for  a  variable  peritxl  and  examining 
ttilli  till- microscope.  ^ 

Dermatitis  Due  to  Animal  Para8if..-The  mast  important  di.sease 
t"  he  cmsidercl  here  is  xr„b,rs,  an  inflammatory  affection  due  to  the 
^'<M'>ii  "t  the  itch-inite  or  a.arus  .scabiei.  Th^  impregnate.1  female 
"nte  penetrates  the  epidermis  and  l,um,ws  its  wav  into  the  rete  or 
2"^'^  l»r  as  the  upper  layers  of  the  corium,  forming  a  cur^•ed,  .so'me- 
h.H  sacculat«l  rack.  In  the  eariy  stages  the  parasite  can  usually 
1  ■  n.o.n,.e.l  at  the  bl.n.l  end  of  the  burrow  as  a  whitish  spet-k  the  si/e 
;;  •'  l'j-|...mt.  In  the  burrow  are  also  to  In-  foun.l  bnnvnish  or  blacki.sh 
.ramil.,,  the  fec-es,  ami  sometimes  more  or  less  numerous  immature 


'Inr, 


V  .ry  full  conHi.leration  of  this  form  of  dermatitis,  see  Ricketts,  Oi.liomvcosis 
•  ol    the  hkm  ami  its  I'unei.  .tour,  ni  \  '  ' 

:t73. 


^IW„vco^s)  of   the  Skin  an.l  its  Kunp,  .lour,  of "  iloci:  H;;;;;;M;ew  series) 


932 


THE  SKIS 


'UU' 


mites.  Owing  to  the  irritation  cau.se«l  by  the  presence  of  the  pu 
and  also  fn)m  the  scratching  intluceil  thereby,  considerable  inflaiii 
is  set  up,  so  that  an  eczematous  eruption  is  usually  the  result,  (•hi 
ized  by  the  formation  of  pustules  ami  vesicles.  In  long-staiuhii 
the  skin  may  undergo  a  marked  change.  The  stratum  com 
hypertrophied,  the  cutis  is  thickened  and  infiltrated  with  intlani 
products,  and  the  papillae  are  increase*!  in  length. 

Pedicidosh  is  an  inflammatory  affection  of  the  skin  pnxluced 
agencv  of  lice  um)n  the  skin  or  in  the  hair.  The  inflammation  is 
a  mild  one,  and  is  producetl,  in  part,  by  the  irritation  causejl 
insect,  and,  in  part,  bv  scratching.  Three  different  forms  are  de 
In  pe<liculosis  capitis  the  parasite  is  found  upon  the  scalp  or 
hairs,  while  the  ova  can  l)e  detecteti  attacheil  to  the  hairs  by  ii 
oils  sheath.  In  long-standing  cases  markwl  inflammj.tion 
Pustules  or  even  small  abscesses  may  form  in  the  .scalp.  1 
considerable  exudation  and  the  hair  may  In-  consi(lerai)ly 
together  (plica  polonica).  This  is  seen  most  often  just  above  t 
of  the  neck.  The  irritation  in  the  case  of  pediculosis  corporii 
market!.  The  lice  infect  the  clothes  and  wander  on  tlic  skin 
Owing  to  the  long-continuetl  mild  inflammation,  the  skin  1 
somewhat  thickene*!  and  pigmentet!  and  scored  with  .scratche; 
bond's  disease).  Peiliculasis  pubis  is  usually  found  in  the  pubu 
hv*  mav  affect  the  other  hairv  parts  of  the  b«!y.  The  ova  an 
to  tho.s^  of  the  head-louse,  but  are  smaller.  The  secondary  inflai 
disturiwnce  is  trifling  in  this  variety. 

A  somewhat  similar  disturbance  is  caused  by  certain  other  p 
among  which  mav  l>e  mentioned  the  pulcx  irritans,  or  coimi 
cimex  lectularius,'or  l)edbug,  the  pulex  j)enetrans,  or  sand-fle 
lar%ie  of  certain  diptera  are  sometimes  found  lieneath  the  ski 
most  common  offender  is  the  gail-fly  (a-strus  !)ovis). 
Cysticerci  and  echinoc(x-ci  have  been  found  in  the  skin. 
FUaria  nmlinensiii  ((Juinea-worni)  is  a  parasite,  found  in  war 
tries    which  gains  access  to  the  Ixxly  through  th<    ingestion 
containing  the  larva-.     The  female  worm,  which  is  the  one 
the  disease,  is  from  fifteen  to  forty  inches  long,  and  one-ten 
inch  in  diameter.     For  ten  to  fifteen  months  the  worm  n-niaiii 
in  the  muscles  and  then  gra.lually  works  its  way  to  the  surfa; 
ImhIv,  where  it  can  In-  felt  as  a  soft  coil  under  the  skm. 
over  the  worm  ultimately  gives  way  and  a  small  ulcer  is  [i 
Abscess-formation  may  result  in  some  cases  in  lymphangitis,  st| 
am!  gangrene. 

Crair-rraw  is  a  rare  disease,  in  the  form  of  an  acute  su|mtI 
inatitis,  which  affects  principally  the  negroes  of  the  west  coast  < 
It  is  suppose<l  to  lie  due  to  a  worm,  allied  to  the  hlaria  w 
Dermatitis  of  Neuropathic  Origin.— It  is  a  weU-known  fact  that  i 
dis(.i(lers  of  the  central  nervous  system  and  of  the  penph.i 
trunks  the  skin  mav  undergo  striking  changes.  These  may  I 
minor  alterations  in  the  appearance  and  texture  of  the  .skin 


DERMATITIS  OF  SKUROP.M HIC  OHWIS  933 

amount  to  actual  iRflamination  or  other  prc»found  disturbance  Thus 
m  -uses  of  rheumatoid  arthritis,  the  skin  over  the  affected  joints  .s' 
oftcu  found  to  l,e  .soft,  velvety,  an.l  of  smooth,  glistening  appearance. 
In  -ertam  organic  diseu-ses  of  the  spinal  cord,  gangreni  ofdie  fkin 
ami  snlK-utaneoas  ti-ssues  (bedsores)  often  come  on  ,vlth  great  rapiditv 
ho  also  m  tabes  dorsahs,  penetrating  ulcere  on  the  extremities,  usually 
over  the  great  toe.  are  m-casionally  „  ^t  with.  Besides  these,  there  is 
a  (■..n.sulemble  numl.er  of  .hsorders  of  the  skin,  which,  with  mow  or 
le.s.s  certainty,  may  be  attributed,  either  whollv  or  in  ,  irt,  to  neuro- 
trophic influences.  '  ' 

Fio.  248 


rrli,a:itt  fn.titia  (»..Ri.meunwi,).     (Hyde  and  Orm«by.) 


.\     njr    he  co.„htions  wliu-h  may.  in  some  instances  at  least,  In- 

ttnl.uled  to  i.erv«,i.s  ('..sturbances  should  Ik-  inenti«ne<l  urttcr!,,     Th^ 

IS  an  iinnioneiirosis  in  which  an  idiosyncnusv  of  the  individual  oiavs  an 

in.portan,  prciispos^ng  role.     The  disease  is'  found  in  tiu.se    ?!  Sm?i  • 

1  IHranuMit,  and  has  lieen  known  to  follow  up„,.  mental  worr' 

'1  ,,.L  "t.     '"'"'"'^  °f  "''K^-^'i""-  .^astro-intcstinal   intoxicatioii.  are 

h«       sh.11.^"."'  r'T  P*''"''""\«""  '"••«'«^">"t  of  certain  ^.kkLs,  sii.h  as 

•l>«M    slelf:.sh.  fruits,  or,  again,  certain  .Irugs.     In  those  predisi,ose.l 

12  L.  TT^^:'   '"   '"/'""■'■"  /'"•"■"■"   Clt-'n^atograVhia     rhe 

on  „         7  '      '"  .*"'K^J-"*''    »«"•■  the  skin  is  followcl  in  a  few 

EiaH,!;^  '"■'""""  "^"  "'"■'*'•  '"^"^^  '""f-ning  to  the  n.gi,.„ 
Tlu.  ,.v,,,.t  pathogeny  of  the  condition  is  not  altogether  agreed  upon 

M'-t  M..,,.  to  think  that  there  is  a  p^-liminary  brief  contraction  Jihe 


>1 


■  i 


.0 


>\ 


ll    , 


934 


THE  SKIS 


vessels  This  is  followed  by  paretic  dilatation  wi  h  exudation  of  ph 
and  local  stasis.  At  first  there  is  producetl  an  elevated,  soin. 
firm  n(xlule,  of  dull  red  color,  which  soon  l.ecoines  paler  in  the  ( 
(the  wheal).  This  last  change  is  attrihutetl  to  the  compression  . 
capillariti  of  the  part  by  the  increasing  exudation.  Ihe  eiTusn 
plasma  nay  be  so  great  as  to  ele"E*e  the  superficial  epid.  mis,  th 
forming  blisters  (urticaria  bullosa).  Or.  again,  the  (ledeina  iiu 
foUowefl  by  extravasation  of  blood  (urticaria  henuyrrhagica  pi, 
urticun.1).  In  still  other  cases  there  is  an  ac-cumulation  of  pi^ 
in  the  deeper  layers  of  the  rete,  wiih  persistence  of  papules  aiul  lu 
after  the  wheals  have  oisappearevi  (urticaria  pigmentosa).  In  the 
nate  u-tinria  of  childhood  small,  inflammatory  papules  may  Ik-  fo 
apparently   follicular   in    origin   (urticaria   papulosa,   lichen    nrl 

strophulus).  ...       .  .  .•      J 

A  closely  allied,  if  not  identical,  condition,  is  angioneurotic  a^em 
p  1 13).  This  probably  does  not  depend  upon  external  irntution  i 
l)elieved  to  originate  in  the  subcutaneous  tissues. 

;V„„„o._The  term  "prurigo"  ^ .  rather  kwsely  employed  by  .!» 
ologists  to  designate  any  pruritic  dermatitis  as.s.Kiateu  with  the  f 
tion  of  more  or  less  persistent  papules.  The  prurigo  ..f  Hehm 
aifection  of  early  childhood,  which  persists  mostly  throughout  lil 
begins  with  the  formation  of  urticarial  nodes  nu  the  extensor  sii 
of  the  extremities,  associate<l  with  the  most  intense  itchir.g.  1 1. . 
of  time,  owing  to  the  irritation  produced  by  scratching,  sniall  ii 
matorv  nodules  are  formed,  over  which  the  skin  is  excoriated  an.l 
covertil  with  scabs.  It  may  be  complicateil  by  et-zema  and  erys 
Auspitz,  V.  Hebra,  Schwimmer,  among  others,  class  it  among  the  nei 
llerpes  is  an  aifection  of  the  skin  characterized  by  the  for. 
of  papules,  which  are  soon  converted  into  vesicles,  and  after 
days  into  pustules.  The  efflorescenc-e  corresponc  s  fairl.v  ar.  > 
with  certain  nerve  tracts.  Various  parts  of  the  bo<ly  may  be  i.iv 
the  face  (herpes  facialis),  the  forehead  (herpes  frontalis),  the  it) 
tion  (herpes  ophthalmicus),  the  lip  (herpes  lablalis),  tiie  genitalm  ( 
yroqenitalis  and  preputialis),  and  the  trunk  {herpes  zoster).  Ih.^ 
cause  is  not  known,  but  is  l)elieveil  to  be  some  loc;.U  or  reflex  n 
disorder.  Herpes  o(  the  face  and  lips  is  found  in  certain  ml. 
,  iise^ises,  notably  pneumonia,  and  gastro-intestinal  derangements.  I 
progenitalis  mav  be  reflex  or  the  result  of  some  Ux-al  irritation. 

In  herpes  zo.ster  the  lesions  are  found  along  the  course  of  ..in-  n 
intereostal  ner%ts.  It  is  usually  unilateral.  The  affection  is  1. 
bv  some  to  be  bacterial  in  origin.  Others  consider  it  an  -.m^vm 
The  pathological  condition  most  frequently  fouiul  is  intlann.m 
the  posterior  ganglion  ami  of  the  nerve-trunk  suppl.ymg  th.  a 
portion  of  the  skin.  Changes  of  various  kinds  have  also  Ih-.m,  n 
in  the  central  nervous  sy.stem.  . 

Histologicallv,  the  rete  cells  undergo  rapid  pn)liferation  an.l 
of  them  degenerate,  forming  small  cavities.  Ihe  papilhi.v 
in  turn  become  inflamed  and  the  cavities  coalesce  to  form  <. 


PLATE   XIII 


rotie  a'dcmii  (str 
irritation  iiiul  is 


a;     .  • 


Herpes  Zoster. 

(Iri.rn  Hi.-  Skin  Clini,-  .,f  th,.  .\l,„,iroMl  (ii-niT.-il  ll..-|.il„l  , 


1:1: 


DKRMATms  OF  f/.VAT.VOir.V  .I.V7>  IHWHTFUL  ETIOLOGY     ft'{.-, 

(iilclirisj'  foiiiHl  ill  thf  |)upiilur  utaj^e,  liefore  the  fonnatum  of  the  vesicle. 
a  noiiilile  multiplitatioii  of  the  iiiiilei  in  the  rete  without  any  intwase 
in  thf  mitotic  figures. 

ll,rfH'»  iri»  is,  accorriinj?  to  KajMwi,  identical  with  erythema  iris. 
The  vrsicles  are  found  on  the  hands  and  feet. 

Dcrmiitltiji  herpetl/ormU  (dermatitis  multiformis,  herpes  gestationis 
hvdroii  herpetiforme.  Duhring's  disease,  pemphigus  pniriKinosas)  is 
an  nl)S(ure  affection,  reganle.!  hy  Duhring  as  intermediate  hetween 
|rni|.hij{tis  and  erythema  iniiltifonne.  It  is  mast  likelv  neuropathic 
in  nature.  It  has  l)een  attril)ute<l  to  many  caiLses,  neura-sthenia.  general 
(Ifhilitv.  renal  and  other  organic  disease.  *aiid  pregnancy.  The  process 
is  an  acute  inflammation  of  the  papillary  laver.  'I'here  is  a  marke?! 
nudalion  of  plasma,  leukcxytes.  uiul  r«l  bjowk-ells.  The  exudate 
is  Khniioas  in  nature.  I^rge  iiuml)ers  of  eosinophiles  are  found  in 
thp  hi(MMl  and  in  the  hx-al  lesions. 

DwmatitU  of  Unknown  and  Doubtful  ttioUtgj.—DermatHh  exfoHufim 
IS  the  l.nn  rather  l<K)sely  employed  to  designate  anv  inflammation  of 
the  skin  a.ss(xiate<l  with  «lesc|uaination  of  the  epidermis.  The  con- 
dition s(>inetinies  complicates  eczema,  psoriasis,  lichen  rulier.  and 
other  varieties  of  dermatitis.     Occasionally,  it  arises  idiopathicallv 

In  the  curly  stages  there  is.  according  to'Cnxker.  a  superficial  inflam- 
matioii  of  the  corium.  characterized  hy  congestion,  owlema.  and  cellular 
inhltratioii.  The  rete  is  thinned  and  there  is  separation  of  the  upper 
portion  of  the  stratum  corneum.  I^ter,  there  is  proliferation  of  the 
rete  cells  with  some  conne<-tiye-tissue  hyperplasia.  In  the  most  ad- 
van«^i  forms  the  horny  layer  is  thickened  and  there  is  more  or  le.ss 
atrophy  ()f  the  rete  and  corium  and  o;  the  Imir-follicles  and  sebaceous 
j:ian<ls.  ihe  pttyr„m»  riJira  of  Hehra  is  by  many  coiisidere<l  to  b- 
a  severe  form  of  dermatitis  exfoliativa.  It  is  a  rare  affection,  which 
may  (■ontiiiue  for  many  years,  and  is  usually  fatal  from  marasmus. 
Ilist(il,.;;„.a|ly.  It  seems  to  c-orrespond  fairly  accumtelv  with  the  more 
.■uivan<e<l  form  of  exfoliative  dermatitis.  '  Kxfoliative  dermatitis  has 
Iwi  found  III  young  infants  (Hitter)  and  may  lie  epidemic  (Savill) 

I it>,mi.vH  rmca  (herpes  tonsurans  iiiaciihlsiis.  pityriasis  iiiaculata  et 
nrc.i,atii)  is  a  somewhat  similar  disease,  a  simple  superficial  inflani- 
niation  running  an  acute  course,  and  a,ss(x-iated  with  branny  desciiia- 
nwtion  of  the  epidermis.  Kapasi  Mie\eil  it  to  l)e  due  to"  the  hx-al 
iHtioii  ot  a  pani-site,  but  it  is  more  probably  due  to  a  systemic  infection 
A(ror(liMj;  to  I  nna.  there  is  a  supefficial  inflammation  with  (wlema 
•"ijl  e'llular  infiltration  of  the  cutis  and  lower  portions  of  the  rete 
..Hienia  ..t  the  ui>|xt  rete  cells,  acanthosis  and  parakeratosis,  together 
Mill  tile  formation  of  minute  "sulx'orneal  pre.ssure  vesicles." 

Ao  /„„  IS  jxrhaps  the  most  common  form  of  inflammation  of  the  skin. 
iliei  is.;ise  may  Ix- aciit*-  but  is  often  chronic,  and  has  a  notable  ten<lencv 
10  Pelii!,....  The  lesions  are  strikingly  polvmorphous.  The  skin  is 
more  or  less  re<ldened  and  swollen,  and  inav  Ix-  covereil  with  papules 


'.Johns  Hopkins  Hosp.  Hop.,  1. 


II  '< 


n.t(t 


THE  SKIS 


vesitlt.^,  pastulw,  anil  <nwts.  The  affettetl  part  iii  very  \iv 
l>e  exfoliutiiiK.  ami  often  is  moist  fn>m  exudation.  In  the  rhro 
the  skin  w  thii-kenwl  and  often  fifwuml. 

Ahh«»uj{li  the  c-onilition  has  been  freijuently  ami  carefully 
the  etiology  is  still  to  a  jjreat  extent,  olwcure.  Many  cases  u 
aftril)ute«l  to  external  irritation,  such  as  may  lie  caiwetl  l>y  j 
sfratc'hinjf,  moisture,  or  ncriil  «lisehar>^s.  Some  individuals  i 
susceptihle  to  the  action  of  these  c-aases  than  are  others.  ( )tl 
are  the  result  of  some  systemic  disorder  or  of  disturlied  nu-i 
such  as  K'»"'.  rheumatism,  toxemias,  gastro-intestinal  deran 
and  malnutrition.  In  still  other  instances  there  seems  to  be  a 
••;^nc-v  at  work. 

In  the  mildest  form,  where  the  irritation  is  not  extreme  or 
is  not  particularly  sensitive,  small  nodular  elevations  are  fom 
skin  (eczema  pii'puloiium).     In  somewhat   more  .severe  case.« 
may  Ik-  pHnluc-ed  {erzevut   ir*iV«/a  urn).      Wien  the  c-onteni 
blisters  are  aksorln-d  or  dry  up  the  supc  'ficial  epidermis  may  Ik-  e 
When  the  inflanunation  is  more  intense,  considerable  areas  of 
iKH-ome  painful,  re«l,  and  swollen  (eczema  erythemnioHum). 
inflamed  base  may  \w  formed  blisters,  which  subseciuently  ma 
purulent  (eczema  piiKt'iloiium).     Should  the  epidermis  l)e  lost. 
rubl>iiin  or  scnitchiuK,  we   jjet  a  weeping  surface  (eczema  m 
Where  considerable  patches  of  epitlermis  are  lost,  the  underlyii 
presents  a  dusky   red   appearance  {eczema  riihrum).      Vm\w 
serous   or  purulent  discharge  dries   upon  the  surface   into 
crusts   (eczema   cruniaium).      Under  the  c-rusts   pus   may  h( 
(eczetrui  impeilijlnomm).     In  other  cases  the  epithelium  may  ] 
l)eneath  the  st-abs,  -so  that  the  surface  appears  to  lie  reddeiu 
eued,   and    scurfy    (eczema   nquamonum).       Flczema    chanutt 
somewhat  larger' pustules  covere<l  with  crusts  is  often  calle<l 
W'.en  the  pustules  and  crasts  are  still  larger  the  condition  is  I 
ecthifma. 

liistologic-ally,  in  acute  eczema,  one  finds  congestion  of  i 
atid  Ivniphatic"  vessels  in  the  corium,  w^th  exudation  of  plii 
diape<lesis  of  leukcxytes.  The  connective-tissue  fillers  an 
and  compressed,  ami  there  is  to  some  extent  proliferation  i>t 
nective-tissue  corpuscles.  In  the  milder  fonns,  the  pnKcss 
confined  to  the  papillary  regions  and  upjier  layers  of  the  co 
in  severer  ciises  extends  to  the  siilx-utuneous  tissues.  'I'he  (•( 
rete  are  swollen,  and  there  is  effusion  of  fluid,  with  more  or  It- 
Otis  wandering  <-ells.  The  rete-cells  may  also  undergo  a  ( i 
necrosis  with  the  formation  of  cavities.  When  the  exudation  i 
vesic-les  or  bulla-  may  form  lietween  the  rete  and  the  horny  i;i> 
contain  serum,  fibrin,  leukocytes,  and  detritus.  In  the  pusinl 
the  numlwr  of  lciik<wytes  "is  very  considemble.  Desciii.ii 
the  sujieriicial  epidermi.s  takes  place  in  many  instanc-es  and 
acteristic  change  in  eczema  .sciuamosum  and  rubrum. 

In  chnmic  eczema,  proliferation  of  connective  tissue  in  t'.> 


issue  in  <'■■<■  <'<>niira. 


hKHMATITIS  or  ISKSOWS  AXD  DOUBTFUL  ETIOLOGY     937 

with  <lep«Hie  of  pi^iiMiit,  Jon,  lier  wiili  hvppri>|.wiu  of  thf  rrte. dominate 
tin  picture.  'Ihi'  priM-esw  inuv  exteml  to  the  sulHUtaueiius  ti.s.Hue.s, 
|.r.Klu«inK  ntn>pli.v  of  the  fat,  hair-fiJIiiles,  and  >{land.s.  Otrasionallv, 
owiitu  to  the  «»lKstru<tion  of  veins  and  lyniphaties,  a  fonn  of  elephantiasis 
n-Mihs.  The  acute  fonn.  however,  n'ay  heul  witliout  pn««lu<iiij{  much 
|>.rtiiun«nt  chanjp'.  save.  |)os.silih-,  a  little  pigmental  ion. 

Erijfl'.rmn  rxudntintm  multiforme  is  an  affection  <»f  unknown  etiol«i({v, 
llu-  ( httraiteri.stic  features  of  which  are  congestion,  cedenia.  and  some^ 
liiii.s  heuiorrhaKe  in  the  skin.  It  is  foun<l  usually  in  vounjf  persotw 
hikI  tliiise  of  a  rheumatic  tendency.  In  some  ca.s«'s  tl  .•  <liWa.se  i.s  svnip- 
loiiiiitic,  l)einj{  found  in  such  afftrtions  as  rheumatism,  (vphus.  svphilis, 
anil  ).i)norrlia'a.  Here,  it  is  jiosiihly  of  the  nature  J.f  an  infe<tive 
iiHtustatic  «lermutitis.  In  <.ih«r  cas*-..  it  is  thought  to  Ik-  an  anfjioneu- 
n)>is  caused  l>y  .some  refle.x  liisturlmnc-e  (.r  a  «-in-ulatin)t  toxin. 

Ill  the  mildest  form  «>f  the  affection  then-  is  simple  conjfesiion  of  the 
skill.  In  others,  then'  is  an  inflanunatory  exudation  into  the  papillary 
iiikI  middle  layers  of  the  <-oriuni.  and  so'inetimi-s  even  into  the  ileetie'r 
lM)riioiis  of  the  coriiim  and  the  sulKUtantous  tissues.  The  cells  «)f  the 
n-lc  iiiuy  show  prolifemtion.  Where  the  .s«-n)us  exudation  is  iiiarke<l 
it  may  lead  to  the  accumulation  (»f  Hiiid  in  the  rete.  or  the  elevation 
of  the  epidermis  into  blisters  {her|K-s  iris,  herpes  circinatus.  er\thema 
Itiilldsiim.  hydnta  vesiculosiim).  Ther«-  is  always  more  i>r  le.s.s'  extra- 
vusiition  of  the  re<l  IiIimmIm-cIIs. 

hi  rri/thimn  nixlomm,  nither  deeply  seated  painful  iukIcs  i.re  f«)rm«l 
III  the  cutis  and  siilMiitaneous  tissues.  These  often  pn)jei(  sli);htlv 
iilMivf  the  surface  as  firm,  dusky  re<l  infill ration.s.  .\s  the  pnx-ess 
>iil)>i(lcs,  the  color  chanjjes  to  hliiish-red.  jtrec  11,  and  yellow.  In  excep- 
liimal  cases  the  inflanunation  i.s  .so  inteii.se  as  to  re.sult  in  ganRrene. 
Tlie  disease  is  usually  ass.Kiate*!  with  infiammatorv  rheumatism,  hut 
may  (xciir  without  arthritic  manifestations.  It  is  prolmhlv  a  siMiruilic 
nivfxitis  of  infective  orijjiii. 

I'l  III phl(f  11.1  is  a  somewhat  ohscure  affection  of  the  skin,  the  chief 
feature  of  whi(;h  is  the  efHoresceni-e  of  niimenms  vesicles,  varyinj;  in 
size  from  that  of  a  pea  to  that  of  a  goose  egg.  The  \esicles  'api)ear 
(Hrasionally  on  appaw'titly  healthy  skin,  hut,  as  a  rule,  develop  in 
patdics  of  erythema  or  urticaria-like  iukIcs.  Thev  contain  a  dear 
«ai  ■•  Hiiid,  or  .sometimes  l)loo<l.  which  e\  mutually  UKomes  cloudy  and 
|)tinil(i.|.  The  vesicles  then  dry  up  with  the  formation  of  crusts 
(/j(m/</(V/iM  nil(farh).  In  some  cases  the  siijH-rficial  epidermis  is  cast 
0^  >»  that  the  corium  is  exjmsed  over  coiisidenihle  areas  (pemphigm 
l>ilinni,„).  A  red  weeping  surface  is  thus  prcxluced.  In  such  ca.ses 
lilt"  <(irium  is  more  or  less  infiltrated  and  there  mav  l)e  a  certain  amount 
"f  necrosis  {pcmphlf/ii.s  (llphthcritlcii.s).  Fresh  granulations  mav  l)e 
foriii.d,  which  in  their  turn  are  destroyed.  In  the  .so-called  pemphigm 
'''■;!■ /■■■■x.  which  is  the  nio.-t  .severe  form  uf  llu-  affection  and  prugre.s.scs 
raiiiclly  toward  death,  the  intiannnatory  phenomena  are  more  marketl. 
111.'  vesicles  appear  at  first  on  the  skin  of  the  genitals.  <m  the  inner  side 
of  ihr  thighs,  the  axilhe.  and  the  miKous  membrane  of  the  mouth, 


'T 


f  i 


■if 


naK 


r/r/i'  .sA,7.v 


pvf iitiiultv  .s|mNi<liiiK  Jo  flu-  ojImt  inii(i>ii.s  surfun's  uihI  tin*  skin 
\k\uAv  \mh\\.  WIh'ii  tlw  »ii|M'rti(iul  t'pitlennis  '\>  oxfiJiulwl,  iiiiii 
|M>lvi)oi<l  or  wiirtv  rxfn'siriMf.s,  (•lo^(«•ly  M't  1(()(HIht,  un-  pnn 
wliich  Im>c«)Iih'  iNiiiiultti  Wvuii  exc-oriul*-"!  /.oih-.uihI  l»ie»'r.  hiv  siirr.. 
I»y  crtliiT  lilixtew.  A  foiii-HiiielliiiK  tlisi-hurn*?  in  thf  rrsiiU.  wliicli 
into  mists. 

The  liistolojfHal  H|i|M'unuMfs  in  pinplii^us  liavi-  liwii  vui 
int»'q)ifteii.  Sum-  think  timt  tlu-  imxi-ss  is  ii  |»rinmrv  tU-ni 
Aiispit/.,  iinionj:  otiu-rs.  U-li^-vt-s  tliut  thi-n-  is  first  ii  sudden  iilx 
of  Hiiid  fn)ni  the  ves'^ls  of  the  derinii,  whieh  nwlianiiulK  .s»'|mr«i 
••«<lls  of  the  rete.  S\hu-va  un-  tlius  fornuil  whi<-h  etmlesee  to  foi 
vesieles.  The  vesicles  or  huihe  may  ori>{iimte  lietween  the  ni 
the  su|)erHeiul  horny  hiyers,  hut.  mronlinjc  to  Cnieker,  may  a 
foutui  entin-iy  withiii  tiie  rete.  I.4iter  the  s\fim  of  a  se<oiidary  i 
mation  .set  in. 

Numerous  etioioKit-al  fa«-tors  have  U-en  hehl  to  l>e  the  ca 
IK'niphi^as.  Many  cases  are  attrihutaliU>  irw-tly  or  indire«' 
disorders  of  the  crntrul  nervous  system  am.  K-ripiieral  nerves,  > 
such  cases  may  lie  repinhsl  as  trophone..  iim-s.  Chills  {('n 
hysteria  (Dumesnil),  tramnatism,  and  hnal  \vound-infe<-tion  ( 
aiid  Hull<H-k)  liave  also  in-en  assigned  as  muM's.  A  curious  p 
the  marke<l  int-rease  of  the  eosinopiiiie  cells  in  the  KKxmI  and 
HuitI  of  the  vesicles.  There  is  .some  evidence  in  ♦avi-  of  a  in 
origin  for  the  disea.se. 

Clasely  related  to  |)«-mphi);us  is  the  disease  known  as  /x»m 
(cheiropiimpholyx.  dysidrosis).  Here  the  vesicles  are  mori' 
seatetl  in  the  palms  of  the  hands  and  soles  of  the  feet.  The  coi 
is  an  inflammatory  r>ne.  The  vesicles  form  in  the  upjK'r  layers 
rete,  the  cells  of  which  are  compresstHl  and  pushed  apart,  and  iir 
with  seiuin,  filirin,  and  later  with  leukiK-ytes.  The  swcat-j 
almost  without  exception,  ar»'  imaltered.  The  up|M'r  layers  of  the  i 
show  slight  inflannnution.  The  affection  is  found  most  often  ii 
of  a  nervous  teni|Mrament,  or  who  suffer  from  worry  or  overwoi 

In  hi/drofi  rtiiriiiifiiniir  vesicles  form  ujMin  the  skin,  not  uiiiiki 
found  in  variola.  They  present  a  central  dark  depression  iiii 
mately  ileal,  forming  a  scar.  The  disease  is  a  ran-  one,  Ik-^ 
usually  ill  infancy,  and  apjn-ars  to  follow  «-xposur«'  to  the  sun' 
and  to  heat  and  cold.  The  pnKcss  seems  to  iH'niii  with  iiiHaiii 
of  the  iip-KT  layers  of  the  coriiim,  followed  liy  the  formatinii  of  \ 
in  the  midtlle  portion  of  the  rete.  This  j;ives  place  to  a  sharpl\  < 
iie<-n)sis.  involving;  the  n'te.  the  up|)er  jMirt  of  the  c<jriiim.  and  lh< 
layers  of  the  stratum  corneum. 

'I'.ioridnis  is  a  ratlier  common  affe<lion  of  the  skin  which  lH'j.'ii 
the  formation  of  small  hrownish-red  |)apuU's  that  in  the  c<iui- 
few  davs  l)ecnme  topped  with  a  whitish  silvery  siale.  This 
removed  leaves  a  somewhat  re<ldish-l)rown  surface  in  which  i 
seen  a  small  hleetlin^;  point.  In  some  cases  the  patches  iiwiy 
considenihle  size.     As  the  pnKess  heals,  the  scale  is  exfoliated   i 


Via    3W 


mnsiATiTis  oy  vsksows  .\sh  wvhtfvi.  h:rioi.o<iy    atit 

fpnli  rmis  rptiirns  to  its  iioniuil  (i>iulitioii,  mivi-  ihut  u  «rrtuin  iiiihiiimi 
I)'  pi^riiH'iitutioii  iwuullv  n-inHiii.s.  SoitifliiiH.s  the  |hiUIh-.s  lu>al  al  ehr 
ccnln'  while  PXteiHliriK  at  i\w  \wn\i\wT\  {.pmtriimH  antiiUariii  siv«'  ififnita). 
T\\v  lt>ioiw  «»f  |xs<>riu.sis  iiHually  affei't  chiefly  ih^  extensor  siirfa«-«'s  of 
ih.-  limlw  in  the  iiei^'hlN>riiiM)<J  of  the  joints,'  the  saenii  re>{iini,  ami  on 
ihi-  liiiirv  jmrts  i>f  the  head. 
Any  jHirt  of  the  JMxIy,  how- 
(Vfr,  nmy  lie  involved,  even 
the  iiiiils. 

Ilisiolo^icHl  examination 
nIii)»s  the  horny  layer  to  lie 
(i)iisiil)-nilily  thi('k;>ne(l,  the 
irlls  U'injf  more  ur  le.s.s  dis- 
'tiit'ialcd  fpMii  eueh  other,  .so 
that  siNU-es  are  formed  which 
coiitaiii  j-ell-tlehris.  iMNlien 
that  an'  thought  hy  some  to 
Ih-  tiii(nK'(KTi,  and  air.  'I'his 
lireseiici'  of  air  j;ives  the  scales 
their  ciianicteristic-  silverv 
<hefii.  Coriiitication  is  im- 
perfti  I.  The  stratmn  ^'ranii- 
liisiiiii  is  ill  places  thickened, 
ill  o(l:*T-i,  thinned  or  ahsent. 
The  cells  of  the  rete  show 
lindilcralive  chanjfes.  There 
are  eiriision  of  stTiim  and 
extnivasalion  of  cells  into 
the  coriiim.  In  advancetl 
(hses  tlicr*'  is  ()ver>;rowth  of 
ilie  |.ii|)illic,  tojtether  with 
hvpcrphisiii  of  connective 
tissue,  and  the  priK-ess  miiy 
pread  even  to  the  .siilM-iita- 
ii«)iis  stnicfnres.  These  a|)- 
|Har!iiii  (s  have  Ih-cii  variously 
.Ntpti.ivicl.  Some  have  held  that  the  iiiHammatioii  in  the  coriiim 
:;  i.riinary,  tmt  later  oliservers  tlm,!:  that  it  is  secondary  to  the  clianires 
in  the  ivie  and  the  dwjM'r  layers  of  the  epidermis. 

The. lis*. -se  is  an  ohstinate  one,  and  certain  individuals  seem  to  have 
a  spp<ial  priMlisposition  to  it.  In  ..iich  persons  slijr|,t  .-xternal  irritation 
ma,-  invcipitate  an  attack.  It  is  common  al.so  in  those  of  a  rheimiatic 
or  ffmty  tendency. 

Lirh,N  nihrr  ariiminiitiis  (Kn[H>s\)  is  characterized  hv  the  formation 
ofim,,.,., ,  l,i,rd,  reddish  papules,  covered  at  their  Miiiiniits  with  tliickeiMsi 
epueriiiis.  The.se  enlar>,'e  hy  peripheral  jjrowth,  until  lar>;e,  diffiise 
f«l<lish  scaly  patches  are  pnxluced.  Kveiituallv  the  whole  hodv  inav 
w  iliviilved. 


I*iM>rittnip. 


(From  Dr.  .Sl,p|ili..r.f»  Skin  Clini...  .M.m- 
tr«l  (isnpral  iiii»|iiial.) 


Ml 


:  ^J 


■r  ;i, 


fH 


'.m 


THE  SKIX 


Hist()loj;i(ally,  one  finds  ()vtrj;rowth,  and  imperfect  comifici 
tlie  horny  layer,  involving  the  outlets  of  the  sebaceous  follicles, 
is  a  <-ellular  infiltration  about  the  vessels  of  the  coriuin,  tli( 
glands,  an<l  the  pupillary  luKlie.;.  The  rete  is  thickene<i  and  tl 
papillary  pnx-esses  are  irregularly  hypertrophic*!.  The  disease 
genenilly  believed  to  l>e  the  same  ii.,  the  pityr'mnh  rubra  pllnri 
French  school.     The  cau.se  is  not  known. 


Fia.  250 


I.irlifii  ruln'i  uruininatus  in  a  iiPKri'.      (Uiiwanl  Ftix':*  caw.) 


Ill  llclii'ii  ruber  ploiiux  the  nodes  are  Hat,  somewhat  coiiciivc 
a  glistening,  pale  or  reddish  waxy  appearance.  Cnx-ker'  lio 
tile  priKcss  is  an  intlanimaticm  of  the  upper  layers  of  the  corii 
secondary  involvenicnt  of  the  epidermis. 

The  disease  is  said  to  cH-cur  most  fre«|iiently  in  tho.se  of  ii 
disposition  or  who  are  suffering  from  .some  derangement  of  tlic 
system. 

IIy|)crtropliic  and  verrucous  forms  are  descril>ed. 

I.iijiii.i  friitlirmiilonii.i  is  a   rather  uncommon  affection  <>f  ll 
foiiiKl  most  often  in  women,  and  during  the  third  dwadc  of  lif 
etiology  is  (piitc  olisciire.     Some  believe  the  disease  to  be  ;i 
tuberculosis,  but  this  view  is  not  supported  by  a  study  of  the 

.Vccordiiig  to  Kaposi,  lu])us  erythematosus  begins  witli  the  In 
of  small,  elevated,  n'diiish  patches  the  size  of  a  jjin-head  up  Ic 
a  lentil.  Tiicsc  are  somewhat  depressed  in  tlie  centre,  wlml 
glistening  scar-like  appearance  or  is  covered  with  thin  adiitic 
The  jinMcss  may  ileal  at  the  centre  and  advance  at  the  perinlur 
iriithciiKitoniiK   (linroiilfK).      In    other  cases    the   disease   pn.-n 

'  Discuses  of  tlio  Skin,  soonml  edition,  l.SOS. 


SECONDARY  OR  SYMPTOMATIC  DERMATITIS 


\m 


the  formation  of  sefoiulary  hw\  (lupun  eryth'twitmux  dixurmiiiatuH). 
The  Itsions  may  be  fouiiil  on  the  face,  the  finjrers,  toes,  knees,  and  elbows. 
When  on  the  fare  a  somewhat  ehanieteristic  appearance  is  pnxhiced 
111  the  form  of  a  butterfly-shajied  patch  of  mhiess  extending  across  the 
liridjri'  of  the  nose  over  Inith  cheeks. 

Tlif  lesion  ap|)ears  to  consist  in  an  inflammation  of  the  upper  iavers 
of  the  corium.  in  tiie  nei>{hborh(Mx}  of  tlie  hair-follicles,  sebaceous 
(riands,  and  bicMKlvessels.  This  is  shown  by  the  presence  of  a  more 
or  less  extensive  infiltration  of  the  tissues  with  leukfx-ytes,  and  hyper- 
plasia of  the  c-onnective  tissue.  The  .specific  cells  of  the  glands  show- 
some  overj;n)wth,  but  in  course  of  time,  owing  to  retrograde  changes 
and  the  fibrou.s-t issue  overgrowth,  the  glands  tend  to  atrophy  and  dis- 
appear. The  papillte  and  interjiapillary  process  also  are  destn»ved. 
Small  hemorrhages  may  be  ob.served,  and  the  vessels  show  some  end- 
arteritis, with  (K'casionally,  thrombosis  or  embolism.  The  epidermis 
is  swollen,  heaped  up  into  scales,  or  elevated  into  vesicles.  Later, 
it  becomes  thin  and  atrophic.  The  caseous  n(xles  with  giant  cells, 
(iiardcteristic  of  lupus  vulgaris,  are  not  met  with  here. 

Secondary  or  Symptomatic  Dermatitis.—The  Exanthemata.— There 
are  a  iiuml>er  of  systemic  di.seases,  .some  of  them  certainly  and  others 
prol)a!)ly  of  the  nature  of  infectioas,  in  which  skin  lesions  are  a  more  or 
less  constant  and  characteristic  accompaniment.  The  cutaneous  mani- 
festations may  he  comparatively  trifling,  as  in  the  diffuse  ervthenias 
which  are  (Krasionally  met  with  in  sepsis,  or,  again,  may  l)e  .so'striking 
a.s  to  dominate  the  clinical  picture.  'I'he  diseases  belonging  to  the  latter 
(.Toiip  are  known  as  the  exanthemata.  Chief  among  them  are  measles, 
scarlatina,  varicella,  variola,  typhoiil.  and  typhus,  to  which  mav  jM-rhap.s 
lie  added  seco?idarv  .syphilis. 

The  pathogenesis  of  such  manifestations  is,  jwrhaps.  to  W  explained 
as  the  ctrect  of  cin-ulating  to.xins  upon  the  bloo<lvessels,  cither  directiv 
i>r  through  the  vasomotor  .system,  and  by  the  l(K-al  iiction  of  the  toxins 
u|Mm  the  epidermis.  Acconling  to  I'mia.  in  siuh  cases  when  inflam- 
matory changes  are  present  they  are  secondary  and  unessentiiil. 

The.'xanfhem  of  mrasleti  is  met  with  first  oil  the  nmcoiis  membrane  of 
file  lips  and  mouth  in  the  form  of  small  Imght  red  spots,  in  the  centre 
"f  whicli  are  mimUe  bliiish-white  points  (Koplik's  spots).  These  may 
ap|H-ar  from  twenty-four  or  forty-eight  hours  to  three  or  even  Ave  <hiys 
Ufon'  the  eruption  ap|H'ars  on"  the  skin.  Occasionallv,  thev  mav  be 
found  hcfon'  any  catarrhal  .symptoms  manifest  themselves.  "The  "skin 
lesions  ap|)ear  upon  the  lu-ck,  face,  forehead,  trunk  and  limbs,  in  the 
iinler  named. 

The  spots  are  dull  red  blotches  in  the  skin,  or  sometimes  slightlv 
raistil  iiUove  the  general  level.  They  are  irregular,  (.fteii  crescentic  iii 
*niiIH',  and  in  plat'es  may  'K-coine  confluent.  'I'he  skin  and  sulniita- 
[leiiiis  tissues  are  in  parts  .somewhat  n-dematous.  In  the  course  of  a 
le«  hiMiis,  or  two  or  three  days,  the  eruption  In-gins  to  pale,  and  graduallv 
'lMl)|«Mrs,  leaving  a  .slight  yellowish  pigmentation,  with  Hue  desciuama- 
iion  III  I  he  epidermis.     Rarely,  the  eruption  mav  Ik-  hemorrhagic. 


H 


\A 


■:\ 


till 

i 


042 


Tin:  SKIN 


llistolojjuiilly,  oiH-  liiuls  usiiallv  coiiftt'stion  of  t\w  I>I(mm1v»'.s- 
lviii|)liiiti(s  with  n'il»Miia  of  the  coriiiin.  In  tin-  papiihir  form 
ill  iiililitioii  sh>;ht  (liajH'dosis  of  U-wktK-ytvs  al»oiit  the  vessels, 
tlie  ^'himis.  aixi  in  tlie  papilhirv  lnHhes.  Minute  lieniorrhaj;es 
<K'<asionally  met  with.  In  the  most  severe  forms  then-  may  !»■ 
of  the  e])ithelium. 

The  eruption  in  .inirhitiiid  makes  its  apjH'anmee  first  upon  i 
ami  u|)iM'r  part  of  the  tiiorax  in  fnuit,  extendiuf;  rapidly  to  tin 
the  trunk,  and  hnaily  to  the  extremities.  The  skin  pn>sents, 
the  appearance  of  a  tiery,  n-ddisli-piiik  hlush.  When  examim 
closely,  the  rash  is  foimd  to  consist  of  innuinend)le  fine  reddisi 
closely  set  lojtetlwr.  Occasionally,  the  exanthem  is  more  d 
papular  (Kcitrliitiiin  fyipiiUmt),  or  may  1h'  ass<K'iated  with  the  fci 
of  vesicles  and  '  'ehs  (Kcarliitltiii  vi:iiriiliir!.i  rt  jxiniiliiffoidcx). 
rhaj;es  into  the  skin  may  also  (Krur  (nairldtiint  liniiorrlKK/ird). 
a  variaMe  pericnl,  from  one  to  seven  days,  the  eruption  assumo 
dusky  ri'<l  or  livid  ap|)earance  and  gradually  fades,  leaving;  a 
]>i};mented  -iirface.  Finally,  the  epidermis  des(|uainates  in  tl 
of  fine  impalpable  scales  (descpiamatio  furfuracea)  or  in  lai<; 
(des(piamatio  memhranacea). 

Ilistolo;;ically,   the  liUHHlvessels    of    the  skin   are  fountl   to 
i;csted  and  in  a  state  of  paralytic  dilatation.     It  is  said  by  most,  i 
tills  is  denied  liy  I'nna,  that  then-  is  an  inflammatory  exndah 
interstitial   tissues,  consistin)^  of  plasma,  leukcx-ytes,  and  exir; 
red  blood-cells.     The  n-te  cells  appear  also  to  Ik-  rapidly  prolil 

Uecj-ntly,  Mallory'    has    descriln-d    certain    iMxlies    in    ami 
the  epithelial  cells  of  the  epidermis  and  fn>e  in  the  sujM'Hicinl 
vessels  and  Sjiaces  of  the  <-oriuni,  which   he   is   inclined   to  il 
proto/.oa  and  the  sjH-cific  cause  of  scarlatina. 

In  riiriiild  the  eruption  ap|)ears  about  the  fourth  day  in  tlie 
small,  firm,  sliotty  papules  of  a  n-ddish  color.  The  i)apule-. 
with  first  on  the  wrists  and  on  the  forehead  about  the  border  of  I 
but  scaltert'd  papules  (piickly  form  elsewhen-  on  the  face  iiiiJ 
trunk  {ilisrrrtr  miidllpo.r).  On  the  fifth  or  sixth  <lay  the  \m\< 
transformed  into  vesicles,  which  an"  elevated,  roinided,  and  di 
in  llie  centre  or  unibilicated.  About  the  eif;litli  day  the  vesidi- 
pustules.  These  an'  rounded,  have  lost  the  central  UMii>i 
l)ccoiuiii<;  thereby  mon*  spherical,  and  are  bomided  by  a  /oiif  n 
etnia.  The  intervening;  skin  is  usually  somewhat  swollen.  In  ili 
of  ten  or  eleven  days,  in  favorable  cases,  the  pustules  griiilii 
up,  formiiif;  crusts,  un<ler  which  rejjeueration  of  tissue  ^jriiilui 
on.  .\fter  tlu-  crusts  art-  cast  off  there  d<H's  not  usually  n- 
scarrinj;  unless  the  papillary  layer  has  been  involved. 

In  the  form  of  smallpox  UKMlified  by  vaccination,  known  ii-  r. 
vesiculalioii  and  maturation  take  place  more  raj>idly,  and  tin  ]» 
much  fewer  in  iiuuiIht. 

'Jour.  Med.  Hewarcli,  10:  No  4:  1!K)»:  ».S3. 


1^ 


SKCONDAHV  OK  SYMPTOM  A  TIC  DERMATITIS  043 

MiKli  ni„iv  sever.,  is  the  r„„J1u,;,t  .wmllpoa:  He«.  the  papules  are 
.mi.h  more  tMimer..iis  an.l  .h.sely  set,  an.l  while  at  fiiNt  thev  inav  Ik- 
.  iMH-te,  they  s(H.n  iH^ome  more  or  less  fii.se<l,  so  that  lar>;e  amis  of  the 
skill  are  transformed  pm.lieajiy  into  an  extensive  suiH-rficial  al.scess 
ll„.  skm  IS  Kroatly  swollei.  an.l  .edematous.  'I'he  separation  of  the 
s<i,l.s,  m  the  .-ases  that  re.-.,v..r.  is  a  sl.,w  pr.K.-ss,  an.l  searriuK  is  often 

( )c.asionally,  fh.'  <-ru[ition  assumes  a  hem..rrhajrie  tvpe  Of  this 
two  varieties  are  m.,p,ize.l;  th.-  first, /,»r;>«r«  nmol,,',,',,  in  which  the 
li.rii„rrlia«i.-  extravasation  ap,K-aiN  early,  and  the  secon.l.  in  which 
111.'  .•(fusion  ..f  I.I.khI  .HcMirs  aft.-r  the  vesicles  an.l  pustules  have  In-en 
foriiicl,  rariola  piixl idomi  lirmnrrlinfj/ra. 

The  pnK-ess.  as  s(u.li...l  hist..l..«i,aliy,  iK-«ins  with  I.K-al  hvpen-mia 
of  the  papilla-  with  exu.lati..n  .,f  inflammatorv  pr.Mlu.ts  into  "the  rete 
II..'  .•xu.lati..ii  lea.ls  t<.  ...lema  .,f  the  ,H|s,  which  a«-  also  fr.,m  the 
|.r.N>iire  .)f  the  ouf-p..iir.-.l  (lui.l,  .liss.niat.-d  iii.,r.-  .,r  l.-ss  fr..in  each  .)tlier 
an.l  ••..mpr.-sM-.l  int..  a  filament.,us  m.shwork.     In  (his  wav,  owinjr  in 
part   t..  inleiNt.tial  ,.xu.lati.,ii,  an.l   in   part   t..  .•..lli.piative  necHHis  of 
■lu-  r.t.-  cells,  a  v..si,.l,-  ,s  forni.-.l  which  is  ,M-c-uliar  in  that  it  is  traverse.1 
l.v  a  numlK-r  of  d.-h.-at.-  l.an.ls  .•om,,.,s,..l  of  the  .•ompn.ss.-.l  epithelial 
.•.■Ik     1  lu-  vesi.les  ...ntaiii  plasma,  ,ell  .letritus,  nn.lear  fragments, 
aii-i  hl.rin       1  he  sujK-rh.-ial    epi.lermis  is   in  this  wav  elevate.l  al,.,ve 
til.'  .'.neral  level      AI,.M,t  the  (n-riphery  the  tissues  an-  ...n^este.l  an.l 
.nor.    .,r  l.-ss  mhllrale.l   with  Icuk.Kytes.     Th.-se  ^rmluallv  w.,rk  their 
w,,v  ,„„,  th..  ves...  e,  an.  ,  jjra.lually  in,r,-asinK  '""  nnmlK-lN,  ....nvert  it 
int..  a  pustule.       1  he  .leli.ate  septa,  lM-f.,r.-  n-ferre.l    to,  dve  wav  an.l 
til.'   piistue    assumes    a    in.,r.-    spheri.al.    el.-vate.l    apiK-araiue. "  The 
paiHlarv  layer  is   usually   inta.t.   but   in   the   nu.r.-  seven-  cases  there 
may  U-  mfiltrati..ii  .,f  the  .•oriiini  with  necn.sis,  resultin.'  in  th.   f.,rina- 
tmn  ..fa  s.-ar    in    the    pr.H-.-ss  .,f  healing.     Certain  spheri.al   iKnlies, 
l^l,.v,.d  ,„  k-  sp..ro/.,a,  have  In-en  .les,'rit,e.l  l.v  numen.us  ..[.servers' 
as  .K.urrin;:  1„„|,  within  the  nn.leus  an.l  in  the  pr.-u,,^.sm  ..f  the  epi- 
t  i-'lial  .ells  m  the  p,Kk,  whi.h  have  heen  h.-hl  t.,  I..    ,;,e  s.K-cifi,.  cause 
:-t  tiM.  .hsease.      I  he  n...st   ivent  an.l  important  work  ..n  th.-se  lines 
-  'i,,,t  of  (  ..uiKilman,  Ma^rath,  an.l  Hrin.'kerh..tr,'  who  c,.n.l.i.le  that 
■       liav  .lis..,.ver.-.l   the  s,M-.ific  ..aiise  of  vari..la.     'I'he  life   hist..rv 
of  t!Hir  orKamsm  has  l.een  stu.li,-,|  l.y  Calkins.^  who  i.lenfifies  ••.  with 
|li.'/ ;  lory.tes  .,f  (Jimrnieri.     Inasmu.h  as   it   has  hithert..  pr..v,-.|   t.. 
i«;  mi|.ossil,|,.  t..  cultivate  th.-  sp,.r.,z..a  on  artificial  me.lia,  the  .l.-ter- 
mm,.no„  of  the  eti..|.,p,al  ini,M.rtan,e  .,f  these  ..rKanisms  is  ren.lere,l 
|-v.--iv,.|y  ,hfh,.ult,  an.l  we  f,-.-l  that  -mtil  further  li^^ht  is  forth,'..ming 
^ti.'  "hole  siil.|»-<t  must  remain  .v(//>  yW/Vr. 

Tl,,    |,.sions  of  rnrrlnia  are  in  all  r.-s,.ects  c..mparal.le  t..  th..se  of 
^arini,,.  i„,tl,  „,  their  .linical  pr..}rressi,.n  an.l  in  histoL.jrical  striu-ture. 

MM'.,|''t2"''"^''"''   •^"""""■''    "'"'    '"^"'l"«>-   "f   Variola,  .Jour.  .\I,.,1.  Hesoarch, 
1-    I'K-'-l'istory  of  Cylorvctcs  Variola,  (Juariiicri,  ibiil,,  l;W. 


I! 


(■■  1 


944 


THE  SKIS 


i;:l 


-I 


Viirlirlln  l)eiirs  ii  fjcnenil  rfsi-mhlaiue  to  variola,  hut  the  p<xl< 
forine<!  iii(»iv  rapidly,  are  usimlly  uidiv  wuiity  than  in  iinnio 
smallpox,  and  the  disease  altoj^-ther  is  attended  with  but  trifliiij 
comfort.  The  p(xks  iH'Kii"  »'*  reddish  papules,  which  rapidly  art 
vertetl  into  clear,  pearly  vesicles.  They  (piickly  become  slijihtly  ti 
or  iK'casionally,  pustular,  an<l  finally  dry  up.  Kach  vesicle  is  sii 
deKne«l.  consillerahly  elevated,  and  surrounde<l  by  a  hypn-mic 
Sc-arrin^j,  as  a  rule,  dtH's  not  take  place. 

Histolofjieallv.  the  lesion  somewhat  closely  resembles  that  of  vii 
but  is  more  suiHrficial.  The  vesicle  formation  both  in  varicelli 
in  zaster  is  attributed  by  I'nna  to  a  peculiar  forin  (  '  cell-de>ienei 
which  he  terms  "balliK>ninn  coUiquation."  Certain  .nultuuicl 
cells  have  Ihhmi  found  in  the  vesicles  in  both  the  diseases  ju.st  ineiili 
and  have  In-en  regarded  by  some  as  parasites,  although  this  is  !)»■ 
bv  (lilchri.st'  t«>  l)e  erroneous. 

"  The  msh  in  fifphold  fcrcr  is  characterized  by  the  formation  of  isd 
sli^jhtly  elevated  papules,  of  a  r(»se  pink  color  (rose  spots),  which  :i 
first  uj)on  the  abdomen  and  the  lower  thoracic  zone.  As  a  rule,  the 
are  ratlier  few  iii  numl)er,  but  in  some  cases  the  eruption  is  abm 
involving  the  back,  and  even  the  t'xtremities.  The  papules  con 
in  successive  crops  after  the  end  of  the  first  week  and  in  v.  or 
(lavs  gradually  disapjiear,  leaving  a  slight  brownish  stain.  The 
are  from  2  to  4  mm.  in  diameter,  an-  palpable,  and  disappear  inc 
tarilv  on  pressure.  Occasionally,  the  rash  is  sudaminal  in  diiii 
Uarelv,  the  eruption  is  hemorrhagic."  After  the  ritsh  has  disap) 
the  skin  may  dcMiuamate.  The  spots  are  largely  congestive  in 
acter  and  c(mtain  the  sj)ecific  baiillus. 

In  fi/phim  ffirr  the  rash  is  rather  characteristic.  It  ap|K>ars  ii 
l)etween  the  thinl  and  fifth  days,  and  in  the  cours  •  of  two  or  tlint 
more  is  completely  out.  The  eruption  is  composed  of  two  cIct 
papular  rose  spots  and  ])etechia'.  The  rose  spots  and  the  pn 
apjiear  together,  or  else  many  of  the  rose  spots  become  hemorr 
Tiie  skin  between  the  si)ots  presents  a  curious,  appan'titly  decp- 
or  sulxuticular  mottli'ig  of  a  dusky-r»'d  color.  Sudamina  an-  nm 
mon.  In  the  case  of  childn-n  the  disease  has  been  mistaken  for  im 
The  rash  does  not  disaj)pear  after  <leath. 

Si/phil!x.--  In  the  secondary  stage  of  syphilis,  tiiat  is  to  say,  iilt 
iiifei'tion  has  In-coine  systemic,  skin  eruptions  an-  an  almost  i m 
feature.  It  is  characteristic  of  syphilitic  exanthemata  that  iIm 
extremely  polymorphous;  so  much  so  that  the  lesions  may  -in 
almost  any  of  tiie  ordinary  skin  eruptions.  Consetpiently  many  v 
sjK'ak  of  syphilitic  roseola,  lichen,  eczema,  psoriasis,  impetig".  li 
peinj)iiigus,  and  so  on. 

The  most  common  efflorescence  upon  the  skin  iKcnrring  in  >"  " 


'  .Inhiis   Hopkins   Hosp.    Hep..    1. 
■' Sfc  .NichoUs  ami   Kcirimmtli.    Tlic 
Laticot,  Lomloii,  1  ■  l'.K)l ;  ;$().■.. 


lIcinorrhiiKic   Uiatlu'sis  in  Typli 


,!■:  j 


SECOXDARV  OR  SYMPTOMATIC  DERMATITIS  945 

lues  is  the  s(M-alle,I  syphUUk  rosmla,  or  .na<i.l,.panular  svphilide 
1  lis  apiM-ars  usually  upon  tlu-  trunk,  l.ut  inav  .-xtt-nd  to  the  anas  and 
other  parts  of  the  \unly.  The  face  may  Ik-  exempt.  The  ..atehes  are 
re.l.lHh-lmwn  in  eolor,  somewhat  elevated  alw.ve  the  m-iieral  surface 
varviMf;  ,n  size  fnm,  that  of  a  lentil  to  that  of  a  bean,  and  tend  to  l,e 
symM,...rieully  .l,.str.l,ute<l.  After  one  or  (wo  we..ks  the  spots  become 
a  <hrty  hn.wn  or  ^niy  color  and  >;riidually  disai>pear. 


*..«.lar,v  ,„a,ular  syphilide.      (Fr,„„  Dr.  Sheph-r,!'-  Ski,,  .■li„i,..  M„„,reul  ,;e,„-ral  Ho.pi,,,,, 


^■uiotluliH    and  [K-ntliehal  proliferation.  is  ,„.)».  or  less  extra- 

^..-ation  of  leuk.x.yte.s  about  the  vessels  a„  .„ds.  tojrether  witli  some 
Heina.  \  ck  on  an.l  („rard,  among  others,  nave  fouii<l  the  Spir<x'h.Tta 
[•ulliiiii  111  (ins  lesion.  '      '^"'''•* 

^  The  papular  svphilide  assumes  various  form>.  It  begins  with  '"le 
-rmaiiuM  of  mldish  patches,  the  size  of  a  pin-head  or  larger,  within 
^^..  .■■  uimnate  or  flattened  papules  develop.  When  tit-  papules 
^"■MiMll  (he  condition  iK-ars  a  general  resemblance  to  lichen  ruber 
^n.l  i>  known  as  lichen  si/phiUficuK  In  some  cases,  vesicles  or  pusc-Vs 
•,  ■".  ui-..  the  papules  (hrrpr.',  .v/phililin,..  lmprt!f,o  s,,phllitira],  which 

Dion'  wr'"\r 'r''-  -'^''"r  '^ •'■^^  •"'""'""  '»•-  '»>« --fo™ 

nptiun     Where  the  lesions  mvolve  the  soles  of  the  feet  and  palms 


946 


THK  SKIN 


of  the  hands,  the  papules  are  flattened,  and  ..hen  involution  hi 
plaee  are  attended  with  tlie  prcHhielion  of  ahunchint  scales  ^j 
plnntitriK  if  imlmarin  KijphUiticit). 

In  regions  wliere  warmth  and  moisture  are  eomplieating  e<i 
the  papules  are  eonverteil  into  the  so-<alle«l  cimdijlomnM,  whieii 
elevations,  of  a  j;ni\isli  eolor,  with  a  moist,  siiiny  surface,  so 
secreting;  an  offensive  «li.siliar>^. 

Micnist-opically,  in  the  papular  |iluiide  the  pnx-ess  is  chiel 
observed  in  the  papillary  layer,  i)Ui  may  also  extentl  to  the  dee| 
of  the  corimn. 

The  vSpirocha-ta  i)alliila  has  reiM-atedly  k-en  found  in  stt-ondarx 
(I/evaditi,'  Hasehke.  and  Fischer),  and  in  the  condyloma  (Blase 


l-l.i.'liSi 


Syphilitic  rupia  on  tlie  arTn.     (From  the  Skin  Clinic  of  the  Montreal  (ienerul  II 

The  luhcrculnr  .si/pliitidr  is  slower  in  development  and  more  ii 
than  the  papule.  The  priKcss  may  \>e  ditfuse  but  is  more  < 
cumscrihed.  There  may  lie  more  or  less  absorption  in  tlic  > 
the  nodules,  or,  afjaiii,  central  necrosis  may  result  in  the  fcni 
an  ulcer.  In  the  transition  j)eriod  from  tiie  swondary  to  tin 
stifie,  the  lesions  may  l>e  covered  with  extensive  crusts,  pn  ■ 
curious  and  characteristic  concentric  arrangement,  somtil 
an  oyster  shell — .syphilitic  rupia. 


'  Compter  n'liil.  Soc.  de.  Riol.,  I':.ris,  .5!»-  liK).5:  .i27. 
'  Blaschko,  Med.  klin.  Woch.,  1900. 


Pal  (Jciierul  H'-i'ital. 


W,^fATlTIS  FROM  DRUGS  OR  OTHER  TOXIC  SUBS,  ANC,S      947 

2;:^r''' '"  ^"'"^  ''•^'"'^''""  »^  •--  -  ''.«t  mo.  or  i^ 

la,;ii:X'S"2'  'ff '"'*''"  '"•••'-  -••<•"'—  -structures  and 
syphilis.  „.!d.  indei     h;:;L\'"i"  ;;.7„7    r'-- , "■-".Nance  to 

Th.-  h..cr  lesions  art-  usually  „.  ]l  Zmlln   1^  „':  '"  *-"'«r'"*'"»- 

an.l  an.  fun^oi,!  i„  ,.hara "fer     Tv  1  y,  '"•''"'■'  "^  ''"'  ''"<'■■'' 

.he,   p..senf   the    ap;";;    ^    7?  t^^^^^'uiTr  '' ^""T" 
msernhle  the  other  inflrtive  Kranul„,„as    '        '       "'^•"'•"•'"'"'b-.    they 

,Vs.io,M,f\.ert«inr.;s  .ml    II     I  T/  '^  "^  ""■  "••^""  "^  '''e 

a((i..i>  of  thedrui-  i  ,  ..thers   L    Ir.      '  .    '.'"'*.«".'  ''"•-  t<>  d'e  direct 

;;;;* ';:;3;- .,z,.sj:;;l";;,: ,  F-^  ^^™ 

diph.h..riaa..tit.«i,'ll  „..;"'  ':'''''■  "" 'f'^':;'"';    ""<'    'l-""--.-.    an<l 

•f  |.il.a.,ui..ineJ.clh2Ze;,  T^  rt   "    M  'T  ^^'"'•!""" 
SalicvliV  aci.l  and  its  c()mnn,„,l.  1'       '"''*'''''' ''^  I'"'"''-*'"'"- 

nenn..,ro.sis.  """P"""<l^  '"".v  PhkIuc  ,.rythen.a.  ,H,r,.un.,  or 

.i-it;;';l.!^s;;rn;i;:;;,i;'T^r''^T'"^'''"-  ^'"'-  '••-  -^ 

les.  or  -.n.v„«a         ,    ;;*''",v^,     ll'*;:;.;:'"'  •'"  "•"  "'"">-  imply  c-are- 
i"toa,.„,„„.  ^  ''"""*''  "'"^v"<Ta.sy  „,„.st  often  U-  taken 

'l.eno..an.lears,;::^i;;?:J:,;,!;;;''''^'"-*  "•«'  *-^  '--  <".mn.only 

A'-M„„  totn  ItSr^^i;  7     PrP;3«-'».  "-ally  maize. 

I"-'""*.':..!;  to  the  aspergillus  famih-  (Lnt  ^  '"''''"''  "  "  ^""^"'^ 
'^  ervduina  of  the  skin  I  nter  -Vh  i'  f  *"  *"'"■''*"'*  ma.n-festations 
^^f"li."-.     S,.netii,es  crust    .r;f  ."     T'""'''  ''"••"""''  ''«'^''  «'"' 


F  ■- 


Hiv. 


'SJKT.  di  frumat.,  Rcggio-Emilia,  ;J3:  1«>07:  1. 


-I 


948 


THE  SKIN 


RITKOORBBSIVI  MITAMORPBOSU. 


Atrophy.— Simple  atrophy  of  the  skin  is  characterized  by  tli 
of  almost  all  its  elements.  The  ctindition  may  lie  local  or  ><«■ 
It  may  be  primary  or  the  result  of  some  preexistfnj;  patholoj; 
As  a  t.vpe,  may  be  taken  the  pliysiolojjical  atn»phy  found  in 
Here  the  cutis  liecomes  thiimer,  and  the  papillie  tend  to  \w 
and  may  disappear,  while  the  epidermis  liecomes  dry  ami  bril 
sulK'utaneous  fat  is  to  some  extent  alworbed,  and  the  ski 
thrown  into  folds.  The  elastic  tissue  involutes  and  the  i 
vessels  undergo  degeneration.  It  is  not  uncommon  to  find  g 
pigment  of  brownish  color  in  the  c-ells  of  the  rete  and  about  ( 
of  the  cutis.  The  deeper  layers  of  the  epidermis  are  atroplw 
the  stratum  corneum  is  less' widely  separated  from  the  papill 
The  hair-follicles  also  partake  in  the  process  and  the  haii 
downv  and  eventually  fall  out.  The  openings  of  tlie  follicles 
quently  become  bUxked,  owing  to  the  accunmlation  of  epideri 
and  they  may  be  dilated  into  cysts.  The  sebaceous  gland- 
are  obstructed,  and  the  hair-follicles  and  sebaceous  glancl 
tended  into  one  cavity  containing  hairs,  fat,  and  epitheli 
the  so-called  atheroma. '  Eventually,  the  sebaceous  glands  at 
finally  disappear.  Not  infrefjuentfy  the  superficial  epidermis 
up  here  and  there  into  branny  scales  (pityriasis  simiJex). 

Local  atrophy  is  often  bnnight  alniut  by  distension  of  the 
whatever  cause.  The  regioas  usually  affecte«l  are  the  breasts, 
and  thighs.  The  commonest  cause  is  pregnancy,  but  simi 
are  sometimes  pnxluced  by  tumors,  lactation,  ascites,  and 
During  pregnancy  the  alxlomen  is  covered  with  re«ldish  liv 
which  after  delivery  are  traiisfonne<l  into  whitish  silvery  lin( 
(lineee  albicantes). '  On  exi-.mining  such  a  scar,  the  papillic  i 
l)e  flattened  or  absent,  the  connective-tissue  fillers  of  the  ( 
dissociated,  the  elastic  fillers  and  bloo<lvessels  are  atrophic. 

A  somewhat  similar  local  atrophy  of  the  skin  is  found 
absorption  of  the  subcutaneous  fat  in  the  course  of  chroii 
diseases,  and  even  in  certain  acute  febrile  processes,  notali 
(Osier).  Lineie  atrophica  are  also  met  with  on  the  thighs  am 
as  the  result  of  the  pressure  of  corsets  or  other  articles  of  api 
Idiopathic  diiluse  symmetrical  atrophy  has  l>een  reported 
observers  (Bronson,'  Elliott,  and  Fordyce). 

Neurotrophic  Atrophy.— In  certain  ncr^■ous  affections,  such 
neuralgia,  and  neuritis,  the  skin  supplie<l  by  the  nerves  invob 
found  to  he  thin,  smooth,  and  shiny,  and  there  may  lie  was 
glands  and  hair-follicles  (Paget,  Weir-Mitchell). 

Ulceration. — Bedsores. — Bedsores  (decubitus)  are  a  form 
of  the  skin  and  underiying  parts  due  largely  to  pressure  in  tUi 

'Jour.  Cutan.  and  Gcnito-iirinary  Dis.,  13:  1895: 1. 


m 


AINHVM 


949 


gna.ls  reduc^  m  health.  Impoverished  blood,  a  weak  heart,  and 
.he  rtyumbent  pos.t.o,,  are  the  m,«t  important  pr«li.sp«.i„g  V^u^s 
Nei.n.trophjc  .nfluenc*,.  however,  often  plav  a  part,  for  iLlforesTre 
ap,  to  deve  op  w.th  ex«.p,io,.al  rapidity  In  u.nL  ^ffe^ti^eh  IS 
talHs  .i„«al.s  an.!  mye htis.  The  ^.^ions  usually  involved  a^  th^ 
^sarrnn,  trochanters,  heels,  and  scapuhe.  The  affWted  part  iMK-omes 
Jmsh-hlack  or  black  in  c„lor.  the  skin  cra.ks.  and  thSn  oS T 
mfHl,on  wuh  putrefactive  ,erm.s.  a  spivadin,/ ulcer  or  Ka",gZ.is 
Ci  rotheZe!  "'"'  "'^"''^  '"  *''•'  -»x.ut:neou.  .oft  tlssu'es 'and 
Perforttlng    Xnc.r.-.S«,mewhat    allied    to    this    is    the    perforating 

the  s,  n,al  cord.  A  .leeply-jH-netratrng  ulcer,  which  extends  rapi.llv 
I,  pr<xl,.ml.  usually  at  the  metatarsophalangeal  joint  of  the  R^aiuL' 
The  process  may  lay  bare  and  enxle  the  bone.'  It  mav  pfs^b  v  ^ 
due_to  pressure,  but  m  the  majority  of  instances  is  of 'neCotn'ph^ 

S„m!l  ulcerations  are  also  foun.l  on  the  hands  in  .ynngomuelia 
an  «ff«t  on  of  the  spmal  con!  in  wlm-h  the  sensorv  fibers  are  TaCh' 
.nterfm.1  w.  h.  These  ulcer,  are  pn.bably.  to  some  extent  at  E 
to  be  referre.  to  tniuma  or  irritation,  which  more  readily  occur  b  cS 
where  sensation  is  impaired.  ^  ^ 

Ia..on.  as,  for  example,  .n  the  lower  extremities  as  a  result^f  varSe 

Senile  Oangrene.-Senile  gangrene  is  a  form  occurring  in  old  nereons 

h..  have  advance,    arteriosclerosis.     It  genemllv  begi,«  in  one'^Fr 

u^  an.!  may  sprea,  gra,iually  upw«„|.    \t  i,  usuallv  ofX  dry  variet^^^^ 

=t™:.i'-:!^s  the^rt:::;:""^ ^-^  ^"  -'^-^'^  ^-^^ 

t"rtt£of'"l    *T  '^^-'-I.':^  -veral   observers,  notably 
'•  •'    •'  '""n  of  scierotlerma,  m  which  the  epidermis  is  thickened 
Ae  pa,.,Ihe  are  narrowe,!  an.l  lengthened,  and  the  ov^iiowth  S^^ 

'  Clark,  Trans.  Kpidemiol.  .Soc.,  Lond.,  1860. 


*    4i 

M  M 

'     ''^11 

r           K 

:Mf-' 
• 

950 


THK  SKIS 


leaiLs  to  .stran((ulation  of  the  deeper  layers  with  coaw<'Utive  iii( nw 
The  vessels  of  the  rutw  are  ililutetl  and  there  is  some  roumUHl 
infiltration,  with  oKstniction  to  the  Kinphatics.  Cases  huvf  U. 
reporte«l  in  this  eoiintry  by  F.  J.  Shephenl. 

OoUoid  Trantforouitlon.  -  Colloid  tnmsfonnation  of  the  iviii  Uolli 
milium)  is  a  rare  disease  in  which  the  eells  of  the  derma  and  ilie  iii 
nective  tissue  underp>  colloid  changes.  The  de^jeneration  i  - 
marked  about  the  hUnxlvessels,  ner>es,  and  seliai-eous  glands. 


tni 


ABNORMAL  nOMIHTAnOH. 


f 


The  anomalies  of  pigmentation  fall  into  two  dass«'s:  the  first,  in  wlii 
tht'ic  is  a  diminution  or  increase  in  the  amount  of  the  normal  <<>li)ri 
matter  of  the  skin,  and  the  se<-ond,  in  which  there  is  a  deposit  of  jmtl 
logical  or  extraneous  pigments. 

Congenital  alwence  of  the  pigment,  leukopathia  congenita  orallmiis 
has  already  l»een  referreil  to  (p.  tH).S). 

Acquired  laukopathia,  leokodemu,  or  vitiligo  occurs  spontaneously,  i 
occasionally,  after  the  infectious  fevers.  It  Is  apt  to  l)egiii  in  t-a 
life,  and  is  conunoner  in  the  black  races.  In  certain  n-gi<ms,  as 
Turkestan,  it  is  said  to  \w  endenii*-.  The  disea.st  is  chanictfrizcd 
the  pnxhiction  of  whitish,  pigment-free,  blotches,  often  syniinctrii 
usually  on  the  face,  tie<-k  and  hands.  The  condition  tends  to  >\m- 
and  by  the  coiiHuence  of  the  patches  large  areas  of  skin  InMoirif  wlii 
The  hair  upon  the  affected  regions  also  iHH'omes  bleached  (/xV/iw/.*  < 
cumncripta). 

Histologically,  one  finds  lack  of  pigment  in  the  decolori/.nl  are; 
with  occasionally  an  increase  of  that  in  the  surrounoing  norc  noni 
skin,  usually  in  the  corium. 

The  etiology  is  unknown.  Ix'loir  was  of  the  opinion  that  the  iilTccti 
should  l)e  referred  to  ner\ous  influences.  Perhaps  less  olisdiif  i 
those  cases  of  Uxal  symptomatic  leuk(Mlerma  resulting  from  inllaTnii 
tion,  such  as  the  forms  wiiicii  (x-cur  in  boils,  eczema,  lupus,  \v\m 
and  syphilis.     Here,  the  skin  is  smooth  and  sometimes  cicatrizi  '1. 

Lentigo. — lentigo  is  a  term  somewhat  loosely  employed  to  .lisi;;iu 
sharply  definetl  spots,  of  yellowish  or  i)rownisli-l)lack  .-olor,  \,irviii); 
size  from  that  of  a  pin-head  to  that  of  a  lentil.  They  soinewliiii  rrsciiil 
small  nevi,  appear  shortly  after  birth,  and  persist  throughout  iiff. 

Iphelides.—Epht tides"  or  freckles,  are  small,  irregularis  siiaiK 
yellowish-brown  blotches,  which  are  found  ustially  on  the  f:iri-.  iiiiin 
and  arms,  but  occasionally  on  other  parts  of  the  body.  TIkv  are  m 
common  in  chihlhood  and  early  life,  and  are  due  to  the  adi'Hi  nf  i 
light,  which  causes  an  increase  of  the  pigment. 

Ohloasma. — In  vvoinen  who  aiv  prcguuiit,  nienstniaiing.  i  r  «lio  i 
suffering  fnnn  disease  of  the  genital  organs,  it  is  not  micoiiiMoii  to  i 
pigmentation  of  the  skin,  usually  on  the  forehead,  temples,  di.  iks,alH 
men,  and  breasts.     Bright  brown  or  blackish-brown  patciu 


it  varvi 


PLATE   XI 


L«i«"Utive  iirirosis 
loine  n>iiii<l-<'ell*i| 
Ciwes   liuvr   Ufn 

if  the  riiii  (Killdiil 
I'rnui  und  ilif  nm- 
•iierutioii  is  nio^i 
IS  {(IuihIs. 


the  first,  in  whiili 
le  iiorinHl  cnlorin^' 
I  deposit  t>l'  |iatlii)- 

ireiiita  oralliiiiism, 

.s|H>ntitiu>iiiislv,  iir. 
to  l)ej;iii  ill  <'arl\ 
uin  regions,  as  in 
s  clianiftfrized  in 
)fteii  sviimu'lrical, 

I  tends  to  sprciil, 
ikiii  Ikm'oiiic  wiiilf. 
lehetl  (f>i)li(>.v!i  cir- 

deeoloriznl  nrea<. 
(ling    noH'  iioniiiil 

II  tliat  tlie  iiffectid!! 
s  less  (liiMiliv  :in- 
\fr  from  iiillaniiiiii- 
la,  hipiH.  If|mis\, 
escicatriziii. 
)lo_ved  to  ilrsipiiitt 
k  .-olor,  \, in  ill);  in 
soinewiiiii  rociiiiilf 
i^rhont  lilV, 
rre>;nl!iii\  ^iiapil, 
)n  tlic  f:ii  '■.  liii'iil^ 
Iv.  'riif\  iirt"  iii"^' 
1)  the  act  i' 111  of  ilie 


iinting. 


who  an 


t  uncoiiMiioii  to  !,ft 
iples,  cli'fks.alNlci- 
patiiit 


II 


varviiij; 


Leuki.der'm 


a   and    Leukonychin    i 


n   u    Negro,     i  Howard   Fo 


X.) 


m 
uU 
I'hi 

i 

ad 
crp 
i 
of 

l)rii 
I 
iiritl 
irril 
itiiil 
'I 

()I>,S( 

thtv 
atid 
(iisd 

I( 
ofti 
and 

I'l 
Ileal 
fcirii 

I'i 
wall 
nitr.i 
mtlt 
the  .. 
gnnp 


H3 

liiffei 
|ila.si{ 
alreai 
):reat 
ftiold 
Imnlt 
Ctl 

found 

'Tn 
also,  J. 


NOMESTATIOS 


Ml 


,ixe,  often  WominK  conflui-nt.  an-  pn„lii,.«l.    'I'hi.  i,  termwl  r*A*„m.i 
«frr»;«m.   AftiinilurcolonUi..n  is  sonietimes  fouiMl  in  tli<M«-  suffiTinit  fr«>m 
chr-mie  wastiMK  «Ii.ieii.s«..  |.>.,Hvial|y  HilH-rtiilusis  Uhlm>,mu  r„rhfrt!,-7,n,m) 
AddlMB  •  DtaMM.-Ii.  A.l<?!s,.„'.s iViM-HM'  t\»-  skill  aiMi  rnii<  oi.s  .siirfu«.,. 

fsij,vinll>- of  tiK- fm*.  nioulli. -hnrnt.  IuuhIs,  hnuisrs.  ,,,,.1  Kt-nitalia.  tt,s.siune 
.  (lurk  bnm-MHl  apjK'amiur.  .Mi(r(«<o,ii<allv,  all  that  is  strti  is  an  in- 
rrpiisc  of  pi^iiK'tit  III  the  «(>riiirii. 

HemoehroiMtoiii.  A  .iirious  .lull,  hrownish.  <,r  bluish  «lis«„loration 
of  (If  skill  IS  that  known  as  h«'in.Khn)iiial<«i.s.  whi.h  is  a  svinptoni 
as.s.H  laUtl  with  ,s.)im'  cases  of  (irrh.wis  of  tlu-  livt-r  an.i  .lialn-tes  (.lial,>te 

ri«iiH'i.tatioii  of  the  skin  also  wsiilts  from  a  variety  of  thwink,  ehtBieal 
ami  mMhaniMl  insults,  which.  owiiiK  to  their  iianm.,  nnnluee  chronic 
.mtaiion.  huch  are  siinhuni.  sirat.liiiiK.  jwrasitic  diseases  and  parasites. 
uii.i  the  application  of  niustanl    .r  flv-hlisters. 

The  exact  natim-  of  the  in<r.       ,1  pi;rn,en(«ii«n  in  these  .  .ses  is  .aiite 
nl,s,ur.-.     It  seems  Kenemllv  a      ,,t«|  now  that  the  normal  pigment  of 
Ihrsi  III  IS  pr.Mliice.1  through  the  nietalM.lism  of  iheepith.-lial  <rlls  (  L.k-I,') 
iind  It  may  Ik-  iiifem-,1  that  we  ar.-  .lealin^j  with  incifa.se.1  or.  at  least' 
tlisonlen-U  metaholisni  in  cases  such  as  have  Ih-cii  inentioiie<l 

Ict«M.-l<tcrus  is  a  yellowish,  yellowish-^nrn,  or  olive  <lis."olorution 
of  he  skill  an.l  external  surfaces,  <lue  to  the  presence  of  hilc  in  the  l,loo.l 
ami  luiiph. 

IVmentation  is  fn-.,uently  foun.l  alK.ut  varicose  veins,  .hroni,-  ami 
heahl  ulcers,  ami  is  ,lue  t.,  hemorrluKe,  the  efrus,.|  |,|,hh|  In-iiu'  tmns- 
formr.1  into  hemosi.lerin  an.l  in  some  <ases  into  hematoi.li-i 

.^rnentimon  may  also  |,c  .1,,,.  ,„  ,|„.  ,|,.,,^,,i,  „f  .j,,.,.^  j,,  „„.  ^.^^^^,_ 
»^lls  and  hhrous  tissue  (trgyriMi.)  in  ,H-rs.,ns  who  have  Ik-.-ii  takii.i: 
nitraf  of  silver  for  prolon^re,!  ,K.ri.Hls,  .,r.  similarlv,  t..  arsenic  (tnenic^ 
meI«io«i»).  Anrnn^  the  extrai.-ons  pif;m,.nts  sometimes  f.,im.|.  als...  in 
iMpowdw""^'        '"*■"""'"■''  ^'"""  ^  "'"*  ""»^«  <i"  tatf.M)inp)  and 

PB00RE8SIVS  MliTAMORPHOSES. 

Hyperpla8ia.-nyper,,lasia  ..f  the  skm  is  met    with    .m.ler   wi.lelv 

ff.;nM.  .•oii.litions  «n.|  m  „  variety  of  f.,rms.     The  .•onp-nital  hvpei:- 

t  V '  l'"        r    ''•''"•:"^'^    c-<'..Ke.iita.    elephantiasis,    an.l    i.evi  "l  ave 

b.K    l.,H.„  .lealt  w,th,p.!K.7ets.H,.).     The  a,..,uir.Hl  forms  a«.  in 

MV.  t  -Measure  due  to  inflammation  an.l  irritation,  although  in  s.m.e  the 

!  I    I    ".  '."'""'  "'  ""'^""""-      Ortain  of  them,  a-rain.  an-  on  the 

lK.r,l..,lMn,l  hetw«.„  simple  hyiK'Tlasia  un.l  i„fla,mu,,n    , 

C^us.-Ihe  sim,,lest  form  of  liy,M-n,lasia  is  ../,',«,. a;lositas.tvloma), 

i.-nony  met  with  as  the  n-sult  of  int.-rmitte.t  f,T.:snre:     It  is 

f'-'un.!  ..„ally  on  the  palms  of  the  iia.uis  ami  so„ ,  of'd.e  feet.     The 

aJlo'^rf  wr^'r"'!"  "'"'  *'"'^"  "'  ''''-'"'^■"''  """'^''"■'  "^t"'"'  ''■■  'S^O^ZSO; 
•US',  .Jo'irii.  Amer.  Metl.  Assoc,  31 : 1,S<J,S:  1302. 


If 


li 


;f 


I 


Ml 


952 


Tin:  SA7.V 


outer  layers  of  the  epidermis  are  eompressed  into  a  dense  homojy 
mass.  As  a  n-sult,  tiie  middle  layers  are  tliiekenetl,  while  tli 
and  papiihe  are  atrophied.  In  ailvaneed  cases  the  cells  of  tl 
extend  deeply  into  the  corinni,  where  they  heconie  fused  tojjet 
form  a  sort  of  core,  givinj;  rise  to  the  well-known  corti.  As  i 
there  is  more  or  less  seconiiary  inflanuuation  in  the  neinhborinj;  I 
which  are  swollen  and  hy])eremic. 

Oomu  Cutaneum.  -Cormi  cutaneum  is  a  remarkable  out{ 
of  the  epidermis,  forming  a  horn-like  excrescence,  which  often  i 
a  considerable  size.  The  usual  situation  is  on  the  forehead,  1 
and  hands.  The  horns  nuiy  develop  on  otherwise  healthy  si 
in  connection  with  scars,  atheroma,  or  tumors.  Acconlinj;  to 
the  pnx-ess  is  a  combination  of  acanthosis  with  hyperkeratosis, 
cells  of  the  rete  f;row  downward  between  the  pa])ilin>,  some  of 
become  narrowe<l  and  elon};ated,  wiiile  others  undergo  atnipli 
the  pnK-ess  advances  the  horny  layer  becomes  thickened  and  tii 
are  heaped  up  until  a  hanl  outgrowth  is  the  result. 

Palmar  and  Plantar  Keratodermia.  Palmar  and  plantar  kerat(x 
(tylosis,  keratosis  palnue  et  pianta-)  is  a  hnal  keratosis,  believe<i 
the  result  of  disordered  ner\e  finiction.  It  is  a  rare  disease, 
congenital  or  acquired  early  in  childiiootl,  but  has  been  known  to 
hyperidrosis  and  the  prolonged  use  of  arsenic'  A  somewiiat 
condition  is  found  in  eczema,  lichen  planus,  syphilis,  and  other  i 
mations  of  the  parts. 

Ichthyosis. — The  .so-<alled  accpiiri'd  form  of  ichthyosis  di 
shortly  after  birlii,  and  is  met  with  in  all  degrt-es  of  severity,  I 
simple  thickening  of  the  skin,  scanely  if  at  all  to  be  dislini; 
from  lichen  pilaris,  to  irhflujoaix  niiiiplf.r,  and  finally  to  irii 
stiunxicrmn  and  ivhf  hi/on  in  lii/stri.r,  in  which  the  skin  is  thick, 
or  warty. 

In  the  milder  grades  there  is,  acconling  to  I  Una,  a  marked 
keratosis  of  cells  derived  directly  from  the  rete  without  the  intcqi 
of  the  granular  layer.  The  cells  of  the  rete  are  small  and  iiypo] 
the  papiihe  broad  an<l  Hat.  Excess  of  ])igment  is  found,  cliictly 
palisade  cells.  In  the  cutis  the  collagenous  fibers  are  thickcm 
elastic  hbers  and  f.it  ten<l  to  disappear,  and  the  lymph-clianii 
obliterate<l.  Secondary  inHanunation  is  not  uncommon.  In  i 
called  iclithyotic  eczema,  there  is  more  n-action  on  the  ])art  of  il 
as  shown  by  proliferation  and  hyper])lasia,  with  reappearanci' 
granular  layer.  A  moister  pnx'e.ss  with  the  heaping  up  of  1 1' 
prtxluced.  When  the  hyperplasia  alTects  the  papilla-  as  well,  a  t;i 
or  niHlular  surface,  and  even  actual  warts,  may  be  the  result  (irli 
hi/.strl.r).     One  form  is  ass(H'iafed  with  ele|)liantiasis. 

Scleroderma. — SdercHlerma  is  an  atl'e<lion  of  doubtful  etiol<>i;y. 
most  conunon  in  females  and  in  tho.se  of  a  neurotic  disposition. 

'  HonibfTR.  Klin.  Wnhr.  u.  IV'ohacli,  Ik-rliii,  ls.")l :  22S;  Krasimis  Wil  " 
of  Cut.  .Med.,  1 :  l8(i,S:  3.">5. 


ELKPHASTIA.Vft 


953 


simis  W  il   ill,  Juiir. 


A„at(.,nK«lly,  iMimy  he  .llffu.r  .,,,1  wulespn-a.!,  or  pve  rise  to  1,k-«1 
esM.Ms  of  a  iHH-ul.ar  ,l.„ual  type,  ki.own  as  morphwa.  The  diffuse 
orin  ess  of|e„  the  nn-musvriM,  .Krasionally  eon/es  on  after  expasure 
.0  .ohl.  ervs.,H.|a.s.  a.ul  an.te  rheinnatis.n.  I„  some  cases  of  inomluea 
|t  >s  poss.hle  that  some  .hsonler  of  the  nerve  centres  is  at  work  but 
,n  tlu-  majority  of  cas^s  the  natnre  of  the  s<.ler,xienna  is  quite  obscure, 
h.  a  few  cases  h.  ;,.  -v...  .l„n,l  has  been  fo.m.l  to  be  diminished  in 
size  (dinger  an<!  I  ....•>  The  -h'  rtse  is  n.et  with  on  the  trunk,  face" 
or.-x.r,nmt.es  ...1  .,  character..^  ,1  by  a  pe^-uiiar  brawnv  indumtion 
of  the  skin  and  uh,  utancons  ti  ues,  whicli  feel  much  as'if  they  were 
fmziM.  Ihe  .hs  ■-.  ,  .ay  come  on  quickly  and  extend  rapidly,  it  mav 
reniain  stationary,  or.  apain,  i....y  finally  retrograde. 

h,.  histologual  changes  are  conHned  almost  exclusively  to  the  corium 
ami  underlying  parts.  At  most  the«.  may  be  slight  pigmentation  in 
som.-  cases  in  the  jleeprr  parts  of  the  rete.  The  vessels  are  thickened" 
t  e  lyniph-c-hannels  are  narrowe,!,  an.l  there  is  hypertrophy  of  the 
elastic  ami  hbrous  tissue  There  is  a  certain  amount  of  cellulaJ  infiltra- 
tion Ihe  newly-forim.!  connective  tissue  finally  un.lergoes  cicatricial 
cnntracdon  and  atrophy  of  the  various  glands  results 

A  pcuhar  f..rni  .H-.urs  in  childn-n,  usually  in  those  of  low  vitality 

kn-mii  as  ,0 ,T,v»„  nronatorun,.     It  is  congenital  or  begins  in  the  earli;; 

Hmrhs  of  he.  aiKlusualy  affects  the  legs  ami  feet.     Acc-oixling  To 

L  ger  ,t  IS  due    o  the  soli.lifi,.ation  of  the  sulKUtaneous  fat.  procluc^d 

In- the  lowering  of  the  temperature.  ^ 

„Sf  "'T'^'*;!:!"""'^''  ^'■'':Pl":"'i"sis  Arabum.  pachvlermia 
•ipiiMi.  )  s  a  condition  characterized  by  the  most  extreme'  hvper- 
plas.,,-  .hickening  of  the  skin  and  sulKUtaneous  tissues.  The  cl L^s^ 
IS  e„,l..„uc  in  certain  tr.,pi,,,l  and  subtropical  countries,  as  Arabia 

ah  nut  «,th  ,n  the  temperate  climes.  Some  cases  begin  with  the 
d.n>.a   manifestations  of  a  hnal  inHammatorv  prcness,  as,  for  instan  e 

o  .lie  tliKkemng  o    the  tissues,  which  finally  becomes  extreme. 
'  »i  1  r,,  again,  are  mon-  sluggish  and  insi.lious. 

llu-  .tiology  ,,s  not  altogether  clear.    Manv cases, although  not  all  are 
:j   ..  .he  presence  of  the  Kilaria  sanguini;  hominis  an.Mts  eSdln"" 
1  -  ■    urumulate  in  the   lymphatic  ,.hannels,  usually  of  the   lo'wer 
J-  .1  ics,  scrotum   or  abdomen,  where  they  cause  sta.sis  of  the  Ivniph 
I    I    J.V.U. ve  inflainma.,.,n  an.l  fibrous  hypen.lasia.     ( )bstruct-ioi:  o 
.1     '  „  "'''*''•*•»!'-■•'•  7'<l>  "-^  the  pressure  of  inflammatory 

1.  .11  ';•  ■■:.""""'  ::'-.''*-^t."'^'iv.-  .lisease  of  the  lymplmtii- 

.  p-cdispose  to  the  coiuiition.  if  they  ,|o  not  a..tuallv 'cause  it. 

■  ..r.Ml .  cases  are  not  infre,,ue.itly  i.t.ribu.able  to  passive  congestion. 
r;:  ;   '""V:;     T'-''""f  '""->-"-'-.-'•'.  aslr,si,H.|as.Lenm 
S   ifi'mo,       "  "T"  " '""  •  '7'."^'  "'■'*''''<'"^l.v.  without  inflammatory 
uue  to  iiilieritcl  peculiarities  or  mtra-uterine  pathological  conditions 


1^ 


954 


THE  RKlS 


In  acqiiirtHl  elephantiasis  tlie  tissues  involveil  present  mow  ( 
thiekeninft,  n-sultinj;  in  some  cases  in  enormous  enlargement  of  tli 


Yui.  2M 


IrJephalitiasi^  i>f  llif  Icf?.      Ijmrnmus  friliirK<'rn(*nt  of  the  limb,  witli  iclitli> 
(Kroiii  tlie  I'alholoKicat  Museum.  Mc(iill  L'niversity.) 


with  obliteration  of  the  normal  contour.  The  skin  and  siiiicii: 
tissues  are  thiekeneil,  firm,  and  indurated.  Thev  may  he  hani  A 
iiam  dura),  or  soft  and  grayish-white  {E.  moUis).    In  some  ^joj 


u 


CONDYLOMA 


955 


inent  of  llit-  |iiiri. 


lymphatics  are  dilated  and  on  section  abundant  serous  fluid  exudes 
(A..  l!i>n),h,n,(,,rrtalin,).     The  .skin  .surface  is  smooth  {E.  glabra)  warty 
(L  rrrr  :ro,a),  ,um\uUit{E.  luhrmmn,  or  piii»\UmaUmH{E.  pa  pi  llomat,mi) 
I>.  M.MH.  ,;a.ses  tile  horny  layer  is  thickenefl,  forming  scales  or  plates 
(iic'liiiml  iclith;/o.iis,  hrrafosin).  '^ 

Micnwcopically.  in  tlie  .severer  forms,  the  connec-tive  tissue  of  the 
nUH  IS  hyperiilastic,  witli  .some  atrophy  of  the  fat.  The  i)loo.lve.s.sels 
ar.'  .hlatetl  and  thickened.  I,ut  not  iiivariai.lv  so.  and  there  is  often 
perivascular  leukcnytic  infiltration.  In  the  tn.pical  varietv  the  Ivm- 
phafcs  are  dilated,  their  walls  thickened,  and  the  sulKUtaneous  tissues 
arc  ..dematous.     The  epi.lermis  presents  varying  degrees  of  keratosis. 

Mcsides  the  diffuse  form,  l<K-al  tumoi-i  of  similar  appc;irance  are 
.  es.TilKMl  as  occurring  on  the  .scrotum,  pn-puce,  vulva,  and.  rarelv,  on 
the  hreast. 

Keratosis  Pilaris.- Keratosis  pilaris  (lichen  pilaris)  is  characteriaed 
l.y  the  torination  of  small  papules  a(.out  the  hair-follicks.  The  proce.ss 
may  l.e  simple  (^rw/fty/,,  pilaris  alba),  or  complicated  l.v  inflammation 
^krwtavx  pilaris  rubra).  Various  grades  and  mixlifications  of  the  tlisease 
«ist  la  we  1-marke.l  cases  there  is  hyperkeratosis  in  a:.d  about  the 
folli.  Ics.  which  become  cK-cluded  by  horiiv  j.lugs  at  their  orifices  The 
^Miij.!.'  varietv  is  usually  found  on  the  e.xtensor  surfaces  of  the  limbs 
will  -■  the  inflammatory  form  is  apt  to  involve  the  flexor  surfaces  as 
well. 

Keratosis  Follicularis.  —  Keratosis  folliciilans.  or  Darier's  disease  is 
a  |..Hiilmr  affection  of  the  skin,  Hrst  described  l.v  Darier'  under  the 
nainc  "psoro.spermo.se  folli<-ulaire."  since  he  thought  that  certain  cell- 
inchisu.ns  in  the  rete  were  of  the  nature  <.f  psor,.si)erms.  These  arf 
now  generally  thought  to  I)e  jieculiar  f(.rms  of  celhlegeneration  The 
.liseasc  usiir,  ins  i,,  cIuMIkhhI.     The  eti..logv  is  unknown.     The 

e.sjoM  ,  ons-s-  „„ary  keratosis  and  parakeratosis  ,.f  the  .seba.ec.us 

follHcs  and  ,.  ,  .,s.  The  pr.Kr.ss  apparently  begins  in  the  m..uths 
..fill.'  fo  hcles  and.  later,  extends  to  the  interf<.llicular  tissues.  The 
mon.h.  uf  the  follicles  are  (lilate<l  and  ..ccbi.led  bv  imperfe.tiv  cornified 
cells,  it  IS  believed,  also,  that  the  lesions  mav  at  times  origiiiate  in  the 
epi.i.rin.s  and  about  the  (.rifices  of  the  swea't  diu'ts.  !„  the  rete  are 
t"  «■  seen  certain  n.iinded  bcnlies  that  closelv  resemble  i.sorospenns 
and  at  the  l.<.ttom  ..f  the  f<.llicle-plugs  an-  compressed  li..in<.gene..u.s 
nmvs,.,,  w  nch  IJarier  <-alled  "grains."  Fissun-s  ,.r  lacuna-  are  oKserve,! 
I^lw.cn  the  cells  of  the  rete.  'I'lu-  rete  generallv  shows  marked  pro- 
if.raiH.ii, and  may  exten.l  deeply  into  the  <<,riiiin.  The  stratum  granu- 
losmi,  IS  ab.sent.  There  is  slight  cellular  infiltration  in  the  corium 
an.l  a  il.-|.osit  of  pigment  at  the  [M-ripherv  of  the  lesi<.n. 

Condyloma.  L,xal  outgrowths,  reseinbling  papillomas,  are  lu.t  infre- 
:|i»'Mly  found  m  situations  where  the  skin  is  subjected  to  chronic 
■rritaiinn,  as.  for  instan,-e.  the  presence  nf  inflammatorv  proce.sses.  dis- 
(iiarn.  s  ,|,rt,  and  friction.     Warmth  and  moisture  predisjw.se  fo  their 

'  Internal,  .\tlas  .s<.lt.  H.iutkrankli.,  S. 


956 


THE  SKIS 


formation.  We  find,  therefore,  that  they  are  most  commonly  present 
about  th-i  external  ^nitals  and  near  the  anus,  where  they  form  what  are 
usually  known  as  coiidylomatn  ncuminntu.  (lonorrhnea,  venereal  ulcers 
and  dreomposing  set-retions  play  the  most  important  part.  They  \wg\n 
°s  «'riall  papillary  excre  ceiices,  and  may  increase  until  extei.iive  wartv 
or  cauliflower-like  gro.vths,  of  firm  consistence  and  whitish  color,  are 
pnxluceil.  The  process  is  essentially  an  overgrowth  of  the  papilla;, 
which  increase  in  length  a.« '  usually  become  branched.  Histologically 
the  outgrowths  consist  of  vascular  connec-tive  tissue,  containing  collec- 
tions of  round  cells  here  and  there.  The  lymphatics  are  fretjuentlv 
packed  with  inflammatory  round  cells,  which  are  also  numerous  in 
the  immediate  nei};hl)orh(KKl.  The  epithelium  over  the  hj-perplastic 
papillie  is  markedly  increuswl  in  thickness. 

Flo.  254 


f  !; ' 


The  variiius  Kradeii  nf  waits  anil  cjlaiimux  papilKiman.     (Perls.) 

Warts.  —  Wnrh  (verrucie)  are  of  vario'is  kinds,  hard,  soft,  or  papil- 
lomatci.  The  common  wart  is  found  usually  upon  the  IuiimIs.  It 
is  often  multiple,  a  fact  suggesting  a  possible  contagious  natun .  The 
cause  is  unknown,  but  inasmuch  as  «arts  fre<]uently  disappear  after 
persisting  for  some  time,  some  local  irritation  is  probably  at  worii. 
Warts  form  small  licmispherical  elevations  up<m  the  surface  o*  iln'  skin. 

Microscopically  there  is  an  excessive  development  of  the  pai)iilK, 


FIBROMA 


857 


mai%  those  in  the  c;entre  of  the  no.lule.     The  eentral  vessels  are 
dilated,  and  the  overlying  epithelium  is  hyperplastic 

Tianor«.-nhroin«..-Fil,ronias  are  not  infrequently  found  in  the 
t\  au^  "'^  "^'^"  multiple  and  may  attain  considerable  size.  The 
hanl  fibroma  {jiboma  durum)  is  much  rarer  than  the  soft  form  {fibroma 

Microscopically,  it  is  compose.!  of  interlacing  bands  of  dense  fibrous 
tissue,  with  relatively  few  nuclei,  and  but  few  elastic  fibrils  and  blood- 
vessels. ^^ 

The  soft  fibroma  (fihrmna  molle,  fibroma  moUuscm,.,  moUmcnm  simplex 
moUuscum  pendulum)  is  coinpased  of  a  loose  meshwork  of  connective 
tLssue,  often  oedematous  or  my.xomatous.    The  new-growth  In-gins  in 


Fli;.  255 


^.f.  Hbroma.     Winrkel  nbj.  N„.  ,!.  witl.out  ocular.     (Fnm,  Dr.  A.  (i.  \U-h..lW  , 


illpi-liiin.) 


he  M,|„,,taneous  tissues  and  cor.um,  an.l  projects  secondarilv  into  the 
p  lemns.     1  he  papilhe  are  flattened  from  pressure,  and  the  -epi.lermis 

th  IS  forms  a  uniform  thin  layer  over  the  tumor.    Possiblv  of  the  same 

nature  is  the  soft  wart  or  acrochordon . 
.\..cr.ling  to  V.  Recklinghausen,'  the  soft  fibroinas  arise  from  the 

fibo,,s  sheaths  o    the  s-ilx-utaneous  nerve  filaments,  whi.-h  proliferate 

ami  torm  connective-tissue  gmwtlis  of  rather  cellular  tvpe.     He  c^! 

^^mi.tly  terms  them  neurofibrom.U,.     These  tumors  maV  |>e  restri.-ted 

it  'IZ\7^^      X'    ^  P''""■"'«^'«""•-.  «>•■  may  Ik.' disseminated. 
ii>  the  local  form  a  large  soft  tumor  is  prrnluced  {molluscum  elephant- 

'  Ueber  die  n  ultiplen  Fibrorae  der  Haul.,  Berlin,  1882. 


958 


THE  SKIN 


iaaticum).  In  other  cases  a  complicated  meshwork  of  cimi 
tissue  arises  from  the  emioneurium  {plexiform  neummu;  "Rank 
rom,"  q.  v.).  These  in  the  course  of  their  development  soni 
lead  to  dilTuse  fibrous  thickeninjj  of  tiie  skin  and  sul)cutaneous 
(elephnnflanlg  neuromnUmi).  This  form  is  often  conj;ei)"tal  niid  d» 
mental  in  nature  and  gives  rise  to  curioas  li>l)ulate<l  f  >lds  of  tin 
recalling  the  appearances  in  certain  pachyderniata.  In  the  c 
dermntolijiih  or  cutis  laxn,  found  in  the  so-calle<i  "india-rubU-r' 
the  connective  tissue  has  l)een  found  to  l)e  transformed  into  niv 
toas  material,  while  the  elastic  fibres  were  normal. 

Diffuse  fibromatosis  of  the  skin  {ylrphuutiusii  fibromi)  is  me 
as  well  as  an  abnormal  overgn)wth  of  the  fat,  leading  to  thie 
of  the  skin  {elephantiasis  llpomatosa). 

Gerhardt,  Baerensprung,  antl  Simon  have  <lescribed  a  nniltip! 
mented  papilloma  or  nevus,  which  is  sup|M)sed  to  develop  in  ct  v 
with  the  nerve  trunks  (neuropathic  papilloma,  ncrvennevus,  nwrim 
laterls).     Little  is  known  about  it. 


Fio.  IJoti 


I''   I 


i;     M 


IS — 

i 

.^. 

r 

%.> 

iw 

i 

"% 

Sr^ 

1 

•wa^^ 

^ 

*^ 

-i^^^H 

Keloid. 

A  peculiar  form  of  fibroma  is  the  keloid  (dieloid),  wliii  li 
flattened,  round,  or  irregular  masses,  placpies,  and  elevatcil  s 
over  which  the  skin  is  smixitiilv  stretched.  In  general  it  !i!:!>  'i 
that  the  new-growth  resembles  scar  tissue.  The  disease  is  nut  ■■<» 
but  is  said  to  \w  more  frequent  in  the  negro  race.  It  i>  usi 
divide  the  cases  into  true  or  spontaneous  and  false  or  clcatrl<  nl 


KELOID 


050 


Both  vaneties  are  probably  of  the  same  nature,  although  it  is  not 
alwav.  iKxss.ble  to  get  evuienoe  of  a  previously  existing  scur.  Keldd 
usually  oUows  tr«u„,at..sn.  as  a  .s<ar.  a  vesicle,  a  pustt.le,  a  burn  or 
even  a  blow.  (Jcra.s.onailv.  no  etiologi.-al  fa.-tor  ean  Ik'  made  ^ut 
The  growth  .s  apt  to  Ik-  n.ultiple.  au.l  while  .,„t  malignant,  in  the  usual 
sens,',  ccmmonly  reeurs  after  removal,  owing  probablv  to  a  persisten 
temii  iK-y  toward  overgrt.wth  manifested  in  th.-  new  scar  1*"'^'^"' 


^f|: 


Fid.  257 


Keloid  ill  a  iiprt".     (Howard  I-ux's  case.) 

Histol„gi,.ally,  keloi.l  in  the  earlier  stages  is  nia.le  up  of  numerous 
spn.ll..  ...lis  but  later  of  dense  fibrous  tissue  fibrilhe.  wl.ieh  in  general 
are  arn.nge,  parallel  to  the  long  axis  of  the  tunu,r.  The  adventitia 
»f  he  vessels,  even  beyond  the  limits  of  the  gmwth,  shows  signs  of 
prohferation.  and  it  is  probable  that  this  is  the  primarv  change  The 
roniiin  to  some  extent  becomes  involved  in  the  growth  ' 

Heurom«.-\\1,ether  a  true  neuroma  .Kc.rs  in  the  skin  is  doubted 
b)  s.. me  observer..  Duhrmg.  however,  has  describe.!  a  case  in  which 
^ere  found  newly-forme.1  non-medull.-,t.-<l  nerve  fil>ers  in  a  connective- 

S'T^'^'l  ^.T*'?"'  "'''^^-  f'^''''  *^''"'^-    '^^^'^  ^■'^■'^«^''*  ^-^^  thickened 
and  surrounded  by  lymphoid  cells. 

P«piUoma.— Papillomas  are  not  infrequent. 


'1  ^* 


'i  !■ 


ill  i  -I 


960 


THE  SKIN 


LipOBM. — TJpoinas,   or   fatty   tumors,   are   of   frequent    oo(ii 
and  arise  from  the  sulx-utniieoiis  tissue.    Tiiey  form  roun<l,  Ha 


Fia.  238 


Extensive  papilloms  of  the  foot.     (From  the  Patliologii-kl  Museum.  MrCill  I  iiivir 

Fro.  2S0 


Pendulous  lipoma  of  the  slioulder.     (From  tlie  collection  of  the  Montreal  ('•iii  •;!  H 


MKiill  I'liiversitv  > 


XANTHELASMA 


961 


.n.I  Iobulate.1  Rrowth.,,  often  multiple  and  symmetriral.  The'  occur 
c.,m,nonly  on  the  arm.,  ami  alnnU  the  .sho„!,le«.  The  Aa^t  ^" 
|s  not  umle«too,l  Some  an-  congenital,  and  in  some  '».erapZ« 
to  1^  an  n,hent«l  pciHiuritv.  They  may  attain  a  consi.TemWeTzr 
Ran.ly.  they  .Kvome  mflame.1  and  necr^i.  ^ivi,^  rise  to  fu^l  uC 

Fin.  200 


re-1  C. !;.   : :  Hus|'ii»l) 


(iTom  the  Pathological  .MuMum  of  McCill  Universiiy.) 

n;„!r'?T.  "  ^t^«>"™— Xanthoma  or  xanthelasma  is  a  peculiar 
gmented  tumor  fmrnd  on  the  eyeli.ls  an.i  other  parts  of  "h^S 
t  (Kcasional ly  m  the  u.ternal  or^aas,  such  as  the  trachea,  per  Sn^um' 

the  lapsules  of  the  liver  and  spleen  pfncarumm, 

Hist„lo{;icaIl.    it  is  a  new-growth  of  connective  tissue  Wtween  the 

fer.;;  "''"■'•'  '"^  '".  '"  ^'""  '--"^  "^  -P'"-li""»  tvpe^which  van  eon! 
MderaLIv  ,n  s.ze  and  are  multin»cleate<l.  so  that  thev  ^semSe The 
nant  cells  m  .sarcomas  These  cells  are  gr«u,HHl  about  {hrre"els  and 
are  of,.,,  markedly  infiltrated  with  fat.     Thev  ma v  !«,  JZ^SZ  !m 

Wl"''-^-     ^\.^r'^  f™  lohulatetl  masserSltdee^" 

la.^e^  „   the  cormm,  which  (K-casionallv  reach  as  hitrh  as  the  n-te     ThI 

epuieniHs  may  l.e  .slightly  thinne<l,     The  charactSic  >e|low  coloTol 

tuiMor  IS  due  to  a  pigment  calle.1  lipochrome.  found  cSy  in  the 

Xaniliomas  form  vpllowish  growths  in  thp  «i;..  i\.,.  tu  i         ^ 

and  in   l'^  •«  ob«-ure.     Cases  are  occasionally  met  with  in  diabetics 
and  in  those  suffering  from  jaundice,  but  at.  mJr.  usually  sponrneo;;^! 


n!-. 


962 


TUB  SKIS 


Some  observers  attribute  the  growth  to  a  precetlinjj  inflammation, 
while  others  (Ziegler)  regard  it  as  a  lijiomatoan  lymphnngrmm  or 
endothelioma.  PoUitzer*  believes  that  the  xanthomas  found  on  the 
eyelids  are  different  from  those  occurring  in  other  places,  and  im-  not 
really  tumors,  but  are  <lue  to  fatty  degeneration  of  the  fibers  of  the 
orbicularis  .nascle  with  proliferation  of  the  nuclei. 

Myoma.— Myomas  «K-c-urring  superficially  in  the  skin  are  rare.  Tliey 
form  growths  varying  in  size  from  that  of  a  pin-head  to  that  of  u  wiilnut. 
They  are  often  multiple,  and  ari.se  either  from  the  arrectores  piloriim 
or  the  walls  of  the  arterioles.  The  tumors  are  composed  of  interlacing 
smooth-muscle  fibers,  with  a  few  elastic  fibrillw,  and  are  somtliines 


Fin.  MI 


I        !. 


Hnnangioms  nf  the  skin.    Tlie  lurfte  bliK.d  simiscs  are  wi-ll  shnwii.    Z«"i»a  ohj.  DD,  with.ul  ocullr. 
(Frnm  the  ciiUectiim  of  Dr.  A.  O.  .N'ichiills.) 

definitely  eticapsulated.  They  are  generally  fouiul  in  tlie  skin  of  the 
face  and  arms.  They  are  apt  to  recur.  Ilerzog'  has  collectiil  about  a 
dozen  cases  from  the  literature  and  reports  one  of  his  own.  In  some 
instances  the  vessels  are  dilated  (aiujlomtjoma). 

Myzomu,  chondronuui,  and  osteomu  are  rare  in  the  skin.  The 
myxomas  are  more  properly  myxosarcoi.  is,  and  are  found  n->iii'.lly  on 
the  external  female  genitalia. 

Angioma. — No  hanl  and  fust  line  can  be  drawn  betwwn  certain 
birth-marks  compnseil  nf  dilate<l  or  newly-formed  vessel*  (/"rn  ra*- 

'  Trans.  Amer.  Derm.  Assoc,  1897. 

•Jour.  Cutan.  and  Genito-urin.  Dis.,  16  :  1898  :  527. 


ihj.  1)1),  witli'.ul  "cuiar. 


LYMPHANGIOMA  gj, 

mrrnosum),  to  a  tumor-like  X^m^wtlr'-P^/'^'''''"'''''"'''  ""S^"^" 

walhl  vessel,  ,.„,!  ofu-n  so^  eelli^':  '*'Sv !""/""'"«  ''l'"'^- 
.«l  ir.  color,  „„d  are  cove«H  i'  h  s  3,  sk  n '  "n  P"''  °'  P"'''""'^" 
.ui.i,Ie.    IV.en.ed  „evi  „.  n"!  in^;:.^!  J'"o,  ui'Ti:"  ^•''™'"«"'^ 

Kiii.  2(3 


-rd 


I'si: 


fM 


i 


964 


THE  SKIS 


•J 
■:i 


be  iiiferretl  that  they  an-  often  «lue  to  some  dcveloptiiental  nnoiiu 
of  the  Ijmphatifs.  Certain  cases  of  lynjphanniettasis  iii  the  ^'.niiu 
or  lower  extremities  are  often  a.>is«x-iatetl  with  pn)liferHtion  «»f  til.rti 
tissue,  ami  are  pr«)j»eriy  to  lie  renanletl.  in  the  majority  i.f  iiistaru rs 
least,  as  due  to  inflammation  ami  obstruction  of  the  lymplwlmnn 
rather  than  as  true  tumors.  In  all  forms  there  is  ililatatioii  of  i 
lymphatics,  ami.  in  the  lymphangioma  proper,  a  new-forniaii..ii 
lymph-vessels.  Frwiuently  with  this  is  a-ssiM-iatetl  roumlH-ellwl  iiifilli 
tion  about  the  ves-sels  with  connective-tissue  hj-perplasia.  TUvn-  m 
also  1)6  keratosis  of  the  superficial  epidennis.  As  a  rule,  the  l.lw 
ve.ssels  show  dilatation  ami  overjjrowth  as  well. 

Some  of  the  warts  of  the  skin  are  pure  lymphanfji«)mas,  while  otln 
are  composeil  of  solid  masses  of  cells  in  the  corium,  and  have  \w 
called  hypertrophic  lymphanjjiomas.  or  emlotheliomas.  Certain  p 
mente<l  nevi  are  also  to  l)e  inchi<le«l  in  tl  is  group. 

Zarodanu  Pignwntoiuin.  -Under  the  name  xerotlemia  pinnwiitmi 
(nlrophodernM  pigmentosum,  mrlmioslit  Icntlculuris  prMjren.nrii,  Tic 
Kaposi  has  descrii)e«l  a  rare  affection  of  tiie  skin,  IjeKimung  a  few  iimn 
after  birth.  It  is  at  first  manifested  by  the  repeated  efflorescent 
rwldish  spots,  which,  later,  disappear  with  some  .scaling  of  the  sk 
As  the  spots  faile,  pigmenteil  areas,  not  unlike  freckles,  are  left,  a 
the  vessels  dilate.  Tlie  skin  l)ec(>mes  snuxith  and  atniphic,  and  lal 
warty  outgrowths  are  produced,  which  have  a  striking  teiideiuy 
develop  into  carcinoma. 

Multiple  Benign  Oyitic  Ipithelloma.  ^Inltiple  benign  cystu  epit 
lionui  is  a  rather  nirt-  disorder  of  the  skin,  which  has  letl  to  coiwd 
able  difference  of  opinion.  It  was  first  descril>e<l  by  .laciiuit  s 
Darier'  under  the  name  "  hydrad<'>nonie  eruptif,"  and  soniewliat  la 
bv  Brooke,'  who  termed  it  "epitlielionia  adem<i,'es  cysticiiiii,"  t 
bv  Fordyce.'  The  lesion  consists  in  the  formatio,.  of  multiple  sn 
papules,'nodules,  or  tul)ercles  in  the  skin,  usually  ju  the  face,  eveli 
forehead,  trunk,  or  arms.  In  some  cases  superficial  crosidn  ta 
place,  so  that  something  like  "ro«lent"  ulcer  is  the  result.  In  a  1 
instances  the  lesions  are  restricted  to  a  small  tlistrict,  but.  as  an 
numerous  widely  disseminateil  growths  are  observe<l.  'I'lie  <ii.s« 
usually  manifests  itself  in  the  first  two  decades  but  has  l)een  found « 
in  advanced  life. 

Histologically,  the  tun>ors  are  compo.sed  of  irregular,  oval,  or  eloiiga 
masses  ami  stramls  of  epithelial  cells,  resembling  those  of  iIk-  'Iw 
layers  of  the  epidermis.  In  some  cases  the  epithelial  cells  form  a  i 
form  diffuse  growth,  while  in  others  there  is  an  intricate  interlac 
and  anastomosis  of  the  various  bands.  Occasionally  the  gniwili  pres< 
an  alveolar  .irrangemcnt.  "Cell-nests,"  identical  with  tlio^  met  v 
in  malignant  epithelioma,  are  often  seen.     Many  of  these  I  ive  urn 

'  Ann.  de  dennat.  et  de  syph.,  8:  1887. 

'Brit.  Jour,  of  I)orm.,  September,   1892. 

•Jour.  Cutan.  and  Genito-urin.  Dis.,  10  :  1892  :  4.59  ai;  i  M- 


MOLLUSCVM  roSTsaiaWM  ggg 

•re  .lue  to  a  nnmlK-r  of  ^nrntlw  iM^-nm  in  thdr  iwtu^    S„L  h 

lymphmnjiomn  tub,nm,m  multiple  jr.     S.tne  oaJs  liL.VV^  I      'he  skin- 


Fio.  30.1 


?^^ 


M.illiM. 


urn  cntugi,,,,.,,,.     zri„„,,,.  I,|,,  „;„„„.,  ,„,,,„,      ,f^, 
l>r.  <ixkur  KI..IJ.) 


Ml  I  lie  riillertion  i,f 


459  ui:  I  .")lll- 


^"risr':;;;^;;^'- jrr-  (7'He.io.a  con. 

wame;,,  like  the  lastMnJntb  n^^-Z^  dUa  :  thaSl"'"'      ^^'"'"- 
miKh  difference  of  ooiiiion      U  .L^      ."'-'^"''e  tliat  has  given  rise  to 

abou.  .Ik.  size  of  I  Ta  or  I  Jn  l^SZ'"  ^"™,"^  '^T^'"^  "«d"'^« 
It  oceu^  sometimes  ...  „naii  epidemics  and  is  "Wie^^  by 


THE  SKIN 


n 


4  A'i- 


iJIOUS, 


many  (Virchow,  Liveing,  Bollinger,  Klebs,  Stellwagon)  to  be  contagio 
although  this  is  denied  by  others  (Erasmus  Wilson,  Rokitansky,  Hebra, 
Kaposi,  G.  H.  Fox). 

In  general  terms,  the  tumor  may  be  said  to  consist  of  a  series  of  radi- 
ally arranged  masses  of  epithelial  cells,  separated  f/om  each  other  by 
fibrous  septa  and  converging  toward  a  common  centre.  The  centre 
of  the  new-formation  is  broken  down  and  a  soft  tallowy  substance  can 
be  expressed.  According  to  White  and  Rob«>;y ,'  the  most  recent  investi- 
gators, the  new-growth  begins  in  the  rete.  The  lowest  layers  of  ceils 
resemble  the  normal  prickle-cells,  with  the  addition  that  many  of  them 
contain  one  or  more  nucleoli.  Some  of  the  cells  have  lost  their  nucleus 
and  are  composed  of  a  fine  fibrillary  protoplasm.  The  cells  of  the 
layers  above  become  more  or  less  distorted,  are  often  devoid  of  nuclei, 
and  contain  clear  rounded  spaces  which  give  the  characteristic  appear- 
ance to  the  structure  (moUuscum  bodies).  Toward  the  upper  regions 
of  the  growth  the  cells  become  more  or  less  keratinized.  The  signifi- 
cance of  the  changes  has  been  interpreted  variously.  Some  thinii 
that  the  peculiar  vacuolated  appearance  is  d-.e  to  amyloid  infiltration 
of  the  cells,  while  others  attribute  it  to  the  presence  of  protozoa. 
Repeated  attempts  have  been  made  to  cultivate  the  organism,  but  with- 
out success  so  that  the  majority  of  observers  are  now  agreed  that  the 
so-called  "moUuscum  bodies"  are  examples  of  cell-degeneration  and  not 
parasitic.  The  older  views  of  Engel,  Rokitansky,  and  Hebra,  that 
the  growth  originates  in  the  sebaceous  follicles,  and  that  of  Virchow, 
that  it  arises  from  the  hair-follicles,  have  now  practically  been  given 
up,  and  it  is  believed  to  be  more  probable  that  the  new-growth  is  due 
to  a  peculiar  and  characteristic  transformation  of  the  rete  cells  into 
keratin. 

Sarcoma. — Sarcomas  of  the  skin  are  relatively  rare,  and  may  be 
conveniently  divided  into  pigmented  and  non-pigmented  forms.  They 
are  primary  or  secondary. 

Melanotic  sarcoma  (melanoma,  chromatophoroma)  may  ari.sc,  thougli 
rarely,  from  apparently  normal  skin.  In  about  half  tiie  ca-scs,  how- 
ever, it  is  secondary  to  sarcoma  of  the  uvea.  The  majority  of  tiic  remain- 
ing 50  per  cent,  originate  in  pigmented  nevi  or  warts.  Tiic  tumor 
is  recognized  by  its  color,  which  is  brownish  or  brownish-black,  either 
diffuse  or  patchy  in  distribution.  The  primary  tumor  may  be  single 
and  remain  latent  for  years.  It  may  then  form  local  metasta.s(s  rapidly. 
This  form  of  new-growth  is  met  with  also  in  horses,  and  ( iirioasly 
enough  only  in  white  horses,  in  the  dark  skin  around  the  anus. 

Melanomas  are  tumors  of  connective-tissue  appearance,  (irifiinatin!: 
in  the  proliferation  of  certain  cells  which  are  identical  with  the  pigment- 
bearing  cells  (chromatophores)  of  the  normal  skin.  The  new  iy-formcd 
chromatophores  do  not  always  reach  adult  development,  for  many 
are  found  to  po.sse3.s  shorter  processes  or  are  actually  rouiiu*i!  The 
young  cells,  again,  are  often  devoid  of  pigment.    The  growth  com- 

•  MoUuscum  Contagiosum,  Jour.  Med.  Research,  (N.  S.  2) :  190J  :  --'5. 


jmM^.Lafe 


SARCOMA 


967 


Fro.  264 


monly  begins  in  the  deeper  layers  of  the  skin  and  gradually  insinuates 
.tself  through  the  epidermis,  so  that  small  warts,  S«^v  wTZnl 
pea  are  produced  which  eventually  form  a  fungatin^  maS  Unna 
Giichnst  and  others  reganl  these  tumors  as  originati^  inXe  epiE 
hum  and  hold  therefore,  that  they  are  epltheliomatous  mther  thaKH 
comatous.  The  most  recent  investigations,  however,  do  no  aowar 
0  support  this  view,  for  as  llibbert'  points  out,  melanotic  g^X 

are  undoubtedly  of  connective-tissue  origin  "F"ores 

Morphologically,  the  melanomas  are  spindle-celled  or  alveolar  sar- 

vascular  and  may  contain  extrava- 
sations of  blood. 

The  pignrient— melanin— is  foui.d 
in  fine  particles  or  irregular  clumps 
within  and  about  the  cells.  Its  exact 
composition  is  not  known,  possibly 
varying  acconling  to  the  nature 
and  position  of  the  growth,  but  it 
is  peculiar  in  that  it  contains  sul- 
phur. Melanomas  are  very  malig- 
nant, frequently  recurring  after 
removal,  and  forming  metastases 
rapidly  in  the  various  viscera.  The 
secondary  growths  may  at  times  be 
devoid  of  pigment. 

Under  the  term  idiopathic  multiple 
pigmciU  sarcoma,  Kaposi  descrilwd 
a  new-growth,  which  is  pigmented 
and  liighly  vascular,  owing  to  the 
presence  of  numerous  thin-walled 
capillaries.  It  is  not  now  believed 
to  be  a  true  pigmented  sarcoma,  for 
the  color  is  due  to  the  vascularitv 
and  the  deposition  of  altered  h\wA 
pigment.  The  growth  may  last  for 
years,  and^finally  liecomes  malig- 
nant, although  spontaneous  resolu- 
tion sometimes  takes  place.    The 

e.wt  nature  of  this  tumor  is  not  known.    Some  hold  that  it  belones 
to  the  infectious  granulomas.  ° 

Koa-pigmented  sarcomas  also  occur.  They  are  primary  and  second- 
a^',  single  or  .nu  tiple,  and  form  nodular  or  papillomatous  masses 
or  mixKlS'''         '*"'"■    "'"'"'"«''''"-^''  *''^y  *'*   ™""d-,  spindle-, 

•  Lehrbuch  der  speciellen  Path.,  1902:  784. 


Multiple  pinniented  sarcomas  in  the  skin. 
(From  the  coHection  of  Dr.  F.  J.  Shepherd.) 


968 


THE  SKIN 


nfaroiaieoma  and  ugiosareonu  are  sometimes  met  with.  Ani 
urpiginoinm  is  a  rare  affection,  which  appears  to  be  a  form  of  a 
sarcoma  dependent  on  some  congenital  anomaly  of  the  vessels.' 

Sarcoma-like  new-growths  are  found  in  the  skin  in  certain  ca.> 
leukemia  and  pseudoleukemia. 

Diffuse  sarcomatosis  of  the  skin  (Kaposi),  also  called  mycosis 
goidea,  occurs  under  the  form  of  a  round-celletl  sarcoma,  which  pru 
flattened,  knotty  masses  of  new-growth  in  the  skin.  It  extends  s 
until  considerable  areps  are  involved.  The  cells  composing  it  rest 
young  connective-tissue  cells  and  form  diffuse  masses,  or  are  sepa 

Fio.  265 


Melanf>ttc  t*arcotna.     Wiiicltel  ubj.  \«i.  G,  withiiut  ocular.     (From  Or.  A.  (J.  Nittioll 

coUeLMion.) 


A, :  i  . 


I'r*  it 
11.  . 


into  clumps  by  fibrous  septa.  The  vos.sels  are  dilate<l  and  tlie 
oedema  of  the  cutis  and  retc.  This  is  the  stage  of  erythema  and  inl 
tion.  Later,  the  cells  are  more  numerous,  more  uniform  in  .sliii|)t 
size,  and  tend  to  be  arraiige<l  in  columns,  while  the  connectivf  I 
is  reduce<l  to  a  minimum.  Fungating  and  ulcerating  ma.sses  are 
mately  produced.  The  tumor  finally  takes  on  malignant  action,  altli 
occasionally  it  involutes  spontaneously.  It  is  not  yet  settled  wli 
the  new-growth  is  proj)erly  to  be  regarded  as  a  sarcoma  or  wh 
it  is  inflammatory. 

Acanthosis   Nigriemns. — Another  rare  condition   of  doubtful   ii 
is  acanthosis  nigricans,  described  by  Pollitzer,  Darier,  Morris, 

>  White,  Jour.  Cut.  and  Genito-urin.  Dis.,  12  :  1&94  :  468. 


CARCINOMA 


969 


others.  Deeply  pigmented,  warty,  and  papillomatous  nodules  are 
found  mvanous  parts.  Histologically,  there  is  L-perplasia  of  the  papHl^ 
and  epidermis  dilatation  of  the  blood-  and  lymprvessels.  with  increase 
rf  he  pigment  in  the  palisade  cells.  There  is  also  an  imj^rfect  attest 
at  he  formation  of  "cell-nests."  The  disease  has  been  found  assSS 
with  carcinoma  of  other  structures.  Darier  thinks  that  it  is  due  t^soie 
lesion  of  the  sympathetic  nerve. 

•  ^•"••-Carcinoma  is  of  frequent  occurrence  in  the  skin.  It 
.3  found  on  the  lip,  nose,  eyelids,  prepuce,  scrotum,  and  vulva    bu 

!2'."^^7"  '  ^!-''"P.  '•"  "''•^''  '*«'°'^-  I'  '^  •»  this  form  of  caS 
noma  that  long-continue.1  irritation  appears  to  play  an  important  role 
Thus,  It  IS  met  with  on  the  lower  lip  in  smokers,  at  the  mai^ins  of  indoTen 
ulcei..  m  patches  of  chronic  dermatitis  caused  by  soo?  tar.  pamffin 
and  imating  thscharges,  and  alK^ut  warts  or  nevi.  wh  ch  1  a ve  bmi 
fref|uently  rubbed  or  excoriated. 


Fio.  286 


Epithelioma  of  the  lip.     (Hyde.) 


Oininomas  mav  develop  from  the  epidermis  ..r  from  the  enitheli.im 
of  .he  ,Ia„,l.s  and  hair-follicles,  but  it  is  not  always  possible  to  dee™^ 
the  ,,.„.,  of  origin  in  fairly  atlvancetl  cases.  Certain  of  them  ,  ot 
oomuvtetl  with  the  epidermal  layer,  may  originate  rcell-  nc£c^^ 

nvo.  from  the  epidermis  (dermoids), 'or  (^om  the  bZS  de  ts' 
(branch logenic  carcinoma). 

Tlji..r.,h  has  dividetl  skin  carcinomas  into  suinrficiul  and  deep  fonns 
»huh,  however,  merge  imperceptiblv  one  into  the  other  ^  ' 

•AinuMg  the  superficial  fonns  may  be  mentione.1  rodent  ulcer  and 
Page. .  disease  of  the  nipple.    These  form  shallow  ulc^«  wiS  infiltraS. 


970 


THE  SKIN 


slightly  elevated  edges,  which  from  necrosi3  may  assume  a  somewhat 
nodular  appearance. 

Rodent  ulcer  occurs  most  frequently  at  the  corner  of  the  nose,  near 
the  eyelids,  or  upon  the  forehead.  The  growth  is  excessively  slow  in 
its  development,  sometimes  lasting  many  years.  Under  surgical  meas- 
ures it  may  heal  up  for  a  time,  but  sooner  or  later,  as  a  rule,  breaia 
out  again.  The  tumor  is  quite  superficial  and  spreads  slowly  at  its 
margin,  but,  owing  to  the  relatively  large  amount  of  necrosis,  presents 
the  clinical  picture  of  an  ulcer  rather  than  a  neoplasm.  Hbtologica'"^, 
it  is  an  epithelioma. 

Paget'a  disease  begins  at  the  nipple  and  apparently  originates  in  a 
very  chronic  form  of  inflammation.  A  shallow,  reddened  ulcer  b 
prxxluced,  which  slowly  extends  its  borders.  When  well-developed, 
the  microscopic  appearances  are  those  of  a  squamous-celled  epithe- 
lioma. The  tumor  is  further  interesting,  inasmuch  as  several  obser\ers 
have  thought  that  certain  peculiar  appearances  within  the  cells  are 
parasites.  It  is,  however,  more  likely  that  these  are  form,  of  cell 
degeneration.  Occasionally  as  ulceration  progresses,  healing  takes 
place  toward  the  centre  with  the  formation  of  a  scar  (cicatrizing  epithe- 
lioma). 

The  deeply-penetrating  carcinomas  originate  in  nodules  of  new- 
growth,  which,  when  necrosis  has  taken  place,  present  the  ap|)eardnce 
of  ulcers  with  nodular  bases  and  irregular  edges.  VMien  gniwth  is 
active,  fungating  papillomatous  masses  are  produced.  This  form  is  verj- 
malignant,  growing  rapitlly,  and  pnxlucing  metastases  more  {|uicldy 
than  the  sujjerficial  varieties.  All  sorts  of  intermediate  gnules  exist 
between  the  superficial  and  the  deeply-penetrating  carcinoiims,  and 
epithelial  proliferation,  coiine<-tive-tissue  overgrowth,  and  necrosis  may 
be  combined  in  a  variety  of  ways. 

The  microscopic  apjiearances  of  epithelioma  of  the  skin  vary  accord- 
ing to  circumstances.  In  a  well-marked  example  of  a  not  too  rapidly 
growing  epithelioma,  the  rete  sends  out  downgrowths  into  the  under- 
lying tissues  in  the  form  of  processes  which  divide,  sulnlivide,  and 
anastomose.  The  outermost  cells  of  these  downgrowths  ctjrrespond 
in  structure  with  the  lowermost  cell  of  the  normal  ri'te.  As  thev 
approach  the  central  portion  they  liecome  more  cuboidal,  btiii|;  practi- 
cally identical  witii  the  prickle-cells,  while  at  the  centre  they  are  more 
or  less  flattei  d  and  cornifiwl.  In  many  cases  the  cornifitd  areas 
present  the  apj)earaiice  of  Hattene<l,  concentrically  arranged  spindles 
or  plates,  which  may  Im-  comparetl  to  the  stratification  of  an  onion, 
the  so-calltHl  "cell-nests"  (Ferlkugeln).  The  central  jM>rtion  occa- 
sionally becomes  fatty,  colloid,  gnmular,  or  in  rare  instances  calcified. 
The  connective  tissue  enveloping  the  growth  is  normal,  or,  as  in  most 
cases,  thickene<l,  and  shows  infiltration  with  small  round  cells,  either 
the  result  of  cell-prolifenitinn,  or,  possibly,  inflammation.  In  the  more 
rapidly  growing  varieties  the  cells  are  of  the  more  prirniiive  type 
and  present  little  or  no  tendency  to  cornification,  so  that  ci  11-iiests  are 
lacking.     In  cases  where  pressure  has  been  exerted  upon  ilie  processes, 


ALOPECIA 


ime  a  somewhat 


vn 


the  cells  become  flattened  and  spindle-shaped,  resembling  somewhat 
those  of  a  sarcoma. 

Certain  rare  forms  of  carcinoma  deserve  a  passing  notice  One 
of  these  b  the  so-called  "lenticular"  carcinoma.  It  is  usually  found 
m  the  mamma,  where  it  is  secondary  to  a  deeper  seated  carcinoma  of 
the  gland,  but  js  occasionally  met  with  as  a  primary  growth  in  other 
parts  of  the  body.  The  affected  skin  and  subcutaneous  tissues  are 
diffusely  mfiltrate*!  with  new-growth,  and  are  swollen,  hard,  and  resist- 
ant,  resembling  washleather.  On  section  the  structure  is  tough  and 
gristly,  and  may  contain  considerable  fluid,  due  to  pressure  upon  the 
lymphatics.  Thus  a  form  of  elephantiasis,  "cancer  en  cuirasse  " 
IS  the  result. 

Alveolar  carcinoma  may  be  found  in  the  deeper  layere  of  the  skin 
and  subcutaneous  tissues. 

Apart  from  the  local  metastases  that  form  in  the  skin  about  an 
epithelioma,  secondary  carcinoma  is  not  common.  Both  connective 
tissue  and  epithelial  tumors  may  form  metastases  in  the  skin.  Carcinoma 
of  the  breast  is  perhaps  the  most  frequent  cause. 


'  y< 


THE  AOCESSORT  8TRUCTURE8  AHD  APPBHDAOES  OF  THE  SKIH. 

The  Hair. 

The  congenital  anomalies  of  the  hair,  hypertrichosis,  alopecia  adnata 
canities,  have  already  been  referred  to  (see  p.  909).  * 

Alopecia.— The  acquired  form  of  aU)pecia,  or  falling  of  the  hair 
(a  optria  acquisita,  clavities  aajuis  ita),  may  be  a  senile  manifestation 
{dopecm  senilis),  usually  associated  with  atrophy  of  the  skin  and  absorp- 
tion of  the  subcutaneous  fat,  or  may  occ-ur  early  in  life  (tthpecia  pre- 

Alopeoia  Prematura.— Alopecia  prematura  mav  come  on  without 
any  obvious  cause  (idiopathic),  but  is  often  asso<;iafetl  with  disease  of 
the  s(  alp  or  of  the  general  system.  Thus,  eczema,  crvsij)elas,  syphi- 
litic eruptions,  seborrhu-a,  favus,  and  ring-worm  are  common  causes 
of  OSS  of  hair.  The  hair  also  not  infre<iueiitly  falls  out  after  acute 
and  other  infective  diseases,  such  as  t\-phoid,  scarlatina,  syphilis,  and 
tulK-reulosis,  and  during  lactation  in  weakly  individuals. 

Alopecia  AreaU.— Alopecia  areata  is  characterized  bv  the  formation 
of  one  or  more  areas  of  baldness,  which  mav  be  found  on  anv  region  of 
the  l»Hly  normally  covered  with  hair.  The  3ealp  and  the' beard  are 
the  parts  usually  involved.  The  patches  are  round  or  oval,  sharply 
dehii.d,  and  become  (piite  devoid  of  hair.  The  skin  of  the  affected 
part  IS  soft,  smooth,  depressed,  at  first  slightly  reddened,  later  white 
and  glistening.  The  hair  at  the  periphery  shows  no  obvious  chance, 
but  ^'radiially  falls  out  in  turn.  The  sharp  line  of  demarcailon  betw^n 
the  round  bald  spot  and  the  normally  covered  scalp  is  a  characteristic 
feature.    The  spots  may  gradually  increase  until  the  hair  of  the  scalp, 


972 


THE  NAILS 


beanl,  and  eyebrows,  ami  even  of  the  whole  of  the  body,  has  entirely 
disappeared. 

Micniscopically,  tlie  hairs  and  hair-follicles  are  atrophied,  there  is 
diapedesis  uf  lyniphoc-ytes  witii  accumulation  of  mast-cells,  and  altsence 
of  pigment  in  the  rete. 

The  exact  cause  is  not  altogether  understood.  Perhaps  the  majority 
of  obser\ers  consider  the  disease  to  lie  a  trophoneurosis,  inasmuch  as 
it  in  many  cases  follows  injury  to  the  nerves,  shock,  or  other  disturb- 
ance of  (he  nervous  system.  On  the  other  hand,  the  occasional  occur- 
rence of  the  tlisease  in  epidemic  form,  together  with  some  evidence  of 
contagion,  suggests  a  parasitic  cause  in  some,  at  least,  of  the  cases. 
Sabouraud  reganls  as  the  specific  cause  a  bacillus,  which  is  present 
in  the  hair-follicles,  and  identical  with  a  bacillus  which  he  finds  in 
.seborrha?a.  Rarely  ringworm  gives  rise  to  similar  appearances,  and 
has  been  mistaken  for  alopecia  areata  by  competent  observers. 

Atrophy. — Atrophy  of  the  hair  is  due  to  disease  of  the  scalp,  such 
as  seljorrluea,  eczema,  ami  psoriasis,  or  to  some  systemic  disorder  asso- 
ciated with  poverty  of  nutrition.  The  hair  is  drj",  brittle,  and  lacks 
lustre. 

Trichorrhexifl  nodou  is  a  rare  form  of  atrophy,  in  which  the  shafts 
of  the  hairs,  usually  of  the  l)eard,  present  nodular  swellings,  through 
which  the  hair  readily  breaks.  In  monilethrix,  an  affection  which 
is  generally  congenital,  the  shaft  of  the  hair  presents  ring-like  con- 
strictions through  which  the  hair  is  apt  to  fracture. 

Hjrpertrichosis. — Hypertrichosis,  apart  from  the  congenital  and 
developmental  forms,  occasionally  results  in  areas  that  have  l)een  siib- 
jecte«l  to  irritation,  pressure,  inflammation,  or  other  cause  whicii  leads 
to  congestion.  In  women,  hair  upon  the  upper  lip,  or  other  parts  of 
the  face,  is  wcasionally  due  to  an  hereditary  peculiarity  or  to  some 
abnormality  of  the  sexual  functions.  It  is  not  uncommon  after  the 
menopause. 

Canities. — Canities,  or  blanching  of  the  hair,  occurs  physioiogic- 
ally  in  old  age,  but  is  not  infre(iuently  met  with  in  younger  people. 
It  is  sometimes  an  inheritc<l  peculiarity,  or  may  follow  mental  over- 
work, nervous  sluK'k,  or  prolonged  disease.  luteal  blanching  has  l)een 
noticed  in  migraine  and  neuralgia.  The  condition  is  due  not  only 
to  loss  of  pigment,  but  to  the  presence  of  air  in  the  substance  of  the 
hair. 


111! 


The  Nails. 


r": 


Congenital  absence  and  developmental  anomalies  of  the  nails  tire  rare 
and  usually  assix-iated  with  <lefects  of  the  hair  and  teeth. 

White  spots  upon  the  nails  (leukopatbia  ungois)  are  not  infrcijuent, 
due  to  the  prpspiice  of  .air  lietween  the  layers  of  the  keriitii!  They 
are  the  result  of  .slight  injuries  or  of  impairment  of  nutrition.  Tnuu- 
verse  fuirows  are  often  found  upon  the  nails  of  those  who  have  siitTered 
from  acute  disease  or  other  cause  which  has  lowered  their  vit;ilitv. 


BR0MIDR0SI8 


973 


%e  nail  may  be  ditioeatwl  from  its  bed  by  traumatism  or  the  col- 
I«Hon  of  pus  or  blood  f.eneath  it.    This  may  lea.l  to  complete  erfoli.- 

HituTaVltsS.'''"  "^  ^''•^'  '"  "'"P"'*'  •'"""*•'•  ^^■P'^'"^'  '''«'-^- 
Inflammation  of  the  matrix  of  the  nail  (onychia)  and  of  the  surround- 
inp  soft  parts  (paronychia)  may  be  the  result  of  traumatism  or  local 
mfection,  or,  again,  may  Ik-  occasionally  seen  in  syphilis  and  tuberculosis 
tavus  and  nng-worm  sometimes  attack  the  nail  (onychomycosis)  and 
give  rise  to  onychia  and  paronychia.  ' 

In  atroiihy  the  nail  is  thinned  and  softenetl,  becomes  brittle,  and  is 
often  traverse*!  bv  rHlges  or  furrows. 

Simple  oyersn^wth  of  the  nails,  which  may  pmperfv  1«  reganle*l  as 
a  physiologual  condition,  since  it  is  due  to  the  omi.s.^on  of  the  mstomary 
cut  ing  of  the  naiLs,  IS  met  with  among  certain  races,  such  as  the  Chinese 
an.!  among  some  of  the  fakiis  of  India.     In  the  forms  of  overgrowth 
found  in  other  nations,  however,  there  is  evidence  of  disease  as  well 
I  he  nail  substance  is  th.ckene,!  (hypwonychia).  irrcgular.  roughened 
bn  tie,  and  discolored.     The  nails  may  in  time  l,ecome  twisted.  U-n 
and  project  like  talons  l«.y„n.l  the  finger-tips  (onychogryphosi.)     It  is 
not  uncommon  to  fiml  inflammation  and  even  suppuration  going  on 
m  these  cases  l,eneath  the  nail.     The  comlition  is  met  with  in  old 
persons  who  are  dirty,  debilitated,  an.l  uncami  f<.r.  in  svphilis.  eczema 
psoriasis,  and.  occasionally,  in  tulK-rculosis,  lepnxsv,  mCxmlema,  acro^ 
megaly,    neuritis,   and   neurotrophic   disonler..     A   common    fonn   of 
smiple  enlargem-nt  is  the  so-called  "!„groin„q  t,M.nmir  in  whit-h  the 
nail  increases  i,     .readth  and  penetnites  the  flesh  of  the  toe.  giving  rise 
to  intlammation  and  suppuration  (jMiwnychia). 


r 

I 


f  .■ 


lis  iin-  rare 


The  Sweat-glands. 

Hyperidrosis  and  Anidrosis.-Thcse  are  functional  .lisonlen.  of  the 
s«.at-glands.  and  are  either  an  evidence  of  some  inherite.1  peculiaritv 
or  he  result  of  system!,,  or  Icx-al  .lisease.  X„  grass  changes  ^  f,  J 
njl le  glands  but  it  is  probable  that  in  most  cases  the  conditions  arc 
due  („  some  disturbance  of  the  innervation  of  the  part,  or  to  the  dircct 
ComilllVr'"  ""^  '^'  secrcting  cells  in  the  pnK-ess  of  elimination, 
ton.plete  absence  of  sweat  secrction  (anidrosis)  probablv  does  not 
oon.r,  except  locally  in  ca.ses  wherc  the  glan.ls  have  iH-en  destroved  bv 

m^nv'^  ,;r'7'""*'°!'  '"  ♦•'*'  "'"•^""t  "^  ««™t  (hyphidrosis)  is  found  in 
y}  acute  fevers,  in  myx(E,leina.  and  in  such  conditions  as  eczema 
psoriasis  and  pityriasis.    Hyp.iridrosis  is  most  common  in  the  palms' 
so .-s,  axillary  an.l  pubic  rcgions.    Unilateral  or  hxal  hvperi.lrosis  is  met 
«mi  in  some  nervous  diseases  and  in  neurotic  individuals 

Bronddrosls  -Bromidrosis,    or    offensive    perspiration,    is    usually 
ass^Kiated   with   hv-peridrosis.   and   general  I  v  afT«ts   the   same  parts 

aml'L"  *  '^'*'*'"  '^T'"'.*'^  '^"''  ^""»«'t«l  «ifh  onlinarv  perspiration," 
an.l  thus  is  more  evident  in  some  individuals  and  races  than  in  othere. 


ill 

»-- 


974 


THE  SWEAT-GLANDS 


In  stout  persons  or  those  who  perspire  freel-  the  sweat  often  emits 
a  sour  smell  shortly  after  it  is  excreted.  In  true  bmmidrosis,  thr  iHJor 
is  penetrating  and  disgusting.  The  condition  may,  of  rourse,  be  ajwisted 
by  uncleanly  habits,  but  is  often  met  with  in  those  who  are  scrupiiloiislv 
clean.  In  such  we  have  to  look  for  the  caase  in  some  iieur()|)titlii'c 
disturbance.  The  foetid  odor  is  by  many  attributed  to  the  deconipositiun 
of  the  swejit  by  microorganisms. 

Uridioiii. — Uridrosis,  or  the  excretion  of  urinary  salts  througli  the 
sweat,  is  met  with  occasionally  in  Bright's  <lisease,  cholera,  and  .some 
serious  coastitutional  disorders.  It  has  been  recorded  also  after  the 
administration  of  jaborandi.  In  marked  cases  scales  of  urea  mtiy  be 
deposited  on  the  skin. 

Ohromidrosii. — Chromidrosis,  or  colored  sweat,  is  an  excessively  rare 
condition.  It  is  possibly  in  some  "ases  neurotrophic  in  nature.  More 
often,  coloration  of  the  sweat  is  due  to  the  elimination  through  the  skin 
of  ach  substances  as  copper,  or  the  application  of  dyes  to  the  skin. 
One  form,  red  sweat,  which  affects  the  axillary  and  genital  regions,  is 
due  to  concretions  upon  the  shaft  of  the  hairs  (leptothrix),  resulting 
from  bacterial  activity. 

Hematidrosis. — Bloody  sweat  (hematidrosis)  is  a  rare  condition  due 
to  hemorrhage  into  the  sweat-glands.  It  has  occurred  in  neurotic 
individuals. 

Phosphorescent  Sweat. — Phosphorescent  sweat  has  been  descrilHHJ. 

Sudamina. — Sudamina  (milinria  crifsfallina)  is  not  infreciuentlv  met 
with  in  febrile  conditions,  espe<'i;  lly  those  associated  with  profuse 
sweating.  Small,  clear  vesicles,  often  abundant,  form  in  the  liorny 
layer  of  the  skin,  which  disappear  after  a  few  days.  The  condition 
is  due  either  to  blocking  of  the  duct  and  consec)uent  retention  of  tiie 
sweat,  or,  according  to  -^    rupture  of  the  duct  and  escaj)e  of  the 

sweat  into  the  horny  layer. 

HydrocyBtoma. — Hydrocystoma  is  a  rather  rare  condition,  usually 
affecting  the  face.  One  or  more  clear,  deep-seated  vesicles  are  formed, 
apparently  the  result  of  dilatation  of  the  sweat-ducts  in  their  course 
through  the  corium. 

HydradenitU  SappuratiTa. — Hydradenitis  suppurativa  is,  as  its  name 
implies,  a  suppurative  inflammation  of  the  sweat-glands.  It  is  nia<t 
often  found  in  the  axillary  and  pubic  regions.  The  pnxess  Ujjins 
deep  in,  involves  the  surrounding  structures,  and  eventually  leads  to 
destruction  of  the  glands. 


The  Sebaceous  Glands. 

Seborrhosa. — The  sebaceous  glands  normally  secrete  ;in  oily 
substance,  which  is  elaborated  in  the  glandular  epithelium  .mil  ilis- 
charged  upon  the  surface  of  the  skin,  where  it  acts  as  a  sort  of  liKricant. 
Excess  of  this  secretion  gives  rise  to  the  condition  known  as  sel  orrlwea. 
In  one  form,  seboirhcea  sieea,  minute,  dry,  filmy  scales  are  jimduced, 


COMEDO 


976 


:uallv  U'iuls  to 


imposed  m  part  of  dried  sebum,  but  also  of  desquamate.!  horny  epi- 
Wnnn  and  d.rt  or  das,      I„  the  other,  ther,-  is  exc-essive  se^Sn^of 

Seborrhoea  may  be  a  local  or  a  general  comlition.    The  fonnTis 

seborrhoea  is  rather  rare,  and  i.s  mosi  frequently  foun.l  in  vouni;  children 
.•here  the  greasy  secretion  which  normally  cou-n,  the  skin  .luring  intm- 
uenne  hfe  (smegn.a,  vernix;  oseosa)  persists  for  some  time  Z?  b"rt™ 
hjs  not  uncommon  to  find  in  infants  dirty  crusts  upon  the  ialp  cZ: 
p«ed  of  sebum,  d,rt,  epithelial  scales,  and  haii,.'  In  miS  ca;,eT™f 
«borrhcea  sicca  there  is  only  a  trifling  exfoliation  of  the  epUhelial 
soaks  (rf.»rfr«/),  with  slight  increase  of  secretion,  but  in  other^  there  may 
be  considerable  heaping  up  of  material  into  larger  scales  and^iTtJ 
{fiiynas,,  furfuraccacf,pilUt!!).  Seborrhcra.  if  long-continucS  iS 
.0  a  rophy  of  the  hair-follicles  and  loss  of  the  hair.*^   ?t  i  not'  ntZ 

s::!f,^'.:sz:s,)^^  '"«-"'""'->-  ^'—^  (-^^^ 

»i.ent  erf  ot..r  diseasc^notabiy'll^^'tl^'^iTt  2:7^' 
rhus.  t  ,s  f(,und  in  psoriasis,  prurigo,  pityriasis  rubra  pilaris    leomsv 
a^djchthyosis.    The  skin  bcvomes  .ir|,  fissured,  an.l  Te  iZS 

There  are  several  allied  conditions  that  are  ,lue  to  the  accumulation 
0    he  sebum  within  the  sebacc-ous  glands  or  their  ductl    Ss  aceu" 

0  me  (lucts  from  dirt  or  overgrowth  of  the  lining  epithelium    or    in 
Somedo'    i:tT""  '"  the  d.„ra,,..r  of  the  s^.reEon  itS      ' 
Wmedo.-Comedo  IS  a  con.lition  in  «hich  the  excretory  duct  of  a 

iiai  cells   and  not  infrequently  lanugo  hairs.    The  dark  snot  ut  thl 
cause  of  the  cellulai  proliferation.     Not  infrequently;  the  obstruct^ 


m 


&  t 


976 


THE  SEBACEOUS  OLASDS 


glands  liecome  inflamed,  forming  small  red,  elevated  papules  and 

fnistules  (one  form  of  aene).  Comedones  are  found  usually  ii|ion  the 
ace  near  the  nose,  on  the  forehead,  and  occasional  y  upon  the  sliitiildrri, 
They  may  be  very  numerous.  The  affection  bis  been  regHninl  « 
having  some  cr  -nection  with  gastro-intestinal  disti  rbances,  but  is  often 
enough  met  with  in  healthv  people.  It  is,  however,  most  common 
almut  the  age  of  pulierty,  when  the  skin  and  its  associated  gluiuU  are 
particularly  active. 

Hiliom. — Milium  is  a  form  of  obstruction  of  the  sebaceous  glands 
in  which  the  iumina  become  somewhat  dilated,  forming  small  noduh 
the  size  of  a  pin-head  or  smaller,  of  a  whitish  or  yellowish  color,  which 
project  slightly  above  the  general  surface  of  the  skin.  On  inrbin{ 
one  of  these,  a  smooth  or  warty  lobulated  mass  can  be  expressed  con- 
sisting of  fat  and  epidermal  cells  surrounded  by  concentric  layen  of 
keratinized  cells.  Milia  are  found  usually  up6n  the  eyeliils.  Where  a 
group  of  setiaceous  glands  are  enlarged  ancl  distendeil  with  secretion 
and  proliferated  cells  the  condition  is  known  as  acrochordon.  This 
is  met  with  most  frequently  in  elderly  people,  asually  on  the  eyelids, 
throat,  and  neck. 

Inflammations. — Aene  Vnlgaili. — Acre  vulgaris  is  an  inflamniation 
of  the  sebaceous  glamls,  which  is  liable  to  involve  the  hair-follidw 
and  surrounding  tissues  as  well.  Not  infrequently  the  trouble  is  to  I* 
traced  to  comeilones.  In  the  early  stages  small,  elevate*!,  reddeiml 
papules  are  formwl,  usually  upon  the  face,  but  occasionally  also  on  the 
neck,  shoulders,  trunk,  and  extremities  (acne  simplex).  Where  there  is 
a  central  blackish  point  the  condition  is  called  acne  jninctota.  '['k 
process  often  goes  on  to  suppuration,  so  that  elevated,  reildish  piisiuh 
are  produce«l,  varying  in  size  from  that  of  a  pin-head,  or  smaller,  to  that 
of  a  pea,  presenting  a  yellowish  centre  (acne  puatulaia).  On  incising 
this  a  small  drop  of  pus  can  be  evacuated.  In  ttie  so-called  acni 
indurata  comparatively  large  purplish-re<l  and  hard  no<lules  are  pro- 
d>ice<l  which  are  much  indurate<l  .  -d  persist  for  a  consideniide  time. 
They  leave  t  onsiderable  staining  i  '  '  le  skin  and  more  or  less  scarring. 
Occasionally  acne  spots  present  itral  necrosis  and  resemble  variola 
pocks.  Acne  is  most  common  i  j)ersons  about  the  age  of  piitwrtv  or 
in  eariy  adult  life.  Tho.se  who  nave  poor  circulation  or  wlio  are  the 
subjects  of  gastro-intestinal  disorders  are  supposed  to  be  more  liable. 
Acne  may  also  l)e  cau.sed  by  external  irritation. 

A  mycotic  folliculitis  and  perifolliculitis,  involving  the  hair-follicles 
and  sebaceous  glands,  due  to  the  trichophyton,  is  well  known  {tim 
syconis)  (see  p.  929). 

OystS. — Atheroma,  or  sebaceous  cyst,  is  a  cystic  <lilHt;ition  of  a 
sebaceoiLs  gland  or  hair-follicle,  due  to  the  accumulation  <if  secretion 
within  its  cavity.  There  is  usually  a  smooth,  connective-tis-ne  capsule, 
lined  by  stratified  pavement  cells.  The  contents  are  liijiiiil,  .serai- 
solid,  or  cheesy,  and  are  composed  of  fat,  epithelial  debris,  <  liolestenn, 
and  fine  hairs.  The  cysts  may  be  all  sizes  up  to  that  of  a  fist.  They 
are  usually  found  upon  the  scalp,  but  pcc^isjonally  also  in  die  skin  o| 


TUMORS 


977 


4 

i 


n 


111' 


^ppl  '' 

m 

b  Kill  I 

^^^^^^^^Hu£'' ' 

hm 

i  -,  . 

SECTION   TX. 
THE  MlISCIfLAR  SYSTEM. 


(HAI'TEK  XLfl. 

THR  SKELETAL  MUSCLES. 


TBI  MUS0LE8. 


l».  ..p  „u„»„„  i„  „.;'™:;'  .i/t:;*;„;,T  ™,rtt'',' 
r,;;i,ir  •"*' "  "■"  """■»"'>  -»-"•"' » .1 1^^  ^ 

in<   luascles  are  hiirhlv  vascular    t       lnr„^  i    i  .        . 

il«pr.mv.siun,.  ami  these  brerun  i  .-      f  '  ■'*  '"""*^  '" 

of  oapillanVs  w  thin  tt  emlmnvshL      '1^  T       '"  -""""t*^  '"'""''^ 
^"Ppi  in.'  them  are  hiT.hlv        "^r  ^'   J       ''     ""at'ons  of  the  nerves 
1       'U  mem  are  hi^rhly  NiKH-iali/.^l  ari)    ,z«     ,,ig  ..r  end  olates 
Un-M.  normal      .iKlitioa.,  the  U-njrth     n.i    ^.n^aatlL  of  the  t      . 
B7  w..lu„  wide  limits,  acconiing  to  L  d,  ,^  rSaiaHon  t      T   ' 

■onus;;  hi;i.^'ii  Ifir^lt""    ''""'  "'  -««f''*'-e  -laxatlon.  called 


I 


r 


9S0 


THE  MUSCLES 


Muscles  are  liable  to  a  great  variety  of  disease  processes.  Owing 
to  their  expcwed  pasition  and  their  close  association  w'ith  the  skeleton 
in  regard  to  the  tunction  of  locomotion,  they  are  particularly  liable  to 
direct  and  indirect  traumatism.  Again,  owing  to  their  abundant  blood 
supply  they  are  readily  brought  under  the  influence  of  various  circulating 
toxins  and  infective  microorganisms.  And,  further,  they  may  pwsent 
grave  changes  as  a  result  of  defective  innervation. 

The  pathological  lesions  are  manifested  not  only  by  qualitative 
changes  in  the  fil»ers  themselves,  but  also  quantitatively  by  an  imrease 
or  diminution  of  the  muscle-substance,  either  absolutely  or  relatively  to 
the  amount  of  the  connective-tissue  stroma. 


'  i. 


OONOENITAL  ANOMALIES. 

These  are  so  numerous  that  it  is  imjjossible  to  enter  adequately  into 
the  subject  here.  Many  of  the  anomalies  are  interesting,  not  only 
from  the  point  of  view  of  development,  but  also  because  they  have  a 
practical  l)earing  in  regard  to  surgery  and  me<licine. 

In  general  terms  it  may  be  said  that  there  is  no  anomaly  of  the 
mascles  in  man  which  does  not  have  its  prototj-pe  in  one  or  other  of 
the  lower  animals.  Briefly,  these  consist  in  irregular  origin  and  insertion 
of  the  muscles;  complete  or  partial  defect  of  certain  mu-scles  or  jjn)up,s 
of  muscles;  reduplication;  while  again,  certain  muscles  may  be  jjresent 
in  man  which,  though  normally  present  in  other  species,  are  not  regu- 
lariy  found  in  the  human  subject.'  One  of  the  mast  important  of  these 
peculiarities  about  which  a  word  or  two  may  lie  spoken  is  defect  of  the 
diaphragm,  which  sometimes  gives  rise  to  .serious  clinical  manifestations. 
The  diaphragm  may  be  defective  to  an  extent  varying  froni  a  small 
opening  to  one  involving  half  the  structure.  The  deficiency  is  asiialh 
on  the  left  side  and  in  the  nmscular  portioi  .somewhat  posteriorly.  The 
condition  is  often  associatetl  with  other  grave  developmental  errors,  such 
as  anencephaly,  hemicrania,  anil  anomalies  of  the  fingers  and  ten's  In 
manv  such  cases  prolonged  continuation  of  life  is  of  course  ini]Hissihle, 
but  where  the  diaphragm  alone  is  involved  persons  so  aflfectcd  have 
been  known  to  reach  a  fairiy  advanced  age.  Owing  to  the  defineiiry  in 
this  structure,  it  is  usual  at  some  time  or  other,  to  find  certain  of  the 
abdominal  vi.scera,  such  as  the  stomach,  omentum,  intestines,  liver, 
spleen,  and  kidney  in  the  thoracic  cavity.  In  such  cases  there  i.« 
usually  marked  dyspnoea  and  embarrassment  of  the  heart's  adion,  with 
physical  signs  of  displacement  of  the  heart  and  lungs,  and  the  presence 
of  a  solid  organ  or  hollow  viscus  containing  air  in  the  chest  ciivily  (see 
p.  404). 

'  Those  (lesirinK  more  detailed  information  are  referre<l  to  Dr.  F.  f  ^lippherd'i 
article  on  The  Anomalies  of  MuBcleo,  in  the  Heference  Handbook  of  ilr  Medicsl 
Sciences,  0:  IWi:  42,  Becond  edition.     Win.  Wood  &  Co.,  New  ':'otk. 


HEMORRHAGE 


9S1 


OIROULATOKT  DISTUSBANOBS. 

Owing  to  the  free  anastomosis  of  the  vessels,  local  disonlere  of  the 
circulation  are  not  readily  brought  about.  Any  such  changes  are  eausS 
only  by  extensive  disease  of  the  bloodvessels  or  systemic-  affectionTS 
he  blood  and  circulatory  apparatus.     Except  in  the  case  of  the  gi^r 

Z;.ia"  f '"•'  '°  "^"^r^  '^'"•"'«*°'-^  disturbances  post  moS' 
An«mi».-Anemia  may  be  local  or  general.  The  iScal  form  is 
bn,..ght  about  by  obstruction  of  a  main  arterial  trunk  or  compSon 
of  the  muscle.  Toxic  substances  acting  upon  the  bloo<l,  varioiEZcS 
d.sea.ses,  and  weak  driving  power  of  the  hVart  lead  to  general  ane^ 
Muscles  so  affected  are  pale.  soft,  dryer  than  normal.  L  t^'^tn 
coloring  matter,  although  in  some  cases  this  is  increased 
Hypereinia.-Active  hyperemia  is   found    in    the    neighborhood   of 

etXUy"'  """"'■     '"  ''^  "^^"'  ^™  '"^^  fibeHe^rrat"  S 

Hemoniiage.-Hemorrhage  into  the  muscles  is  not  infrequent.  It 
may  Ix-  extensive,  minute  or  petechial.  The  larger  extravasa  ions 
(hematorm)  are  the  result  of  trauma;  rupture  of  ^he  S^lT  Z 
excessive  contraction  as,  for  example,  in  tetanns;  increS  bl3 
pressure  and  certain  degenerative  changes  in  the  vesse  walls^eS 
are  most  probably  due  to  .lefective  nutrin-.n  of  the  wall,  o  the  Su 
anes  ancf  smaller  bloodvessels,  leading  to  fatty  charts  wWchp^^ 
dispose  to  rupture,  or,  as  some  think,  to   diapedesiT  ThSsE 

rhagu  diatheses,  pernicious  anemia  ami  leukemia,  poisoning  from 
phosphorus  and  various  drugs,  and  multiple  suremS^^osis  "'^me" 
the  extravasation  is  extensive  the  muscle-fil,^rs  are  pushed  apart  and 

r  S^l  W '"!  t'f  .P"---  Ro  "»  to  healing,  the  blood  is  absorbed, 
or  part  absoriKMl  ami  in  part  organize.!,  with  the  formation  of  a  pig! 
Thetis      t"  "'""•    ^'^  '^  «".i'-'l-rfect  attempt  at  restoration'^ of 

Eln      I  Tyr^'r*^'  n,etapla.sia  into  cartilage  ami  bone 
tiorrthe  iXi.         T   ''   'T"**  "'"">■   I'H't'Kht  about  bv  obstruc- 
rnti.  li.  '"PP'^'  '^'\  ^"'  '"■•'"'■'^^'  •"  «rteriosclen>sis,  endai- 

For  h,  ri'r'''^!-'""'.^'?''  cireulation.  thrombosis,  and  embolism. 

or  ,1,  reason  inent,one<l,  the  comiition  is  not  common.  It  is  most 
I'keiN  to  be  met  with  in  thase  wcakenetl  by  prolonged  disease.     WhTn 


X,IZ  "  "I"!*'"'  e'»"'i"«tion  of  tho  fnnns  of  he.uorrhaRc  here  referwd  to  . 


tioimhin.  >     a  ■    .,      .     '•      •"»'■"•'<"'  'n  lypnoKl  fever,  anj 

l"-»»h.p,  to  Purpunc  Conditions  in  Cieneral,  Lancet,  London,  1:  1901:305. 


see 

ita 


THE  MUSCLES 


extensive,  large  areas  of  muscle  may  present  what  is  known  as  Zen 
necrosis,  but  more  commonly  multiple  minute  hemorrhages  intc 
connective  tissue  are  produced.  The  larger  areas  of  anemic  net 
are  often  bounded  by  a  zone  of  secondary  hemorrhagic  exudu 
Should  such  an  area  become  infectetl,  al>scess  may  result.  CV 
cases  of  bedsores  and  senile  gangrene  are  of  the  nature  of  infarcts.  'J 
or  partial  ischemic  necrosis  of  the  psoas,  usually  the  left,  has 
noted  in  patients  who  for  a  long  time  have  k-^pt  the  recumbent  posi 


nmAlflMATIOMS. 


Myositis. — Myositis,   or  inflammation    of    muscle,   usually    a 
by  the  direct  extension  of  an  inflammatory  process  from  some  adjs 
part,  or  from  trauma.    Affections  of  the  bones,  joints,  skin,  and  mv 
surfaces  play  an  i.nportant  role,  as  do  also  pleurisy,  peritonitis, 
and  paranephritis. 

In  other  cases,  myositis  is  hematogenous,  the  result  of  bad 
invasion  or  circulating  toxins.  This  is  met  with  in  septic  infertit 
woumls,  puerperal  septicemia,  osteomyelitis,  malignant  endocar 
acute  rheumatism,  tjphoid  fever,  and  glanders. 

In  general  terms  it  may  be  stated  that  the  inflammation  la: 
affects  the  connective  tissue  and  bloodvessels,  while  the  changes  ii 
muscle-fibers  are  mainly  degenerative  and  secondary. 

Acute  Myositis. — Acute  myositis  assumes  several  forms.  The  sini 
type  is  characterized  by  a  slight  exudation  of  inflammatory  pnx 
into  the  perimysium  with  diapede.sis  of  leukocytes.  The  muscle-f 
may  be  practically  normal  {acute  interxtitial  myositis)  or  may  < 
various  grades  of  degeneration,  such  as  cloudy  swelling,  fatty  dejiet 
tion,  and  coagulation  necrosis  (acute  diffuse  myositis).  The  coiid 
is  met  with  in  typhoid  fever,  after  slight  trauma,  about  intrainus( 
hemorrhages,  in  the  neighborhood  of  local  inflammatory  foci,  ar 
usually  a  temporary  condition  of  trifling  import.  Tiie  pnxcss 
heal,  and,  provided  tliat  the  organization  of  the  muscle  be  not  dcstrc 
restitutio  ad  integrum  may  be  complete. 

In  more  severe  cases  the  muscle-fibers  may  to  some  exten 
destroyed  and  be  r 'placed  by  fibrous  tissue. 

In  still  more  se  ,'  _  forms,  where  there  is,  for  instance,  infection 
pyogenic  microorganisms,  diffase  suppuration  may  occur  in  tiu-  uiu 
or  abscesses  may  form  {acute  purident  myositis).     This  is  seen  in 
conditions  as  infected  wounds,  erysijx-las,  septic  arthritis,  iiKeu 
colitis,  septicemia,  and  glanders. 

In  the  early  stages  the  muscle  is  greatly  reddened  and  swollen.  L'radi 
becoming  grayish,  grayish-yellow,  or,  if  hemorrhage  occur,  bn>wnis 
grayish-green  in  appearance.  It  is  soft,  friable,  and  quickly  br 
down,  so  that  numerous  cavities  of  varying  size,  containing:  pus 
shreddy  de!>ris,  are  pro<bicc<l.  The  ab<!cesscs  may  remain  ->''^^ 
or  the  pus  may  burrow  widely  along  the  fascia  and  intennuscniar  se 


MYOSITIS 


983 


ome  exifnt  be 


In  yety  severe  infection,  or  where  the  resisting  power  of  the  tissues 

If.    <*    'ft!!5!*"^  "^^  °*^"'  "»«  '""^•«  turnip  greenish-black  or 
black  and  becoming  converted  into  a  dirty,  evil-smelling  mass,  which 
quickly  undergoes  liquefaction  and  disintegration.    In  the  neighbor- 
hocHl  of  the  abscesses  the  rauscle-fibera  are  found  to  be  in  various  stages 
0  degeneration,  and  where  there  is  a  tendency  to  heal,  there  is  a  2S 
of  granulation    tissue.    If  the  patient  survive,  small  abscesses  may 
disappear  after  the  pus  has  been  absorlied.  while  laiger  ones  may  heal 
when  the  contenl^ave  been  dischaiged,  either  externally,  or  into^some 
caut^    Others  become  encapsulated  by  active  granulation  and  the 
formation  of  connective  tissue.     In   time  the  abscess  contracts,  the 
Z^Z  ^V?^  disappear,  become  inspissated,  or  infiltrated  with 
hme  salte.     VVTien  laige  portions  of  the  muscle  are  destroved.  repair 
by  proliferation    of   the  muscle  cells  is  very  imperfect.    Were  the 
irritation  IS  comparatively  slight,  though  continuouCor  where  repeated 
attacks  of  acute  myositis  have  taken  place,  there  may  be  marked  prolifera- 
tion of  the  connective  tiasue,  so  that  the  muscle  looks  as  if  Travereed 
by  whitish  bands  or  membranes.  imveraea 

A  curious  affection,  the  etiology  of  which  is  still  somewhat  obscure, 
B  the  so-calied  primary  acute  polymyositis,  described  by  Wagner' 
Unverncht,  Hepp.  v.  Strumpell.' and  I^vy.  It  is  characterimi  S- 
calj  by  fever  pain  and  swelling  of  the  muscles  of  the  tongue,  back 
and  extremities  Voluntary  movement  is  usually  completei;  iS' 
There  IS  genemlly  some  redness  of  the  skin,  with  the  production  of  rashes 
of  various  sorts,  so  that  the  disease  has  l,een  called  derraaiora^S. 
The  resemblance  to  trichinosis  is  dase,  and  at  times  a  mici^copic 
examination  is  neeccjsary  to  make  the  diagnasis  «-roscopic 

Post  mortem,  the  muscles  are  brownish-red  in  color,  with  areas  of 
Z-  ^■^""^j^PF*'*"'^.  «"d  P^-f  nt  punctate  and  linear  pigmenta- 
tion     The  fiber,    re  separated  by  hemorrhagic  and  purulent  exudation 
Mar  «1  cxtrava^  tion  of  bl.KKl  between  the  mtsc-le  buEdles  mav  rfoS 

-Microscopically  one  finds  granular  degeneration  of  the  mu'sole-fibere 

i  !^ni  7.'/°^  "^^♦"f ''«"•  proliferation  of  the  muscle-nuclei,  ard 
mun.iK*Iled  infiltration  in  the  intramuscular  connective  tissue 

llie  disease  may  be  of  mild  intensity,  but  is  apt  to  become  chronic 
and  usually  terminates  fatally  after  weeks  or  months.  It  i,  abiost 
certainly  of  an  in  ective  nature.  Senator  was  probablv  the  fireT  to 
advame  the  y^w  that  polymyositis  is  in  the  main^due  to  'aut  "intox icl° 

li  •.         u""  '''^^'•""  ^"^  ^'**"  °''^'^«'  «ft"  «h«  "«e  of  improper 
^e ;,!    T  bee"  suggested  that  the  toxin  is  deriv«l  from  the  LtVo- 

'S  ll!]!'^    K^^*r™P^",'^«'"^^  ''  ^  ''"«  *«  bacterial  touns 
•'tul.iting  m  the  blood,  derived  from  some  local  focus  of  infection 

A  >o.„i,tionof  great  interest  is  the  so^alle.1  myoiitis  OMlflctns,  which 

as  Its  ,m,ne  implies,  is  an  inflammation  of  the  muscles  accompanied 

J  Acute  .'olymyositis,  Deutoclies  Archiv  f.  klin.  Med.,  40: 1887-  241 


984  THE  MUSCLES 

by  the  formation  of  bone.  The  disease  is  a  rare  one,  althougli  it  has 
been  known  since  1740,  when  the  first  case  was  reported  by  Fn-ke  in 
the  Philosophical  Transactions.  Since  this  date  unly  about  85  exampkni 
have  been  recorde<l.  The  etiobgj-  is  still  quite  obscure.  Following 
C'ahen,'  it  is  usual  to  divide  the  disease  into  two  forms,  a  Kx-ali/.tHl  or 
stationary  and  a  progressive  form. 

In  the  first-mentioned  class  of  cases  the  disease  appears  to  l\ 
dependent  upon  trauma  or  irritation,  and  is  found  particularlv  in 
muscles  which  are  overexewised  (exercise  bones).  The  muscles  affected 
are  usually  the  deltoids  and  pectorals  in  soldiers,  the  adductors  of  the 
thighs  in  riders,  occasionally  the  arms  in  gymnasts,  and  the  It-jp  in 
dancers.  The  bone  is  present  in  the  form  of  splinters,  plates,  or  IxMses, 
either  attached  to  the  Iwiies  and  tendons,  or  forming  movable  masses 
in  the  intramuscular  connective  tissue. 

More  obscure  still  is  myositis  ossificans  progressiva,  whic-h  is  dis- 
tinguished from  the  first-mentioned  form  by  the  fact  that  it  Ix-gias 
in  early  life  and  successively  involves  one  muscle-group  after  another. 
The  disease  is  most  commonly  found  in  males,  according  to  Miinoh- 
meyer,  9  out  of  12  cases,  and  Roth,  30  out  of  39.  The  affection  comes 
on  idiopathicallj  or  follows  slight  trauma.  After  a  somewhat  acute 
o?\.s°t  with  local  swelling,  pain,  and  slight  febrile  reaction,  it  subsides 
in  intensity,  but  usually  advances  steadily  by  a  series  of  relapses.  The 
disease  generally  begins  in  the  muscles  or  fasciae  of  the  neck,  hack,  and 
thorax,  gradually  spreading  to  other  parts  of  the  body.  It  invariablv 
ends  fatally. 

In  the  first  stage  the  muscles  contain  areas  which  are  swollen,  painful. 
and  doughy,  due  apparently  to  inflammatory  infiltration  within  the 
intramuscular  connective  tissue.  In  the  next  stage  there  is  an  over- 
growth of  the  intramu.scular  connective  tissue  with  leukocytic  iiifihra- 
tion.  The  muscle-filiers  lose  their  striation  and  show  fatty  or  other 
degeneration,  the  muscle-nuclei  are  increased  in  many  cases,  siiji^resting 
giant  cells,  and  the  fil)ers  finally  disintegrate.  In  the  third  stage, 
ossification  takes  place  in  the  affected  areas.  The  bone  is  found  in 
the  form  of  spicules,  plates,  nodules,  or  arlx)rescent  ma.s.ses  in  liic  con- 
nective tissue  of  the  muscles,  the  fascia,  and  tendons.  In  some  rases 
the  muscle-bundles  are  chiefly  involved;  in  others,  the  tendons  ami 
fascia?;  and  in  a  third  class  the  newly-formed  bone  is  so  a.ssociiitt-.l  with 
the  old  that  the  disease  presents  the  picture  of  multiple  e.\os'o-,es,  or, 
in  parts,  hyperostoses.  In  course  of  time  large  areas  of  iiniMle  m 
replaced  by  bone,  leading  to  marked  deformity  and  immobilii  v  of  the 
joints.  Ultimately  the  patient  becomes  perfectly  helpless.  I'lie  oniv 
mu.scles  which  escape  are  those  of  the  hand  and  the  muscles  uliidi  are 
not  attached  to  bone  at  both  ends,  although  even  in  the  iiiftir  ca* 
immunity  is  not  ab.solute.  The  "ossified  man"  seen  in  (in  uses  is 
usually  an  example  of  this  terrible  disease. 

The  newly-formed  bone  is  formed  directly  from  connective    •■  irranu- 

'  Ueber  Myositia  Oasificang,  Deut.  Zeit.  f.  Chir.,  31 :  1890:  rtT- 


TUBERCULOSIS  ^. 

mas^^es  and  to  ankylosis  pressure  of  the  enlarging  bony 

.umor-formation  and  inflamiliTioriia  ,  a„<^^^at^^^^^       ^'T^^ 
rwirc     t  as  a  true  tumor      ^  ,^i    i     •  ^  .  ".  "'  """O"!?  o'***"- 

.0  some  disease  of  tL  sJbaTcSij  "'  """''^  "'''*  '*  '•"  ^^"'^'"y 

J;il^t:ic!'S:;^X::rrh™^^^^^^^      r^-  - 

exciting  cause  is  trauma   ^\LT^  meumatism.     Ihe  most  important 

This  ,Jays  the  ^^^T^^^  ;^Tt^^S.rfoZi^^:'^^^''''- 
We  have  analo^.„us  fonVation  of  bone  in  th^  chZd  of  ^K      '*'"-^- 

;  rer.tS7.r  ;v^  -""'t^  ^-^^^^^^^  -taK 
.iid'^sattrte  ii^'ririlnTrr'^^  "r  '^"^  '\^  ^-''«"' 

localized  form,  in  which  he  in,.l  ^J  •  «  "'''"■  '***  ^'^'^  '•»«*  >"  '^e 
"exe«-ise  bTe  "  th.,1  ;  ^  •  '■  '""""imatoT  ossification  and  the 

^\^^Z^lL\s  "  "  "^''"'""^  "^"'^•""  '°  'he  splint-bones  of 

Hallux  valgus  ^lZTtior»„H  ^  .  ''•""'/^  P*'  ^"'-  "^  'he  ca.ses. 
.ion.  have  S  ^nZ^"^  R'^-ftr  k^"""'"  '''^^"^  «'  S^"^™" 
that  portions  of  the  osSSui/r  .h  ^"  '''^''■'  *^  ""^^  «««""« 
orp<Ksib!v  bone^orTS  u    -.1     '''•  Pf""^'^"'"  «■•  it^  forerunne.^, 

from  thl  ^^ly    ■  ^  "r**"*  '■*"'«'^  '"  «*»«  «•«""«  of  growth 

7.  ,  "'^"  proper  environment,  formine  "rests"  within  ♦!.-.  K^ovnn 
fhiri  have  suh<!eniion«i,.  »„i,         """'"K     rests     withm  the  muscles, 

^  <h..  spinal  colmnn'^^v.v;    ^'^"^"'"V  f'  "•  '^^"'^  "^  tuberculosis 
and  duteal   mu«Jer;i^         bones    an<l  hi,,- oints.     The  iliopsoas 

luaba     ertebr^^thT  '**""!•""'•■  'T'^*^  '"  tuberculosis  of  the 
^eneorae  and  the  sacro-ilmc  synchondrosis. 

ue  nitt,  Amer.  Jour.  Med.  Sci.,  120:  1900:295  ^    f  f> 


986 


THE  MUSCLES 


The  intermuscular  connective  tissue  in  such  cases  presents  clironic 
thickening,  and  there  may  be  the  fonnation  of  numerous  granulomas, 
which  by  their  confluence  Icati  to  the  production  of  large  ciiseous 
nodules  and,  when  they  soften,  to  the  so-called  "cold"  abscesses.  'ITie 
aliscef '  cavities  are  lined  by  tuliereulous  granulation  tissue.  Tin-  puri- 
form  material  often  burrows  extensively  through  the  miucle  and  siloii^ 
the  fascia,  and  may  bunt  externally,  leaving  discharging  fistiiliv  or 
sinuses.  Large  areas  of  muscle  and  c«innective  tissue  may  Im;  de.stn)ved 
in  this  way.  The  process  spreads  through  the  formation  of  new  tuber- 
cular foci  in  the  neighborhood  of  the  abscesses,  which  in  their  turn 
enlaige,  become  confluent,  and  break  down.  In  the  more  chronic 
forma  there  is  a  considerable  proliferation  of  fibrous  tissue,  which 
invades  and  replaces  the  mascle-bundles  and  in  its  turn  Imumes 
caseous. 

Microscopically,  the  tuberculous  nodules  consist  of  a  caseous  necrotic 
centre,  bounded  by  a  zone  of  lymphocytes  and  epithelioid  cells,  witii 
possibly  oc-casional  giant-cells.  The  smaller  bloodvessels  may  he 
obliterated  by  proliferative  endarteritis.  The  muscle-flbers  in  the  iieigli- 
borhood  of  the  destructive  process  are  usually  atrophied,  wliile  the 
nuclei  are  increased  in  numl)er.  In  many  places  all  that  reinains  is 
the  sarcolemma  sheath  with  nuclei.  Wliere  the  muscle  has  disapiH-anxi, 
its  place  is  taken  by  connective  tissue,  which  may  be  seen  in  plai-es  to 
be  infiltrated  by  tuberculous  granulation  tissue. 

Primary  tuberculosis,  so  far  as  is  known  at  present,  is  rare.  It  i? 
always  hematogenous.  The  rarity  of  the  affection  is  believed  1)\  some 
to  be  due  to  the  bactericidal  action  of  the  muscle  fluids,  wliicii  Tna 
states  is  more  powerful  than  that  of  other  tissue  juices.  Primary  tuber- 
culasis  may  be  a  manifestation  of  general  miliary  infection,  or  may  lie 
purely  local.  Multiple  miliary  fwi  of  tuberculous  granulation  tissue 
may  l>e  found,  or  larger  single  or  multiple  nodules,  which  in  time  mav 
soften  and  break  down  into  abscesses.  In  certain  cases  these  abscesses 
become  delimited  by  connective  tissue.  In  some  instances  there  is  a 
mrjre  infiltratitig  or  diffuse  process  at  work,  which  at  first,  or  until 
caseation  sets  in,  bears  a  general  resemblance  to  sarcoma. 

Sjrpbilis. — Syphilis  of  the  muscles  takes  the  form  of  clinmic  pn> 
liferative  inflammation  of  the  connective  tissue  (myosiiin  Jihm.-i  nuphi- 
litica)  or  of  gummas.  The  njuscles  usually  affected  are  tht  biceps 
and  those  of  the  neck,  back,  throat,  tongue,  and  sphincter  ani.  The 
gummas  are  often  of  large  size,  and  are  surrounde*!  by  dense  ti'iii)e<tive 
tissue.  In  the  early  stages  the  vascular  granulation  tissue  m.iy  easily 
be  mistaken  for  sarcoma,  but  the  course  of  the  case  and  the  il  i  rapeutic 
test  will  generally  differentiate.  The  muscle-fil)ers  in  the  n- ii.'hlx>r- 
hood  undergo  secondary  atrophy  and  the  extensive  fibrosis  inipiently 
leads  to  marked  contractures. 

Ctonorrhoeal  Myositis. — Gonorrlueal  myositis  is  occasioiiMl'/  hema- 
togenic, but  usually  arises  by  extension  from  the  joints  or  i-  nes.  In 
this  form  interstitial  proliferation  of  the  connective  tissue  i-  !i;aH;e<1 
feature. 


PARASITES 


087 


Ol»nden.-GIanders  may,  J^  acute  or  chronic.    It  produces  multiDle 
,b«^sses  throughout  the  muscle.     The  infection  is  hemZ«n"c  or 
kmphogen.c.     The  muscles  of  the  calves  are  the  ones  chiXTvohed 
The  al^*,es  contain  a  thin,  gaw,  purifonn  fluid  of  gm^vish  color 

Act|llomycosi..-Act.nomy«wis  is  meta.static  or  pro<luc-ed  bTdirect 
extension  from  some  ne.ghlK.ring  part.    Sluggish  gm„uIoma.s  are  foZd 
5how.ng  fatty  degenemt,,.,,  and  li.,uefactic,n.''  I„^his  wav  aCiTare 

■"SJ.     Tr/"^'  "'">  •'*"'  ^'^""'*"""  «'  «'™  nodul^        """ 
raraates.-!  he  chief  parasites  are  the  Trichina  spiralis  the  Cvtti- 

cercw,  celluloaa,  and  the  Echimx^occw,.  ^         '  * 

The  most  common  is  the  Trichina  spiralis,  which  enteis  the  human 

meanly    pork.     Ihe  parasite  is  found  encysted  in  great  numbere  in 

Firj.  267 


T.:  Una.  encysted  in  muscle.     Zei„  „bj.  DD.  wi.hou,  „cular.     (Colleetion  of  McGill 
Lniver.ity.  P.tholupcal  Department.) 

i'tat  at^?^'  '°"*''"';  "^  •"'''1  "^  '•"'  •"''•'^'  '"^"-^'  »higl^s.  the  inter- 

rCnr  t         •     f  •'''^"^ '"  "">*■'■  P""^-*-    '^'he  embrvos  of  the  Trichina 

re  pr,«Juced  m  the  intestine  and  make  their  wav  along  the  lymphatics 

•^^    .  but  soon  invades  the  mu.stle-HlH.r.  which  in  time  degenerates 
ai  diM ppeuR.     \M,en  the  con.li.it.n  is  fullv  developed  there  is  fo^nd 

±.:  '  ''ST  "1 '"  "t'  ""  P"^'"'^^  "^^  ^«"«1  "P -id"  ^nu'" 
^i  ."ve  ^'17;.7^*^  "•^ '"•■*''^,«'o»»:h  to  be  easily  recognized  by  the 
^1  -.^e.     In  the  eariy  stage  there  is  more  or  less  acute  inflammation 


11 


98S 


THE  MUSCLES 


with  round-celled  infiltration  of  the  intemiusrular  connective  tissue, 
the  formation  of  fibroblasts,  and  multiplicution  of  the  miisclc-nuclei. 
Later,  the  acute  manifestations  pass  off  and  the  cyst  becomes  infiltrated 
with  lime  salts. 


SITKOOBUSin  mTAMORPBOSU. 

The  physical  state  of  a  muscle  is  conditioned  by  the  degre«'  of  its 
functional  activity,  the  nature  of  the  ner\-ous  impulses  reacliing  it, 
and  the  character  of  the  metabolism  going  on  within  it.  In  cases 
where  the  functional  demands  are  diminished  or  altogether  lacking 
the  muscle  undergoes  atrophy  and  degeneration.  Where  there  is  an 
increased  call  upon  its  activity,  hypertrophy  and  hyperplasia  result.  If, 
however,  the  demand  be  excessive  or  too  prolonged,  hypertrophv  in 
time  gives  way  to  atrophy.  Again,  so  long  as  the  normal  relationship 
between  the  muscle  and  the  nervous  system  is  maintained,  the  muscle 
retains  its  natural  tonus.  Wliere  this  relationship  is  disturbed,  as  in 
certain  disorders  of  the  central  nervous  system  and  peripheral  ner\-es, 
the  tonus  Ls  gradually  impaired,  nutrition  is  defective,  and  the  niascie 
eventually  undergoes  wastmg  and  degeneration. 

Flo.  268 


Genermlised  marantic  atrophy,  from  "  summer  diarrhoea."     (Dr.  A.  E.  Vipond'i  caK.) 

Atrophy. — ^Atrophy  of  muscle  may  he  divided  into  four  main 
varieties,  simple,  degenerative,  neuropathic,  and  primary  mipfathk 
or  dystrophic  atrophy. 

Simple  Atrophy. — ^Simple  atrophy  is  found  typically  in  old  ajre  (iifmif 
atrophy)  and  in  athrepsia  and  inanition  from  any  cause  [mnninlic 
atrophy).  In  many  ca.ses  the  condition  is  a  transient  one,  provideii 
that  the  exciti.  g  cause  l)e  remove<l,  and  the  muscle  n-tiiiii>  to  it< 
normal  condition.  In  other  instances,  however,  when  the  ciiinlitioii  v 
long-continued,  degenerative  changes  are  superadded.  .\tr(ii>li,v  firtni 
disuse  may  In*  brought  about  by  fracture  .  a  muscle,  tendon,  or  bone, 
ankylosis  of  joints,  fi.xation  by  splints,  oi  en  by  voluntarv  inactiviiy. 
The  last-mentionetl  form  is  met  with  in  ti  tain  fakirs  in  In.lia,  who 
retain  a  limb  in  some  fixed  position  for  prolonged  peritxlv  Over- 
work, by  excessive  contraction  of  the  fibers  and  exhaustion  of  :  iitrition, 
will,  after  a  preliminary  stage  of  compensatory  hypertrophv,  also  give 


E.  Vipond's  cMf.) 


NEUROPATHIC  ATROPHY 

rise  to  atrophy.  Perhaps  more  common  are  degenerative  atrophies 
sueh  as  those  me  w.tli  m  infections  and  intoxicatio^.  chronic  T3S 
.neinia,  artenosclerosU,  and  pressure.  facnexias, 

In  general  atrophic  mascles  are  small,  pale,  and  flabby,  or  some- 
nmes  brownish  fron™  a  deposit  of  pigment  In  simple  atrophy  X 
changes  are  no  stnkmg.  The  fibers  are  thinner  than  nS,  are 
«,..>«  heirstnation  and  occasionally  are  fragmented.  The  connect?." 
tmue  iH^tween  the  bundles  may  be  relatively  or  absolutely  b^Sd 
and  .nay  present  a  deposit  of  fat-Uponutou.'.troph7.  In  manv^^' 
however  and  possibly  the  majority,  these  changeVire  combh^d  S 
other,  of  a  degenerative  nature,  such  a.  Zenker^ degenerationrclo^dy 
swellmg,  lacunar  erosion,  hydropic  and  fatty  changes.  In  both  "he 
simple  and  degenerative  forms  of  atrophy,  ^ws  or^luste«  of  nuclei 
.«  met  with  along  the  atrophied  fibef;,-upon  which  they  abut    d^ 

tnK  ures     \\  hen  the  atrophy  «  complete,  sareolemma  sheaths  ^ 
found  containing  pigment,  nuclei,  and  multinucleated  cells 

lenropathlc  Atro|*y.-Of  great  practical  importance  are  the  neuro- 
pathic atrophies.  Here  the  process  is  confined  to  certain  mlJ^^^r 
frroufxs  of  muscles  and  is  due  to  a  lesion  in  the  central  or  Spheral 
nemnis  .system  In  the  first  case  one  finds  a  degeneration  of^hTZ 
1  ?  'Tk  ♦f«,a"'"'o' horns  of  the  spinal  col^n,  in  the  pvramldd 
tracts,   he  ntietlulla.  and  the  motor  areas  of  the  cerebral  cortex     ThS 

':^Lrj'^V  ^rl'^  "■••'P^'r'^  P"*'^''-^-^  spinal,  bu^Jar,  and 
cerebral  atrophies.  The  extent  of  the  atmphy  resulting  is  dependent 
upon  the  degree  of  the  disease  present  in  the' trophic  ^ntretSTte 
ocahzation  IS  governed  by  the  particular  centres  involved.  I^  ZZ 
disea-ses  with  a  comparatively  localized  lesion,  such  as  anterior^^ 
myelitis,  myelomalacia,  certain  forms  of  sclerasis,  tumo^^;;  W 

muscles  denving  their  nutrition  from  the  affected  cells,  but^ome  of 
the  affections  are  progressive,  leading  to  extensive  ma^cular  w^Uni 
and  m  some  instances  to  the  involvement  of  nearly  all  the  pri^S 
ma.!.,  of  the  body.  In  some  cases,  as  in  amyotrophyiteral  KZs 
P'""7  degeneration  is  not  confined  to  ihe  trophic  ga^gl  on  «£ 
but   xtends  to  the  pyramidal  tracts  and  other  regions  near  bv 

Ihe  neuropathic  atrophies  usually  attack  persons  who  hav^  previouslv 

^^   «eli  and  strong  and  usually  affect  th^  muscles  which'^ar^  ml^ 

u^d.    In  manual  laborers  the  muscles  of  the  thenar  and  hyp^hTnw 

minenoes    the  lumbricales  and  the  interossei,  are  liable  TCfiral 

nvoive,!    Aran-Duchenne  t.vpe).     In  other  cas^s  the  Slse  berins  in 

he  muscles  of  the  shoulder  and  arm.    The  disease  is  ^.S^ue! 

ot  mvariably,  sj-mmetrical,  and  gradually  extends  from  one  group 

of  muscles  to  another,  until,  unless  the  disease  be  arrested   most  f f  the 

2  es  are  involved  and  the  patient  becomes  almost, 1?'„otenlly 

Wpless.     In  cases  where  the  medulla  is  first  involved  there  is  dTffi: 

^v  ">  articulation  and  deglutition,  with  drooling  of  slva  and  Jee^ 

^  of  the  voice  {progre,»ive  bulbar  parc/ym).    The  muscles  o7  the 


m 


IM  li 


3    1  I 


ggo 


THE  MUSCLES 


lower  extremitin  are  involved  late,  if  at  ail.  Irregular  forms  nre  also 
met  with  in  which  the  wasting  begins  in  the  lower  extremiti<>s  and 
extends  gradually  upwnnl. 

Secondarj'  muscular  atrophy  is  also  met  with  in  certain  utrf<tioa'! 
of  the  peripheral  nerves,  such  as  multiple  neuritis,  chronic  lead  uimI 
arsenical  poisoning,  injuries  to  the  motor  nen-es. 

Fio.  2M 


PnigreMive  muwular  d.vrtr..rihy  ((amily  tjix".  xhnwing  the  clmraitrristic  im.w1 
Uie  clinic  uf  the  Koyttl  Virturiu  HiiKpital.) 


'  From 


Bearing  a  somewhat  close  resemhhmce  to  the  progrcssiM'  spinal 
atrophies  is  the  so-called  primary  myopnthy  or  prognsniir  niiinculur 
dystrophy.  This  affection  fre<|uently  liegins  in  childhood,  imi  is  also 
met  with  in  adults.  The  cause  is  quite  obscure,  hut  it  is  ( lianitter- 
istically  a  familial  disease,  so  that  it  has  been  suggested  tli.it  some 
congenital  anomaly  of  development  is  at  work. 

Three  clinical  types  are  recognized:  the  infantile,  juvenile,  iiiid  adult. 
The  first-mentioned  form  usually  l)egins  in  the  mascles  ol  ilie  face, 
giving  rise  to  a  peculiar  e.\pre.s.sionles.s  appearance  pathofrtKniionic  of 
the  disease — the  myopathic  faries.  The  juvenile  form  iir  !•";  the 
muscles  of  the  calves,  thighs,  back,  shoulder-girdle,  and  anas.    The 


PRIMARY  MYOPATHY  ^ 

•dult  variety  be^rii  s  either  in  the  lower  extremitie*  or  in  #K 
exlrrmities  and  fa^.-  wwemiiies  or  m  the  upper 

ami  dorsal  cord.  The  inainrifv  nf  „k.Jl  *^^  "W'wr  of  the  cervical 
dL,ea«,  originates  in  the  X"L  ^S^'"!*"^"  •"  *'""''  *•-'  *»>« 
ever,  that  the  chanRes  in  The  S.^1  1^*      '  "  ''""*  ?««'"''•  ^ow- 

.«  elated,  and  that'^thaide^lJnrorelro??  "l*^  ''^  ""^•»'' 
it  is  obvious  that  <levelonmental  erm«  „ff    .^  .u    '^^''''pP'n^'n'-    For 

motor  fiber,  would  neZTrilv  iT^rjfTil"'^ '^  .«"'«''^    «""»  «nd 

nene  change,  as  secondary  tHhede^^r/^'?  ^"'^  ""K*"*  'h« 
Clinically  aS  anatomi^aTti^,^  L  Xo  fo^^:  ?!  '^?  ^^^--^bers. 
pseudohypertrophic  ^  ^''"™'  *''«  "'"'M'"  «»d  the 

U.ion.atjophy,andfi„ally5isintSrtion^Jle  n^^^^^^^ 

verse  stnation  is  last  and  the  fibers  aowar  .»  ^^   -ll      il    ^'•«'™ns. 

or  finely  g™nulat«l.  ^utne^^"c^rZ.\^"^Zi."'"'^'^'" 
manv  nuclei,  thus  resembling  giant  w-IlT'  fhe"  I  '  f^  containing 
amount  of  proliferation  of  the  con^nec-tiv'tue  Sm^the  endol?''"'" 
ihese  appearances  have  liof>n  v.q,.;,>.,  i     •  "         ""  K  "•« enaomysnim. 

Wai.i,ve[^ld  that  the  sS«Y"  'Se'5,T':::'a  "*''''"*"•"  """^ 
.iuee.1  by  the  fusion  of  spirulle-shan^lm^^l    ^       ,y>"'.V<'um  pro- 

fiber  as  a  revereionary  .legeneration  The!  »^  lu  u  *  ""^^'^ 
a^  ...mpetent  to  forJ,  neTmtS^m.rs  LuM  :  L Iv  "f  """"  '*'":'"" 
mnnect  ve  tissue.    The  inewn^.  J\u  ■       ■'  Regenerate  into 

be  due  to  thirdej;ne™rnrthe^hrr''%-r"^'""-^'^'''^^^^^ 
»n„e<tive  tis.sue.  It  is  Z J^J^^erlllv  ,ll- ^l^''^™*'""  "'  '^'  "'^ 
inci^aseof  the  connective Ts-^.eTowfJt^  .7"^'  uT'''''  '^'^'  *''« 

.*eurnt„  an  embryonic  rHfndUion  '^"^'""^  ''''^>-  '"^''^'^te  a 

".  .lu-  bulk  of  the  affected  musc4     The  ,^Z^Je A^rl     '"'""^ 
more  „r  le.ss  atrophied.    A  true  hvpertnThv  ofTK.  ''>'''""  "'^ 

the  in..«.ase  of  Connective  and  ^0^'^^^'    h-  tZ.' "''rP''"^'"^ 
Durante.    In  most  cases  th^  r.n^f      ,         '■  """^  ^"  observed  by 

to  of  M  .boul  .  conlmcled  or  fibroid  kWnev  .Ef°i,  ■       P*"^"^ 


n 


002 


THE  MUSCLES 


ill  I 


(ij 


from  timple  prnHuir,  'Itir  fat  is  produmi  proiwhiy  fititn  llw  pn> 
liferating  ceils  of  the  emiotny.tiuiii,  aitmiugli  Kruesing  l)elif<v<'!*  that  tW 
is  a  direct  metapla^  ia  of  a  muM'ie  into  fat. 

Dagtnmtioiil.— 0*  dy  iwwUtaf  .—Cloudy  swelling  ( parrtM  fivmatous 
de){eneration,  al()Uinii  ni  drf;i>iieratioii,  pttrerichymatoas  nivo^ItU)  i^i 
common  acrompanimt.  (  of  acute  febrile  di.<tea.ies,  and  ia  aUn  liroiuilii 
aliout  by  inflammation,  c.  rulating  toxins,  and  disturlwnces  of  cin  iilatiun. 
The  affefte<l  muscle  is  pale.  sw(»llen,  and  dou|(hy. 

Microscopically,  the  Wlx-rs  are  swolh:!,  the  striation  indisiiritt,  and 
the  cytoplasm  ciMitaias  iununieruble  minute  ((lobules  of  an  ulliiiniinau< 
nature,  which  n'tider  it  .somewhat  opttque.  These  are  rea<lily  ili.ss.J\Hi 
out  by  the  ii|){)ii(-ation  of  dilute  alkali  or  ac-etic  acid. 

fatty  I>«f*B«atl«n.— •  severe  cases  the  condition  passes  hv  ns\ 
stages  into  fat^  dagtv .....  -n.  I'his  is  also  met  with  in  pluisphiri. 
poisoning,  in  this  ccmi:  i  th  <  muscle  is  soft,  friable,  and  of  a  ww 
yellow,  streaky  appc      v 

Microscopically,  tl  i<  .i  are  swollen,  paler  than  usual,  s.^m-^hiii 
reti'-ulated,  and  the  show  degenerative  tlianges.    When  the  ti^ue 

is  treatet*  with  osmiv-  acid  the  fatty  droplets  within  the  filien  .^tain 
brown  or  black,  and  with  Sudan  III,  yellow  or  carmine. 

Fatty  Inflhration.— In  fatty  inflltration  tliere  is  a  dep<j.sit  of  fat  in 
the  connective  tissue  of  the  endomysium.  In  the  earlier  stajfes  thm 
is  sometimes  a  pn>liferation  of  the  cells  of  the  etidomy.siiini  In  imnv 
instances  the  infiltration,  or  metaplasia,  whichever  it  may  k',  is  onh 
microscopic  in  amount,  but  in  some  cases,  as  in  pseudolr  (lertrnphic 
muscular  paralysis,  the  amount  of  fat  is  excessive  and  leu'N  !i>  enlar^ 
ment  of  the  muscle  bundles. 

Hydropic  vt  Vaenolar  DegaMrttion.-  Hydropic  or  vacuolar  i^irra- 
tion  is  met  with  in  crdemu  of  the  muscle  and  .some  form.s  of  inriaiaOM- 
tion.     The  muscle  appears  to  l>e  pale  and  watery. 

OolUqaativa  Meeroiii. — Colli(|Uutive  necrosis  occurs  in  clindi,  nlerai 
and  suppurative  inflammation.  The  fil>ers  at  Krst  are  enlarpsi.gf.nuik 
or  vacuolateil,  and  finally  melt  away. 

Laeonar  Iroiion. — Lacunar  erosion  is  a  process  aiiahipms  to  ti» 
lacunar  erosion  of  bone.  Here  certain  cells,  derive*!  possililv  from  thf 
internal  perimysium  or  the  .surcolemma  sheath,  attack  tlic  filets  and 
lead  to  atrophy.  This  is  seen  m<xst  fre(|uently  in  the  ii(i;.'hl)orhood 
of  metastatic  cancerous  nodules. 

Vitreon*.  Waxy,  or  Hyaline  Degeneration. — Vitreoas,  waw  or  hvahar 
flegeneration  is  a  form  of  coagulation  necrosis  affectiii>;  the  ma^d' 
prt>toplasm,  first  describe*!  by  v.  Zenker'  as  occurring  in  tvjilioid  fever 
and  hence  called  Zenker's  tlegeneration.     It  is,  however,  met  with  m 
a  great  many  other  conditions,  such  as  sepsis,  variola,  ii:ioxicaiii 
inflammation,  traumatism,  buras,  freezing,  l)ed.sores,  tct.inns,  atni 
the  neighborhood  of  carcinomas.     The  muscles  u.»"ially  atl'  <  it-d  aiv 
recti  abdominis,  the  adductors  of  the  thiglLs,  and  psoas. 


*  Ueber  d.  Veriinderung.  d.  wiilkurl.  Musk,  bei  Typhus  sbdoni.,  I  <  ipzig,  1864. 


ilmlily  fmtn  the 


!ANOItt\K 


la 


ttfettfij  iinwie  in  Mitt 


I- 1.1.  »7o 


&bdom.,  I '  ipzig,  ISW. 


\Vh»ii  thp  mtidition  in  exu    ,ive,  th«- 
ak  an- 1  Hrmitnifi^utvnt  Ml    raw  fwh 

•nre.    In   the  miliier   fomvs   iht-  -KP^"' 

iiiK'Ifi     n'  pM-jwrvwl  ami  rp|;Fii«T- 

«tHifi  is  IhI«>vmI  to  l»e  p<M.sil)|e, 

hut  in  .s«'vere  rases  the  nuclei  <Ii.H. 
I  ippenr.    There   m  usiutllv  U>   Im 

*fn  ..  siiia)l-<rlle(l   infiltratimi  <if 

tin-  eiHloiiivsiuiii.      In    till-    nHwt 

ailratM'eil  (use    lh»'  swollt'ii  Kl"  rs 

frapnent  hihI  (nalfsce  into  irnj;- 
I  ularhvaliiie  ina-ises  'i'he  n.iline 
I  ■iilwtaiKr,  as  a  riili  .  .ttain-  Sadlv, 

iii)iou);li  at  tiiiifs  it  prest-ni     the 

I  mi(iwhemi«al  iVB<'ti<)iis  of  til»r 

I I  r  colliml.  DisiiitccnifioM  Ls  (x-- 
fusionaliv  -Kextrerm  that  henior- 
rtiai.'w.  often  of  Ihiifi-  si/e,  mav 
lake  |»ia(f  into  the  n  n:-.i  .f. 

ImjMi  TnnsformatioD.  A  .i\. 
Iloiil  tmiisfomiation  i>  mrv  iikI 
japparentiv  always  a  lix-al  coiiili- 
jtion,  Ixiiijr  foiiiid  ill  sitnafions 
|«  tre  tlii-rt  lm>  lieen  previous  in- 
I  tlaminatii  II.  Acconliii^  to  Ziegier, 
jannjoid  (li.seaM-  i.s  met  witli  in  the 
llimgiieaiid  larjnx.     The  pr(x^.s.s 

l^.«  in  tlu- p^rimysiun,     .teri.um  ,n.d  the  .san-olemma  sheath.s,  whirh 
\Z  II  T  **  """"^  *™"''l"«'nt  material  eneroachinK  u;x>n   '  e 

mascle-  U-rs  and  eventually  leading  to  their  atmphv.     In  timeTei-^f 
S  r"'^  l^-otne  conff  u..nt  ami  form  n.^lular  ma.s.se.s.  '       ' 

MdllMtion.  (  alcihcat.on  has  »H-en  ol,.ser^e<l  in  the  muscles  in  the 
\m,\M.n.l  of  OKI  en<.«psulate.l  al,,sce,s.ses.  in  .^rtaiVoE  ci",  .ic 
iJammatory  pnK-es.se.s,  trauma,  and  as  „  .ser,uel  of  marked  alnZ 

Th;;;.Hli..on  ,„ay  follow,  for  example,  .sut,'.,.  of  a  wCun.l  of^He 

miiMi..    A.ronl.nK  <"  Sc-hii  cninoff.  calcification  takes  place  after   he 
Il1l^^  !iav,.  underKoiH-  .olloid  degenemtion  '  ^ 

IbimT'"''/^'""*^"'"''  '"■'""   '"   ^'■^■*'""   '"fective  proc-esses    decn- 

!r,        -'■">"<»'-  or  greenish-black,  ht^ak  up  into  sh«.l.s  or  SuSv 
«!/«»,r, ,,,.).     In  ca.ses  whe,^  the  bloo.1  sujplv  t<.  the  part  sSv 

;  ,  'Ti'". :; '"'"^"'  J"  •''^  f'  "'^  f'""  •'"-  "j>  '''''-->wS 


mUKi'li'   nlxri.    .1 
I  ■  ™ry    li««lii.ii 
utrrady     Nome 
l(l>Mirii,|.ir(frr.) 


<ir  »;,  ,  Hki-.  ilrlriiFnition  .,f 
fc)  w\.i,(i»ii  hourn  ttliit  irm- 
"f  the  Banip.  In  f,  ,h,„  j, 
aiTumulBtinn     .,f    leukiwytn. 


i 


THE  MUSCLES 


in  the  subcutaneous  tissues,  is  the  so-called  emphysematoua  nangrm, 
or  gangrtne  foudroyante,  due  to  the  B.  Weichii  or  the  bacillus  of  malig- 
nant oedema. 

Microscopically,  in  the  moist  form,  the  muscle-fibers  show  simple 
or  coagulation  necrosis,  vacuolation,  and  liqi'cf-otion,  while  there  is  a 
deposit  of  blood-pij^rnent,  cholesterin,  and  triple  phosphates.  In  dn 
gangrene  the  cells  shrink  and  drj'  up  into  a  keratinoid  substance.  Asa 
rule,  the  dead  tissue  is  delimited  from  the  healthy  part  by  n  zone  of 
reactive  inflammation  in  which  the  vessels  are  congested,  and  there  a 
an  exudation  of  inflammatory  leukocytes. 


Fio.  271 


Sriiile  gangrrne  of  the  ureal  ti»,  fmin  a  case  nf  arterial  thrombo»i«.  The  ine  i~  Mlirunkm  i»d 
its  epidermis  is  beinK  exfoliated.  At  the  line  ut  demarcation  the  akin  has  rrtradcd  (al  udiit 
deeper  parts  are  separating  (6). 

Pigmentation.  -Pigmentation  is  a  coastant  accompaniinent  of  ibt 
form  of  atrophy  known  as  brown  atrophy.  The  pigment,  calkHl  heiiii- 
fu-cin,  is  fouD.i  in  the  form  of  minute,  yellowish-brown  ^rrainilcs  in 
the  cytoplasm  about  the  poles  of  tlie  nuclei,  but  in  ailv;iiice<l  (a^fs 
is  scatteretl  throughout  the  greater  part  of  the  filn-r.  In  some  ca« 
the  increase  in  pif;ment  is  possibly  only  a  relative  matter,  due  to  atrophy  J 
of  the  cytoplasm  with  retention  of  the  normal  mu«'Ie  pifrment.  In 
other  cases  there  seems  to  1)0  a  transformation  of  tin-  inyohematin  j 
into  granular  material,  leading  to  an  absolute  increase. 

In  cases  of  hemorrhage,  hematoidin  antl  hemosiderin  may  licdepit" 
in  the  muscle-bundles  and  coiniective  tissue. 


PROGRESSIVE  METAMORPHOSES. 

The  repair  t)f  injury  to  muscles,  such  as  that  protliu  i  'I  by  (li*« 
or  mechanical  trauma,  may  l)e  perfect  or  imperfii-t  aoi.nliiifj  to 'p 
character  and  extent  of  the  lesion.     Provided  that  the  imistle-nucifl  | 


BYPERTROPnr  ggg 

.ml  the  sarcolemma  be  not  destroyed,  slight  injuries  to  the  contractile 
5ubtance  are  repaired  by  the  production  of  neV  muscle-fibe«  SStS 
«  m  Ae  cases  of  the  embryonal  formation  of  muscle.    Volkmnn 
states  that  regeneration  js    unctionally  important  only  after    Xw 
fever  and  freezmg  wh.le  m  injuries  function  is  not  .^stored  unS  the 
wound  .s  small     Where  large  areas  of  muscular  tissue  are  destroyed 
as  by  mflanamation  or  severe  mechanical  trauma,  .^generation  of  mSe 
JS  .momplete  and  a  la.^  part  of  the  deficit  is  mad^gcxKl  by  the  W 
tion  of  granulation  and  ultimately  connective  ti.s.s„e     In  all  casesTe 
repair  13  brought  about  by  the  prolifemtion  of  the  pi^xisting  cells 
of  the  part.     Where  a  fibrou-  scar  has  been  produced,' after  a  m*Lro  or 
\m  prolonge.1  period  it  is  replace,  1  to  a  limit'e.1  extent  by  the  inv^^ion 
ornew  mi^de-hl^rs  denved  fronr.  the  uninjuml  muscle  in  the  1.^3^ 
hood.     Ihe  muscle-nudei  divi.le  either  directlv  or  by  mitosis   vWIe 
a    he  same  time  there  is  a  local  increase  of  the^aroolemmati  «tan«. 
At  he  en,l.  or  at  some  point  along  th .  cour^  of  the  filn-r,  multinucleatS 
buds  of  protoplasm  are  produced  which  grow  out  into  the  gmnuS 
..ssue_    At  first  the.se  present  no  striation,  but  .soon  becomeSlS 
and  the  bud  or  myoblast  as  it  is  called,  becomes  striatal.     Besi.E  the 
myobla,st.s    free  multinucleate,!  cells  may  be  seen  which  are  known 
as  sarcolytes.    The  majority  of  these  pn.bably  „nde,^^>  fatty  deg^^^r. 
on  ..r  nec-rosis  ami  ultimately  disappear,  although  .J.me  of^ lem  mv 
orm    ew  fibers  or  fu.se  with  pm^xi.sting  o-.es     The  san-olvtes  are 
rohably  .Icrim    from  free  mu.s<.|e<.c,rp-...cles.  and,  whero  t  iere  ha^ 
l-een  an  actual  loss  of  substance  in  tl,e^nu.scle.  ar^  apt  to  bTmther 
umemus.    They  are  phagc..ytic  and  may  b.-  seen  to  contain  pigment 
bits  of  necrotic  muscle,  and  detritus.  piKuieni, 

Hypertrophy.-True  h.N-pertrophy  of  muscle  probablv  does  not 
ocur  exeep  ,n  the  ca.se  of  individual  fil^-rs.  It  is  true  tharundeJ 
™mi,  „ms  of  increased  work  the  muscle-filM>n,  increa.se  both  in  length 

0'  h'  .  lht\"::j'''  '""•  "J""*  '"xr"-^'  "J'*'"'^'"^'  '^  "  '•"'"^nation 
0  IniMrrophy  and  hyperplasia.  Ih-,x.rtn.phv.  scM-alled.  mav  l,e 
«.nKeM„.l  as  well  as  acc,uired.  as  in  the  cases  of  genera  a^W^ 
giftantisin  and  hemihvpcrtrophy.  ''  ' 

In  myotonia  congeiiita,  or  fhomsen's  disease,  Erb'  has  descril)ed  a 
mark...  „K.rc.ase  n  the  size  of  tiie  affcrted  niusc-h.-fil^rs  witi  Tro^^^^^^^^^ 

S''"  '""'  .^'^r«4?e  of  the  fil^n,.  pro,lucing  nuinerical  increase  He 
bserv...!  amitotic  division  of  the  i.iulei  msulting  in  the  pnEon  o^ 

KHinl   in   .legenerative    and    regenerative  prcx^ses.      It    is    doubtful 

Shh.,  Iv  ''r'  ."  "•'  "  ''r'--'i-  P—  rather  than  /' 
3  '•''••  ^"  r"*"'".  '■*'■'*'  "^  ""'^''-ular  atn.pl,v,  the  myopathies 
«al  trauma,  and  certain  infectious  diseases,  I  ke  tvphoi.l  Tsoa S 
fibe^  .nay  show  hypertrophy,  apparently  compensatory.'^        '  ^ 

'  Die  TIioDMen'sche  Krankheit,  Leipzig,  1880. 


996 


THE  Ml'SCLES 


Tnmon. — Primary  tumors  of  the  imist-les  art  <juite  rare  an 
erally  arise  from  tlie  faseia  or  iiiterniuscular  eonneftive  tissue.  . 
the  benign  growths  may  l»e  mentioned  the  fibroma,  liponw,  m 
chondroma,  and  angioma.*  Hard  fihromas  have  l>een  obsened 
fascia  of  the  retti  alnlominis,  and  myxomas  in  the  muscles  of  th( 
Mjomai  may  originate  from  tiie  arre«'torcs  pilorum. 

Sareoma.—The  most  fre<iuent  gn)wths  are  the  various  fonns  of  sa 
fihroKurcomu,  myxotiarcomu,  and  myjroHponarconui.  Tiiese  forii 
tumors  and  are  soft  and  cellular,  iH'ing  comp<xse«l  of  round  orspind 

Various  forms  of  degeneration  are  common,  and  there  may  l»t 
plasia  into  Iwne  or  cartilage. 

Kio.  272 


Myiilns  fnini  thr  arm.     Wimkel  iihj    .No.  3.  wi..    'it  ocular. 
Dr.  .\.  (i.  .NirholJii.) 


(From  I  he  !•' 


MifDnarromii,  that  is  to  .say.  a  .sarcoma  originating  from  ciu 
muscle  cells,  is  theoretically  possible,  but  little  is  known  a.-;  ti>  ii- 
occurrence. 

RhiiMomijonui  and  rhahdomi/nxurromn  have  Imh-u  de.s<Til)e<l  by  ] 
and  Buhl,'  but  are  excessively  rare.  We  have  met  with  one  ca,s<  i  F 
of  a  rhalMloinyo.sar(()ma,  in  a  tn)Ut.*  It  is  thought  that  such  tiiiiu 
from  pree.xistiiig  mu.sclc-<'clls  or  jMwsibly  from  cinbrytHiic  <cll  im 

Secondarv  .sanonui  of  the  muscle  is  conunon. 


'  I'oroil.',  II  I'l.lioliiiici.,  Koine,  l."):  I'.HtS:  2.Sil. 
'  KliiilMloiiiyom,  Virrli.   \rcli.,  i»:  \xrM:  172. 
^  l{lml>ilc.iiiy»m,  Zcit.  1.  Hiol.,  1:  IStKj. 
«  AiliiMii,  Moiitmil  :•.•.!.  .lourii.,  :»7:liHI.S:  lt>;t. 


*; 


TUMORS 


997 


rm.tasta.sis  is  rare.  '   '  ^'"'  "'  "'"'""^h.     Hematogenic 

The  growth  is  usually  diffuse  or  in  th^   t..^     t      • 

Fki.  27.1 


HUl»l.uny.>.arriinm  in  a  hriH.lt  In.ut.      lit 
ciiIlFriion  (if  Dr. 


Itei.-I.erl  ..l,j.   .N„.  j,  »i„,„„, 


J.  (tnirKi-  .\rlanii.) 

similar  to  How.shin's  laniiii.      r )»:....  > 

.he  ,.a„..er  ells.  a!;.l  /S^  fluen  •  .'he  SS";'  ''*"  "T'-''^  "^"■°"  "^ 
umi.Tf;.,  atn.,,hv,  .oagulati.,  nmsi  T[  ;''"'•'". ^•«"'^-/''t'  m.isdeH^lls 
appear     There" is  ..s.ih  K-         "r"*^'^'  '"l"ff"«t«on,  a.i.l  ultimately  dis- 

THE  TENDONS.  TENDON-SHEATHS.  AND  BUESJl 


Hi 


WKv 


THE  TENDONS  AND  BURSM 


inclosed  in  a  sheath  containing  a  small  amount  of  synovial  secretion, 
thus  allowing  movement  of  the  tendon  backward  and  forward.  Owing 
to  the  peculiarly  dense  and  resistant  character  of  these  structures  and 
the  fact  that  the  bloodvessels  are  scanty,  primary  affections,  particularly 
the  infective  and  inflammatory  ones,  are  infrequent.  Much  more  com> 
monly,  the  tendons  and  their  sheaths  are  secondarily  involved  from 
disease  processes  in  the  neighborhood. 


OnOULATOBT  DnTURBAHOIS. 

HamoiThag*  into  the  sheath  of  a  tendon  may  follow  trauma  and 
result  in  the  formation  of  a  hematoma. 


DTrLABOCATIOm. 


Tendinitis.  —  Inflammation  of  a  tendon  is  called  tradinitii;  of  a 
tendon  sheath,  twdovagiaitti  or  taaoiynoTitii.  The  two  conditions  are 
more  often  than  not  associated  one  with  the  other. 

In  general,  tendinitis  ainl  tenosynovitis  bear  a  close  resemblance  to 
infiammation  of  the  joints.  The  condition  usually  follows  trauma  or 
arises  by  extension  from  neighboring  structures.  It  is  rarely  primarj'. 
Wounds,  fractures,  and  straiius  may  set  up  inflammation  and  also  cir- 
culating toxins  and  bacteria,  such  us  the  pyogenic  cocci,  Gonococci,  and 
Pneumoccx^i.  Tendinitis  and  tenosynovitis  may  be  serous,  fibrinous,  or 
purulent  in  character. 

Simple  Tendinitis. — Simple  tendinitis  and  tenosynovitis  may  occur 
in  those  of  a  rheumatic  or  gouty  dis{M)sition  after  strain  of  the  tendons, 
expasure  to  cold,  and  rarely  in  certain  infective  diseases,  such  as 
syphilis,  typhoid,  and  scarlatiiiu.  'I'here  is  usually  little  exudate,  but 
owing  to  the  depasit  of  fibrin  U|>on  tlie  surfaces  of  the  tendon  and  slieath, 
a  rough,  grating  seiisjition  or  crepitus  is  felt  when  the  tendon  is  put 
in  action  (tenosffHoviils  sicca  acuta).  It  is.  perhaps,  most  fm|uentiy 
met  with  in  the  tendo  Achillis,  and  next  in  the  extensor  tendons  of  the 
forearm. 

Acute  Purulent  Tendinitii. — Acute  purulent  tendinitis  and  tenosynovitis 
arise  after  trauiiiati.sin  where  a  wound  has  lieconie  infectcil,  or  by 
extension  from  neighboring  parts,  as,  for  instance,  in  erysipciii-.  infected 
wounds  and  abscesses.  It  may  also  \w  hematogenic,  due  to  iIm'  action 
of  (joncK'occi  or  other  py<)geuic  niicroiirganisuLs. 

The  tendon  and  its  sheath  lieconie  (t-deniatous,  the  inltrt'ascicular 
connective  tissue  is  ctjngesled  and  iutiltrated  with  round  (rll>,  while 
there  is  an  accutniiiation  of  pas  within  the  cavity.  Iti  inilii  cases 
recovery  may  take  pla<-e  witliout  much  or  any  interference  \Miii  func- 
tion. In  severe  cases  tiierf  is  liable  to  l>e  adhesion  between  tin-  tendon 
and  its  slieath,  or  the  tendon  may  l)e«'ome  cloudy,  soften,  iimi  finally 
necrose.  Where  the  tendon  has  been  desti-oyed  regeneration  aid  n-pair 
may  take  place. 


IF'I 


V  trauma  and 


le  tit  I  III'  action 


TENDINITIS  ggg 

Ohroale  T«jdliiltta.-Chn>nic  tendinitis  amy  occur  alone  but  is  usu^llv 
^socmted  with  tenosynovitis.  It  may  follow  the  acute  fo!;i«or„SrtS 
Kute  attacks,  or,  again,  may  come  on  insidiously.  ^^ 

h^Le^clS^'Tni^  °'  ^:  '^"f^J?  ^T"°"-    ^"---  -d 
u;aii  re  ciwinjea  laKc  place.      Ihe  mterfascicular  connective  tiuno  :. 

jDcreased  m  amount,  and  calcification  or  metaplasia  i2£,ne  ^cLf 
the  sheath  of  the  flexors  of  the  camS  ^TtiZ^^u  ^  *?"*.'" 

'  See  Hirschsprung,  Jahrb.  f.  Kinder.,  10:  1881 
Virch.  Archiv,  135:  1894:  394. 


ii 


1000 


THE  BVRSX 


stages  the  tendoits  ami  sheathx  inay  iw  incruateci  with  fungous  ^'nmula- 
tioas  covered  with  fibrin  or  purifnm)  exudation.  Tiie  umouiit  of  thr 
fluid  a  often  large,  and  "  rice-iMidies"  un-  common. 


RBTBOORUSIVE 


Degenerative  disturbances  are  apt  to  \ye  slight  ami  unimpMtHiit. 

▲trophy. — Atn»phy  may  (XTUr  where  the  musrie  lielongmj;  to  the 
tendon  has  previously  undergone  atrophy,  but  this  result  is  usually 
long  delayed.  The  structure  peculiar  to  the  tendon  is  1««  and  it  is 
converted  into  scar-like  connective  tissue.  The  suppafftiiii;  stroma 
is  increased  through  proliferation  of  its  cells,  and  may  ite  converted 
into  fat. 

Hjalia*  ami  maeinoni  degeneration  have  l>een  olmerved  in  .some  cases 
of  inflammation. 

After  injuries  or  severe  inflammation  the  tendons  may  nacteie. 

Oaldfleatioii  has  lieen  ol)ser>'ed  in  chronic  inflammations,  and  oatie 
dapoiiU  in  the  tendoas  and  tendon  sheaths  are  frequently  met  wiili 
in  gout. 

PR0ORE88I7X  MKTAM0KPH08I8. 

When  a  tendon  is  .severe«l,  provideil  that  suppuration  does  not  tHTiir. 
function  is  restoretl  by  the  imion  of  the  tlivided  ends.  This  takes 
plac-e,  not  by  the  formati«>n  of  new  tendon,  but  by  the  priHliiciioii  df 
dense  scar-ti.ssue,  more  grayish  and  le.ss  glistening  than  ten<ion,  derived 
mainly  from  the  prolifenition  of  the  comiective-tissue  matrix. 

Metaplasia. — Sletaplasia  of  the  tendinous  material  into  nmciii,  fat. 
cartilage,  or  Ixme  is  met  with  in  many  forms  of  chronic  inflanunation. 

Tumors.— Tumors  are  rare.  Sireoma  may,  possibly,  develop  from  tlip 
tendon  or  its  sheath.  A  very  rare  growth  is  the  lipoma  wborescens,  in 
which  branching  papillary  excrescem-es  of  fatty  tissue  are  formed  within 
the  tendon  sheath. 

Acconling  to  I^edderluxse,'  the  .s«)-calle<l  ganglion  of  the  wii^i,  liack 
of  hand,  and  foot,  which  u.sed  to  \w  ct)nsidere<l  a  form  of  liulmps  (if 
the  sheath,  is  a  new-formation  of  a  myxomatous,  gelatinous,  ur  idlinid 
nature. 

The  Bursa. 

The  bursje  are  connective-tissue  .sues  containing  clear  sui  i\i:il  Hiiid. 
The  structures  forming  the  wall  resemble  in  general  the  tend ni  sheaths. 
Bursje  are  usually  found  in  well-«lefine(l  .situations,  where\i  r  niiiscies 
or  tendons  play  over  bones,  or  where  the  tissues  are  subjeeiitl  to  pres'.- 
ure.     Thev  are  not  constant  in  numlier  or  in  .situation,  i    r  mav  lie 


'  ZeitKch.  f.  aiir.,  .37  :  1N()3. 


INFLAMMATIONS 


1001 


il  in  Home  cusps 


llrE  wL'lilh""'  P'^T'  '"  '^  "'""*  "'  ^*'*"'"  occupation.. 
.1.  places  where  they  ..ni.nanly  are  not  present.    The  patholodca 

HemoRhace  into  l.uml  .,««,  occurs  fn.m  trauma  or  cireulatory  dis- 

iZLi3  '''r^*  '"J^  "'  hematomata  may  l.e  ^nSJ 
InflMmutkHU—Acute  bantti,  or  tent*  hygroma  Ls  due  most  com- 
monly to  wounds    hrui.se,.  or  contasioas.  or.  more  rarely,  t^he^- 
op-nic  infection.     It  may  giye  rise  to  a  serou.,,  serofibrinoas.  or  pu™- 
lent  exudation^    A  painful  fluctuating  swelling  is  pmduced.    cZmon 
examples  of  this  are  the  .s,M-alle.l  " h.n^eMsknee"  and  "m™«T, 

Obnmie  bonttia  takes  the  form  of  an  accumulation  of  fluid  in  the 
cavity-Ai^rop  or  hy,jroma  bur.w.  The  exudation  is  at  fint  yiscW 
and  mucinoas.  but  ater  (.ecomes  thinner  ami  more  waten  The 
swelling  nmy|,e  as  big  a.s  an  apple  or  la^^er.  The  wall  of  the  bum 
.s  no  at  fi«t  much  altere-J.  but  .sooner  or  later  l,ecomes  thickene^lT 
may  Ik.  coyere<l  with  shaggy  fibmas  outgrowth  or  eyen  cartilaginous'  o[ 
Unn-  plates  and  excrescences.  Fre«,ue„tly  "rice-bodies"  are  SC^ed 
In  some  cases  these  may  be  so  large  and  numerous  that  the  .sac  is  filiS" 

Tnbereatonf  bnnitu  is  primary  or  sm,n.lary.  The  wall  of  the  sac 
lje,..n,es  thickened  ami  infiltmted  with  tulM-reulous  granulomas  whX 
.he  surfaj^  ,.s  covere.!  with  fungous  granulatioas.  ^1.ere  Ts  .Isua  ! 
coiiMderable  exudate  ( hifffroma  luherculmum )  ^ 


I      4 


Th 
Itatf( 
lod  SI 
ioeom 
»hkh 
ud  ii 
ippan 
loulij 

force-!, 
fven  i 
'iriou 

:i4trix 
format 
■Je  ca 

In  t 

stance. 
::al|v 

■>  «r.\t 

JS!i!J(-a 


SECTION  X. 
THE  OSSEOL'S  SYSTEM. 


CHAPTER    XLIII. 

THE  BONES,  JOINTS,  AND  CARTILAGES. 

TBI  BONIS. 

ZMTKODUOTOKT. 

Tnr.  »K>ny  skeleton  sulisenes  two  important  purposes  in  the  ommism. 
It  affords  a  more  or  le«  ngid  scaffolding  for  the  ^pport  of  th?o«ans 
an,i  soft  t«sues  generally.  an.l  contrihutes  to  the  im^ant  funcUon  of 

TTT'  *f  •*'",  '^""'^"^'  ^•'"■"'««"^v  and  re.^imto,y  functions 
wluch  th«  mechanical  act  connotes.  Hone  is.  perhaps,  the  m«t  resistant 
itKJ  .ndestnicuble  tissue  m  the  IkxJv,  but,  in' spite  of  its  hanlness  and 
»ppar.nt  solidity.  ,t  is  not  the  permanent,  unchangeable  structure  that  one 
»ou,i  at  first  .sight  suppose.  Like  other  tissues  it  exhibits  the  various 
Mk  and  katabohc  prcK-e-vses  that  are  characteristic  of  all  vital 
.>ree,.     Breaking  down  and   building  up  are  continuallv  going  on 

en  ,n  health,  and  may  be  much  cxaggemte,]  and  per>med  under 
•anoas  pathological  conditions. 

B..,e  is  nonnally  produce.!  in  two  ways.  It  is  derive.1  from  osteo- 
.-enetic  centres  within  a  but  slightly  differentiate.1  connective-tissue 
P^tnx  (intramembranous  fonimtion)  or  from  cartilage  (endochondral 
-rm.  .on).  Ihe  hrst  mo.le  of  origin  is  well  exemplificl  in  the  case  of 
^e  ca  vanum.  and  the  .second,  in  the  spinal  column  and  long  bones 

In  the  intramembranoiis  form  of  osteogenesis.  Iwnv  spicules  con- 
^.nTi_-  I.me  salts,  together  with  iH,ne-c„rpascles  an.l  ce'lls.  are  formed 
^t^un  a  proliferati(>n-ti.s,sue  consisting  partly  of  cells  and  partly  of  a 
:"r  '"  llit"*  P^'f«^''.^-  develop  hoin.,geneoas  or  fibrillar  ground  sub- 
^T      I  ,"•''  ""^r"  >r™''"»":  '••'■'^'a-*  in  size,  and,  when  thev 

^1.  rr,ale:w  to  form  plates,  ;;ain  in  thi.kness  tim.ugh  the  activity  of 
^  .x'emal  connec-tiye-tissue  layer,  which  is  iicK-eforth  known  as 'the 

:,r  ' '™-  u  ."*■'?  '",  •*'<'  '"'""^  »■".••  «'•«"  eailiest  manifestations  of 
«-...  non  begin  in  the  preexisting  cartilage  thaf  is  eventually  to 
^''  bony  skeleton.      From  certain  regions  in  the  surrounding 

-oroc:  investment  or  perichondrium  bony  pr  .cesses  are  formed  which 


ir'i 


1004 


THE  BOSKS 


il  . 


gnuiually  rxtrnl  iiwanl.  i'liis  meth<Mi  of  );rowth  from  tli<-  |N>ri- 
rhuiulrium,  or  fnuii  wlmt  later  liK<onM*H  ihi*  periosteum,  is  foinxl  to 
!<ome  exlriit  throii^^hout  life,  bimI  acrount.H  more  especially  for  ihr 
iiirrea!ie  in  thickness  of  Imiim*. 

Resides  thii«,  tiiere  is  what  is  called  the  endochondral  otwifk'ation,  which 
Ls  hrouftht  alioiit  by  the  marrow  tissue  of  the  primitive  lioiie  proiifcniiiiif; 
and  invailiiig  the  calcifyiuK  cartila((e,  whicli  it  exteasively  destroys.  As 
soon  as  the  marrow  spaces  In-gin  (o  appear  '-iHltK-hondral  l»one  foniia- 
tion  proper  commciH>es.  In  the  neighlK)riuMMl  of  the  medullary  simces, 
wherv  they  arc  Imhi  uleii  by  the  solid  cartiiu^.  the  cartilage  cpIIh  ciihirjp- 
and  pniliferate,  forming  small  clusters,  which  uitimutely  become  arruii^l 
in  rows  imnillel  to  the  long  axis  of  the  bone  that  is  to  lie.  It  is  thnm^ih 
the  proliferation  <>f  these  cells  that  the  incivase  in  the  length  of  Uiiie  is 
brought  almut.  \Mit-ii  the  cartilage  (ells  have  attaine<l  their  full  size, 
there  (H-curs  a  dc|>osit  of  lime  salts  in  the  ground  suKstame  and  the 
capsules  of  the  ciirfilage  cells.  In  this  way  is  fonne<l  a  narrow  line  of 
demarcation  in  the  deeper  layers  of  the  intermediate  cartilage,  which, 
however,  does  not  reniani  perfect,  inasmuch  as  the  vascularize*!  iiuirrow 
gradually  di.ssolvcs  it  away  in  places  and  penetrates  thniugh  it,  icuvin); 
only  islets  of  cartilaginous  ground  substance  and  calcified  tissue.  These 
are,  in  time,  converted  into  Inme  pro|)er  through  the  agency  of  (iTiain 
cells  <lerive<l  from  the  Ijone-marrow,  culle«l  osteoblasts.  The  cartihi^.'e 
in  this  way  is  grudtially  replace<l  by  lM)ne. 

If  one  examines  a  gmwing  l)one  after  it  is  completely  blocknl  out, 
the  following  condition  of  things  will  l>e  ftmnd.  The  shaft,  or  iliiiphysis, 
is Completely  ossified.  At  the  end  Ls  the  cartilaginoiLs  plate  caileti  the 
epiphysis.  lietween  the  diaphysis  and  the  epiphysis  is  the  siKulied 
intermediate  cartilage.  The  epiphysis  contains  within  it  more  or  les.s 
complete  centres  of  ossification.  The  intermediate  curtilagi-  is  ctmi- 
posed  of  two  layers,  a  bluish,  translucent  one,  the  zone  of  pniliftralion, 
and  another  of  a  thin,  opaque,  yellowish-white  ap{>earttnce,  the  /.one  of 
calcification.  'J'lie  centre  of  ixssification  in  the  epiphyses  >.'rii(hiall} 
enlarges  until  the  structure  is  completely  tninsfonne«l  into  liune.  .\s 
soon  as  thr  shaft  and  the  epiphysis  are  firmly  united  into  u  lH>iiy  iiia.ss 
gmwth  in  the  length  of  the  bone  cruses.  This  nonnally  (M'curs  U'tween 
the  ages  of  twenty  and  twenty-seven,  but  under  certain  |iiuh(ih)p('al 
ctmditions  may  take  place  prematurely,  or,  again,  may  Im-  ihiayttl. 
Similarly,  the  .syn«)stosis  of  a  .syndmndmsis  or  suture  arn'st>  further 
gmwth  at  that  jwint.  Synostosis  may  l)e  delayed  or  miiy  iMciir  in 
places  where  ossification  dm*s  not  nonnally  take  place.  In  lii'  >  use  "f 
the  skull  pri'inature  ossification  of  one  or  more  sutures  may  Im"  t'iMiii<i  ami 
leads  to  varioiw  forms  of  asymmetry  and,  in  extreme  conditions,  (i>  iiiicr»- 
eephttly.  Premature  .synostosis  of  the  intersphenoid  aiui  sphi  nnlia-sihir 
synchondnxses  causes  shortening  of  the  base  of  the  skull  iimi  a  ikrph 
set  nose.  This  is  to  l»e  oKser\'«l  in  cntinism  and  some  forms  ni'  .hDiMlro- 
dystrophia.  Premature  .symxstixsis  of  Inith  sacro-iliac  suniiniiiiroses 
leads  to  a  uniform  contraction  of  the  pelvis;  of  one,  to  an  oiili.;i.(  ly  eim- 
tracted  pelvis. 


DWAkf/SM 


1005 


AMOMALIII  OF  OlOWTH  AMD  DITILOPIflllT. 

'IW  arf  nuinemus  ui.,|  i,„,H,rt«nt.  ami  aK>  manift^tecl  in  the  fonm 
rf .  efH-.en..y  or  ext-es«  ,„  Kn.w.h.  .,r  in  some  peculiarity  in  the  uuZ 
of  the  ljo,M..  I  he  causes  that  hrin^  these  aW  mayL  inheri t'ed  2 
«.,...«.!  during  intra-utenne  or  extre-uterine  life.  As\  rule.  impSe^ 
nons  of  the  iKHie.  aiv  ass-.-iate,!  with  analog„,»  abnormali  ie.  i,. "he 
*of,  ,««-,  «.nnec.te.l  with  then,,  although  ex.^ptioa,  .xrur.  The  te„n 
.pF.he.1  to  complete  defect  of  a  lK,ny  or  other  ,tru«-tuiv  Ls  HnmZ 
ipb.U,  hut  these  name,  are  applied  sometimes,  though  imJrm^  to 
.  kvs  extrenH.  degree  of  the  c^mlition.  a  jmrtial  .leficiencv.  TKi;  i^ 
nM)re  properly  styled  hypopUiJa.  ~.-     iniaw 

AgMMy.  i,;  th;  stricter  s.-n.se.  is  always  local,  and  is  foun.l  asuallv  in 
.he  calvanum  and  vertel.ral  arthes.  les-s  f«^uentlv  in  the  ext«.miti« 
.n.!  iKHhes  of  the  ver.el.nc.  The  skull,  as  a  whole,  mav  lie  pS  k 
.l«c„.  as  .n  acrphaly  or  jwrtially  defective,  as  in  anenc-^phalv.  cn'bpl 
.n,i  other  grave  malfonnatioas.  The  spinal  „.lumn  Lv*  «  S^ 
memary.  as  „.  nnencrphaly  an.l  spina  l.ifi,|„.  or  „„e  or  mo,^  ,,f  tt 

lHlinall.>.  lie  ,l,sfal  emU  of  the  radias.  til.ia.  and  fil.ula  m.n  be 
.«♦■.,  .n  ma  fonnations  of  the  hands  and  feet.  Occasional iV  the 
clavK  les  are  absent,  or  the  fibula.  «»i"imiiN    me 

In  another  chm  ,,f  cases  the  primitive  "aniage"  have  l^^n  laid  down 
>o  »r  as  we  know,  m  «  „onnal  manner,  but  the  stn..tu«.s  arising  fmm 
i^M  have  failed  to  reach  their  .-omplce  .levelopment  -hyi^pS 
Th.> .  ..ndifon  may  l.e  hnal  or  general.  In  the  I.k«I  form  the  hJad  imv 
*  «l..,orm«|lv  small  (.me  fonn  of  mleroeaphaly).  an  am,  or  a  leg  ma  Ti 
deh.M„t  ,,,  s,«.  (mlcrobwehlui.  micropu.).  or.  again,  all  four  extSi« 

-^    .1  factor  scents  to  l,e  pre.s.su,v  u,,on  the  f.etas  fnnn  T.-ontrac  ed 
amnion  or  froin  Und.s  or  adhesions,  although  it  is  not  impcKssib  "  ha 
".some  cases  the  primitive  "aniage"  mav  1h-  at  fault       ""^'"'"*  '""' 
Dwtrft•m.-^^•hel,  the  Ixxly  as  a  whole  is  .liminutive  we  mav  speak 

it  :T  T    "*?""*•■  ""«-"^)-     An  «llie<l  condition  Ls  iaLX» 
h  «luch  dw«rf,s„,  ,.s  usually,  but  not  invariablv.  as-scx-iated.     l3 

'mm  1      "";:"•  T''*"""':-^'  ""  """^"'■''""'  "-'""'^  '^e  chai^cteri.s-tic^ 
-nil .  ,.|uld  hrng  after  th.-se  shoul.l  have  .li.sappeaivd.     In  other  woixls 

J!i,ln..rr/'*'M  •""'''  "^  "'««'^""":  '■•'"■'"'■"/  </u'.,r/imn,  in  which  the 
;    i^     n.  "''T :""'  'i''^""*"  """"«'  ^«^-^  '"  '^-  '•"«•  P«rticular 

m    m     ;  r"^    "'"  "■  ''"■'"•^""'  "'"■""•  '■"  '"'•'""•"  '"  •"'■•ninutive  size. 

T,f  ,ml  "i-        '""•";  "*'"*""'  '"^•"•••'"'"•••.  ^'"-h  «.s  ehe  stigmata 

......  ,Mn.  cret.msm.  r.,-kcts.  syphilis,  c«nli.,va.scular  anomahes  or 

iS^^^^  -•  deformities.     In  the  combination  of  diarfi.sm 

intantibsm.  to  which  the  name  ateleiosii  has  Ik^u  applied,  the 


JhAi  i 


NHOraCOPY   HSOWTION  TBT  CHART 

(ANSI  and  ISO  TEST  CHART  No  2) 


1.0 

■  19          — 

|U25 

A 


/1PPLIED  IIVV1GE     Inc 

'65?    E05t    Mam   St'Ml 

Rochester,    Ne*   Vott.         14609        USA 

(716)    *82  -  0300  -  Phone 

(716)    2M  -  5989  -  Fa« 


1006 


THE  BONES 


process  of  ossification  is  greatly  delayed,  and  the  genital  oi^ 
perfect  in  structure  and  function.    Perfection  may  in  time 
but  the  size  remains  small. 

The  most  important  etiological  factors  in  the  production 
dwarfism  are  peculiarities  of  the  germinal  cells,  which  may  1 
or  acquired  de  novo.  In  the  latter  case,  tuberculosis,  alco 
syphilis  appear  to  play  a  part.  Intra-uterine  malnutrition  o 
due  to  hanlship  or  ill-health  on  the  part  of  the  mother,  anc 
of  placentation  should  also  lie  mentioned  in  this  connectioi 
tory  disturbances  and  disortlers  of  internal  secretion  in  the 
are  of  importance.  Virchow  long  ago  pointed  out  the  close 
between  infantilism  and  cardiovascular  hypoplasia,  and  mo 
Gilbert  and  llathery'  have  noted  a  tendency  to  dwarfism  in  c 
of  mitral  stenosis.  The  dependence  of  some  forms  of  c 
athyroidism  is  also  well  recognized.  According  to  Kiister, 
and  others,  removal  of  the  thyroid  in  growing  animals  is 
inhibition  of  growth,  and  defect  of  the  thyroid  secretion  is  nc 
admitted  to  be  the  cause  of  that  interesting  congenital  affe 
cretinism,  in  which  stunting  of  the  growth  is  a  conspicuc 
Inferentially,  athyroidea  may  lie  a  factor  in  the  production 
dwarfs. 

In  secondary  dwarfism,  in  addition  to  general  hypoplasi; 
evidences  of  diseiise  or  malformation,  and  the  changes  in  tlu 
qualitative  as  well  as  (|uantitative.  Many  cases  of  this  typ 
regarded  as  syphilis,  rickets,  or  cretinism,  and  the  lines  of  i 
have  not  always  been  closely  drawn.  In  fact,  the  exaci 
these  conditions  is  one  of  the  most  difficult  problems  in  el 
further  study  is  still  neede(  to  finally  clear  up  the  subject, 
consider  in  this  connection  the  affections  known  as  cretinis 
chondrodystrophia  f«>talis,  osteogenesis  imperfecta,  and  ( 
rosis. 

Cretinism. — In  cretinism  tlie  head  is  usually  large,  the  vert( 
and  the  occiput  prominent.  The  f()nt!ine''es  and  sutures  r 
for  a  long  time.  The  nose  is  retnicted  at  tne  root  and  is  shor 
with  large,  wide  nostrils.  The  lips  and  tongue  are  enlarged, 
appear  late,  and  the  first  dentition  usually  persists  throughoi 
limbs  and  trunk  are  disproportionate  and  the  stature  is  stuiiti 
in  22  cases  out  of  2o,  found  the  height  to  be  less  than  14( 
several  were  under  95.  The  hair  on  the  pubes  and  in  the  axil 
or  absent,  and  the  sexual  organs  are  p(X)rly  developed.  1* 
occur  at  all,  is  late. 

The  disturbance  is  asscx-iated  with  delayed  ossification  of  tli 
Hofmeister,'  studying  a  case  with  the  .r-rays,  found  that  tlu 
ends  ,r  the  bones  grew  slowly,  while  the  epiphyseal  plates  pe 
long  time.     Periosteal  ossification  may  be  normal  or  in  exctv 

'  Presse  m<;d.,  May  7,  1300.  '  Langcnbpck'a  Arehiv,  lil 

*  Fortschr.  auf  dem  G«biet«  der  Udntgen-StralileD,  1 :  1897, 


RACHITIS 


1007 


^licroscopically,  Langhans'  found  that  at  the  ends  of  the  bones  the 
cartilage  cells  were  small,  spindle-shaped,  and  anomalously  arranged, 
beiiif?  longitudinal  to  the  long  axis  of  the  columns.  The  rows  were  inter- 
rupted and  irregular.  The  bony  trabecule  were  shortened  and  the 
marrow  spaces  in  the  youngest  portions  of  the  bones  were  large  and 
widely  separated. 

Cretins  may  continue  to  grow  until  they  are  thirty  to  forty  years  of 
age,  and  ossification  may,  in  time,  lie  complete<l.  The  cause  of  the 
disorder,  namely,  defect  of  the  thyroid  secretion,  may  be  due  to  a  variety 
of  pathological  conditions,  such  as  atrophy,  fibrosis,  or  cystic  degenero"^ 
tion  of  the  gland. 


Fig.  274 


Fio.  275 


Sporadic  creiinisiii.  Rickets.    Fractured  clavicles :  pniminence 

of  frontal   eminences;    Harri«in's  Kroove; 
and  pot-belly.     (Dr.  A.  E.  Viponu's  caae.) 

Rachitis.— The  exact  place  whicii  rachitis  or  rickets  should  occupy 
111  tilt  scheme  of  pathology  is  still  somewhat  debatable.  The  condition 
IS  tli(ni;;ht  by  some  to  be  due  to  infection  or  auto-intoxication,  and,  there- 
fore i„  .some  extent  is  possibly  inflammatory  (Kassowitz').  This  view 
IS  soni.Avhat  supported  by  the  character  of  the  lesions  in  the  bones,  and 


it 


'*,  i. 


'  \  n,  I,,  Arehiv,  128:  1892:  318. 


"  Zeit.  f.  klin.  Med.,  7: 1884: 36. 


1008 


THE  BONES 


I  1 


by  the  experimental  work  of  Morpurgo,'  who  showeil  that  rachitit- 
could  be  produced  in  young  white  rats  by  the  injection  of  a  cert 
lococcus.  The  condition  is,  however,  so  dasely  dependent  on 
trition,  brought  about  by  improper  diet,  overcrowding,  and 
unhygienic  surroundings,  that  in  default  of  more  information  < 
perhaps  be  justified  in  regarding  it,  for  the  present,  simply  a: 
order  of  growth.  Rickets  probably  is  not  here<litary,  altlK 
cannot  be  denied  that  intra-uterine  influences  may  play  a  pa 
limited  extent. 

The  disease  usually  makes  its  appearance  after  the  sixth  month 
the  first  or  secoml  year.  The  lesions  are  characteristic,  and,  if 
lead  to  serious  deformity  and  stunting  of  the  growth.    The  skull 

Fm.  276 


Craniotabes  in  the  newborn  child.     Supported  rause,  rickets. 
Mu!«euni,  McGill  University.) 


(From  the  I'uthotn 


although  the  face  is  relatively  small.  Tiie  forehead  is  s(|uare  and 
nent,  owing  to  the  presence  of  flat  hyperostases  on  the  frontal  c  .i 
The  sternum  projects,  while  the  sides  of  the  thorax  are  drawn  in 
carinatum).  The  alMiomen  is  protuberant.  The  .spine  is  often 
and  the  extremities  greatly  defornied,  owing  to  the  weight  of  tli 
and  mascular  traction  acting  on  the  imperfectly  calcifietl  bom 
pelvis  is  deformed  and  contracted.  Dentition  i.s  delaye<l  and  l!i 
are  small  and  bajlly  fornietl.  In  the  milder  cases  deformities  un' 
extensive,  but  swellings  at  the  ends  of  the  long  bones  and  at  ti» 
chondral  junctions  {rachitic  romry)  are  a  noteworthy  feature.     I'' 

'  Centralbl.  f.  Path.,  13:  1902:  113. 


HAcmris 


1009 


n  <he  i'aih<il"iii<'al 


,..s  wei  as  ep.pl' vsealbone-fcrnuition  is  interfered  with.  The  periosteum 
■s  na-hlv  ...nppej  off  and  the  underlying  hone  is  softer  and  Z^TmZ 
than  norma.  J  he  epiphyseal  zone  of  proliferation  is  tSer'^hfn 
as,i.-,l.  .rresular  in  outline,  soft,  and  hvperemie 

I  lie  pathological  .hanps  n.ay  Ik- "summed  up  in  the  statement  that 
.....  rs  excessive  a  I, sorption  of  the  hone  with  impairment  o?  th^^^iess 
"f  ...kihcation.  Ihc  normal  prcK^ess  of  lacunar  bone-al«omK  is 
nud>  exaggerated,  so  that  the  soli.lity  of  the  gi^ater  part  of  theTSeton 
IS  ...ore  or  less  ,lestn.ve.|.  The  external  denser  lavfr  of  the  hones  £ 
> .....es  o  te.,porot.c  a..d  the  trahecuhe  of  the  spongiosa  are  attenS  ami 
n...v  ,.ven  d.sappear.     This  is  well  seen  l„  the  htnes  of  the  srunhicll 

Ki...  277 


'■■ '  ^-  -' '■'-  '..•, "i.:::::;:^.;:';^;;:  K,,:::"r"""'  •"' ™'"^  "'-■ 

■"'"••'i'Mes  I....O.,,,.  _sof,  a.id  giv,.  way  un.ler  die  pressure  of  the  fin-'er 
:::    sl      lV.^.nmtics  an.l  eve,.  fn.c.,ur..s  /„av  rims  he  hro  S 

Hi  j:.t...g  ..ssue  is  ,.omposed  not  only  of  epithelioid  ose'hEic  cd 

"  m    n  \^    ."r"^  "'•'  '""  ^"•"^*'*"-  '^  ^''-"y  comparable  to 

^^>^Tt^l!?':::^  r  ^^7'  ^"'^^"'^■^    The  tral^ul^  derive,! 

I'-   IHnaslcm.  are  formed  in  mucn  the  same  way  also  as  the 


't-l 


m 

V  1 


1010 


THE  BONES 


outer  callus,  and  are  composed  of  a  cellular  or  cellulofibroi 
In  the  periosteum  of  the  long  bones  cartilage  is  often  laid  d 
in  turn  undergoes  the  characteristic  transformation.  In 
comes  about  that  the  external  surface  of  the  bones  is  cov< 
vascular  spongy  layer,  which  offer  some  resistance  to  the  fi 
readily  cut  with  the  knife.  In  extreme  cases,  the  original  co 
becomes  porotic. 

The  endochondral  ossification  is  also  seriously  interfere* 
the  more  marked  cases  there  may  be  no  deposit  of  lime  salts 
of  calcification,  and  in  the  milder  forms  there  are  merely  spicul 
here  and  there.  At  the  same  time  tht  *  never  fails  to  be  an  t 
of  the  prolifeiation  zone  of  the  cartilage,  manifested  princi] 
long  columns  of  hypertrophic  cartilage  cells.  With  this,  vasci 
spaces  are  formed  here  and  there  which  gradually  encroac 
solid  cartilage.  The  more  severe  the  disease,  the  more  mi 
absorption  of  tLo  cartilage.  Somewhat  behind  the  zone  of  h 
and  vascularized  cartilage  a  zone  of  osteoid  tissue  is  formed, 
be  from  5  to  15  mm.  in  thickness.  As  the  disease  heals.  Hi 
deposited,  beginning  in  the  central  portions  of  the  trabecule 
substance  and  gradually  extending,  until  the  bone  becomes 
and  even,  in  fact,  much  more  dense  and  ivory-like  than  nori 

Ohondrodystropliia  FoBtelii. — ^Somewhat  allied  to  cretinism 
at  least  in  outward  appearance,  is  the  affection  known  as  < 
trophia  foetalis  (Kaufmann)  or  achondroplasia  (I^urrot).  A 
knowledge  of  this  disease  chiefly  to  the  researches  of  ^ 
whose  work  has  enabled  us  to  differentiate  it  from  a  vari« 
conditions  with  which  it  was  formerly  confuseu.  The  obsci 
ing  the  condition  even  yet  is  well  indicated  by  the  numerous 
have  been  proposed  for  it:  namely,  rachitis  foetalis,  pseut 
pseudorachitis  foetalis  micromelica,  cretinoid  dysplasia,  < 
trophia  foetalis,  achondroplasia,  chondritis  foetalis. 

The  disease  'uegins  in  foetal  life,  running  its  course,  as  it 
from  the  third  to  the  sixth  week.  Consequently,  the  parts  chi 
are  the  base  of  the  skull,  the  long  bones,  ribs,  and  pelvis, 
that  are  formed  in  membrane  and  those  that  in  late  foetal  life 
cartilaginous  commonly  escape.  The  individuals  thus  affectec 
stillborn  but  may  survive  to  adult  life. 

In  a  typical  case  the  body  as  a  whole  is  dwarfed,  the  type  I 
melic,  and  the  lesions  are  generally  symmetrical.  The  head 
the  trunk  plump,  approximating  normal  size.  The  micromc 
melic,  and  the  hands  exhibit  what  is  called  the  "trident' 
There  are,  however,  notable  variations  in  the  configuratioi  i 
and  in  the  length,  curvature,  and  consistence  of  the  bones  ol 
ties.  In  rega^  to  the  first-mentioned  particular,  Kaufmani 
two  main  groups:  one  in  which  there  is  a  cretinoid  conform 

>  UntprHiichiin^n  liK^r  die  aogennante  foetale  Rachitis,  Berlin,  189'J 
Beitrage,  13:  1893:  :12. 


ellulofibrous  material. 
rten  laid  down,  which 
tion.  In  this  way  it 
les  is  covered  "ith  a 
«  to  the  finger,  but  is 
}riginal  compact  bone 

'  interfered  with.  In 
lime  salts  in  the  zone 
;rely  spicules  scattered 
I  to  be  an  enlargement 
ted  principally  in  tiie 
this,  vascular  marrow 
ly  encroach  upon  the 
;  more  marked  is  the 
;  zone  of  hypertrophic 
is  formed,  which  may 
e  heals,  lime  salts  are 
;  trabeculae  of  osteoid 
:  becomes  solid  again. 
:  than  normal  bone. 
cretinism  and  ricket.<, 
:nown  as  chondrodys- 
arrot).  We  owe  our 
rches  of  Kaufinann.' 
)m  a  variety  of  other 
The  obscurity  invoiv- 
numerous  names  that 
alls,  pseudorachitisrn. 
ysplasia,  chondrodys- 


PLATE   XIV 


the  type  l)eiiij;iiiitnc 
The  head  is  large  ami 
le  micromeliii  i.s  rhizi>- 

"  trident"  deformity. 
iguratioi  of  the  skull, 
e  bones  ol  tlif  e.xtrenii- 
Kaufmanii  iei'ognize> 
d  conformation  of  the 


Berlin,  1892.  ;iii.J  Zieglers 


OSTEOGENESIS  IMPERFECTA  jqjj 

hea.1,  that  is  to  say  a  deeply  sunken  nose,  promin^-nt  eyelids  and  lins 
iHck  cheeks  and  a  large  mouth;  and  a  second,  in  which  the  noi  is  flR 
.emd  and  retracted  as  a  whole.     In  the  former  group  the  bone^o  croS 

E rSsTe^itlfsor^t'*'  "°"  ^■"^"'"  '^"  "°™''''  -"""'"^ 
at  er  us  texture  w  soft.     Some  cases  are  assoc  ated  with  craniotabe, 

KUMn),and  there  may  be  beading  at  the  costochondral  sutures     DefS 

t.v.  development  of  the  pelvis,  cotyloid  and  glenoid  cavities,  h^  also  b^n 

noted.     The  vertebrae  may  be  involved  (Regnault)    so  that  InnS 

-.suit.     Growth  in  the  length  of  the  bone^  is'serio^iyTnterfeJd'^r 

owMig  to  faulty  oss,hcation  at  the  epiphyseal  lines,  but  periiSoss  fil 

cation  IS  practically  normal,  with  the  result  that  the  boneVSme  Zrt 

r;=  h^'^b^fobse^rJeiTm^l^ta^:  '''-'-  ^"'°  ^'^  ^^^^^^ 

SZ'  it  r-  *^r'''"''""-  '"  '^'  first  variety  the  cartib^s  at^^fht 
end.  of  the  long  bones  are  to  some  e.vtent  increased  in  sizf  but  no 
en  -nrs  of  cartilage  cells  are  formed.  The  cartilage  in  places  i!  softened 
an.l  ,n  othe,^  is  irregularly  calcified  and  assified^   In  thrhZpSc 

Z  thrc'cS"'""  1  '^'  T'^''^  '^  appreciably  behind  the TrS^n 
xtent,  he  columns  of  cartilage  cells  are  small,  the  cells  themselves  are 
c  e„t  in  growth,  l^jng  rpindle-shaped,  irregularlv  arranged,  and  ha^- 
K  the  appearance  of  being  compressed.  The  hyaline  matrk  s  more  or 
:  1  ;'?K  h°™.f  «"«°»s.  The  third  t.>-pe  presents  a  marked  o^er 
mwth  o  the  cartilage  eading  to  notable  fhicLning  at  thTepiphZal 
en; .  of  the  bones.     Ossification  is  e.xtremelv  irregular  ^P'P''^^^*' 

he  etiology  of  this  disease  is  quite  obscure,  and  ii  is  by  no  mean, 
.man,  that  Kp.ifmann'.  three  ty^s  are  different  phaL  of  thTon^ 
ffe,l,o„.  Heredity  seems  to  play  a  part  in  some  cases.  There  is  sorJe 
"HleiKe  for  In-'  .v-n-  that  the  cretinoid  variety  is  reallv  a  form^f  cS 
-  ea.  \\  ,,h  regard  to  the  other  types,  it  is  possible 
tive  aniage  are  at  fault,  or,  again,  intra-uterine 
View  of  the  fact  that  obvious  errors  in  develoo- 
.socio'.d  with  chondrodystrophia,  as,  for  instance, 
^h.',!..*^" '•■■;"■"'  •'''*''  ^"^  ^'^'''  ^'»^  condition  imperceptiblv 

SVfi  T  ^  P"'"""'??^  developmental  anomalv  (MisSung) 
«h'th  .  finallv  represented  by  phocomelia,  ^'irehow  has  obiected  to  thi' 

Muc.>  the  disturbance,  and,  moreover,  attributes  it  to  a  nutritional 

mSS'sST'-T'^'^'  -act  relatioaship  of  the  disease,  called 
is\f  I     1  •  .?•        a"u^'  °^'*;%'<^"«''"-^  imperfecta,  to  chondrodystrophia 
ZV  iTit  la  1'f •:  «r^^""in*.'.\Hildebn.ndt.'  and^HaE 
*.   lo  snow  tnat  It  IS  a  definite  intra-uterne  nrocps*      AWV.»..„k  »u 
affection  has  been  described  only  in  newb^ror'^^r^'you^glZl;' t 


i>maii(l  dut  I., 
lliat  defects    , 
pressure  (K 
meat  are  so. 
pol."lac'tylisin 


M,,.|„l,i,chd.allj;.  Path.,Jena,2. 
'\irrii.  Archiv,  1.58:  1S9<):  426. 


■  Virch.  Archiv,  115: 1899: 357. 
'Zicgler's  rieitrage,  30:  1901:  005. 


1012 


THE  BOSEH 


(  ! 


V[ 


ft-; 


is  iwt  newssarilv  fatal,  and  Ilarhitz  suRRests  that  certain  •)f  tlit- , 
awartisni  that  have  \^n  wRunltHl  as  fu'tal  rickets  niav  ha> 
ttsfoRenesis  ini|»  rli-cta.  There  is,  undouhtwlly,  -some  defect 
pnK-ess  of  ossification,  inasmuch  as  the  Injiies  are  s«)ft  and  l>r 
that  deformities  and  fractures  readily  occur.  Like  chondnHlys 
porositv  of  the  Iwiies  is  (Kcusioiially  inherited,  and,  as  Hml 
shown,' the  two  conditions  may  W  coml)ine<l.  It  is  interesting,  a 
bonlerland  cases,  presentinjr  in  one  and  the  some  in<lividuul  soni 
features  of  chondnxlystrophia,  .)stc());eiiesis  imixTfccta,  and  rick. 
l)een  recorde<l  (Hektoen^). 


Km.  278 


Fragilita'.  .w.iuni.  S«-ti.m  i,  taken  Iransver^ely  thrnugh  tlie  femur  ,.f  a  iii-wIkt., 
eliondrndystrnphia  an.l  ..-eou.  fragility.  Tn  the  rinl.t  is  prri..Meu,.i  w.tl,  a  lay,r  . 
to  the  left  a  portion  nf  the  shaft.  Uone-furn.ati.,..  is  delkient.  as  evi.leniwl  l.y  th. 
attenuate.1  tralw.  ula-      Zeis,  obj.  DD.  without  ,H;uhir.     (Case  of  Dr.  Oskar  Klutz 

In  osteogenesis  imperfecta  a  cardinal  feature  is  the  exlr:i 
manner  of  ossification  of  the  skull.  The  calvariuni  is  not  I. 
continuous  honv  plates  with  regular  sutures,  liut  of  a  multitude 
mosaics,  sometimes  touching  one  another,  but  more  often  ii 
bridges  of  inembnine.  In  a  remarkable  ca.se,  described  by  Mi 
vault  of  the  skull  consisted  of  a  membranous  sac  in  which  wen 
spicules  of  bone.  So  far  as  is  known,  synostosis  of  the  os  trilui-. 
not  occur  in  this  disea.se. 

Microscopic  studv  shows   that   the  traliecuk-e  are  few  m 
irregular,  and  imperfectly  formetl.    There  is  no  continuous  ■ 

'  Luliarsch  u.  Ostertag's  .^llg.  Aetiol.,  Wiesbaden,  1896:  r.;:. 
2  .\mcr.  Jour.  Med.  Sci.,  125:  in03:  751. 


niUASTlS.M 


1013 


tmlwciila-  with  Haversian  canals,  and  Inmelln;  as  in  normal  ]x>ne  The 
(•..use  IS  al«olut.-lv  unknown.  In  (,ne  .  use  hyilmmnios  was  pmsent  in 
iIk-  mother.  ' 

.Vs  has  l)een  mentione.!.  the  condition  of  l)rittleness  of  the  Ikmips 
oiteoputhyroiia  or  fragilitM  osHniB,  is  an  otiasionai  feature  in  thr 
ci.riou.s  afftvtions  just  descrilK-d.  hut  is  sometimes  foun.l  as  a  distinct 
eritit.v^  1  he  exact  connection  l>etwci-n  osteopsathyrosis  and  osteogenesis 
imiK-rfecta  IS  ijy  no  means  dearly  made  out.  As  (Jurit'  has  oKs^rved 
the  condition  IS  (Kcsionaily  inherite.  .X  n.inarkal)le  instance  is  on 
record  also  of  .Iwarhsm  and  osseous  fraplitv  occurrini?  in  the  same 
family  throughout  three  j;enenitions  (Kkmami'). 

The  sum  total  of  these  collective  studies  senes  to  show  that  there  are 
a  nuinlier  (,f  anomalies  of  ^trowth  and  deveh.pment,  nvm-  or  less  distinct 
hut  shmliiiK  off  iini)eneptil,ly  one  int..  the  other.     That  there  is  such  a 
thi..«  as     f.etal  ri.  kets."  in  the  sense  of  rickets  that  has  run  its  complete 
cDiirs.'  .!!irin>;  mtra-iiterine  life,  inav  well  In-  d.)ul.ted.' 

Gigantism.-  In  muny  res|jects' the  antithesis  „f  dwarfism  is  the 
ren.arkal.le  coiidit...n  known  as  gigantism,  or  nu.re  correctlv  mMro- 
genesy.  Ill  whi.h  there  is  a  n..t«hle  increase  in  the  length  and  thickne.s.s 
of  the  iKJiies,  with  .•onc<.mitaiit  changes  in  the  soft  tissues.  We  have 
here  ev.denc.-s  of  increased  prt.liferati..n  of  the  cartilages  in  the  process 
of  ."..d,Kh..n.lral  oss.ficati..n.  t<.gether  with  excessive  dep<.sit  of  l)one 
hv  a;.|Hwition.  1  he  ((..ulition  may  Ik-  congenital  or  mav  develop  in 
later  life.  '  •^ 

Partial  or  Local  Gigantism.- L<K-al  forms,  affecting  chieflv  the  hones  of 
the  face  {Irontm.s,.  „,.„■„.  Virchow),  the  finger.,  aiul  t(.;s.  have  In-en 
ohserve*.  1  he  exact  nature  of  Icntiasis  ossea  is  ol.sc.ire,  hut  it  appears 
to  H-  a  (l.truse  liyi)erost<.sis,  s,.mewhat  anal..gous  to  the  hn-al  exostoses 
m\  l>y,H-rost..ses  omul  n  certain  .legenerative  .list.irl.ances  and  chronic 
..Hai.>.natK.ns.  1  he  l.Kal  gigantism  of  ,hildho.M!  affects  usuallv  the 
npiHT  l.nihs,  a.i.l  may  '...  unilateral  or  l.ilaten.I.  Other  developmental 
ai....,>al,es  may  he  as>.  -d  with  the  overgrowth.  Thoma,*  for  example, 
has  „l,sene<l  ,lef«t.v,  .•.nation  ,.f  the  genital  organs  in  a  vouth  the 
<iii)|f(t  of  iiem.hyjH-rtrophv. 

General  Oigantism.-- Wh'en  the  l>,Mly  ..s  a  whole  is  hypertrophic  we 
>|H'ak  of  general  gigantism  or  macrosomia. 

Tlii;  is  excessively  rare  as  a  c..nge..ifal  an..malv.  According  to  the 
law  ol  deviat.....  forn...lattHl  l.y  Tlu.ma.-  we  ca.i  ass.i.ne  the  exiMence 
of  «.aiit  growth  m  cases  where  the  length  of  the  hody  exceeds  57  cm.  and 

'llMri.ll,.  (Ici  Lohrp  von  lien  Knocheiihniclion.  1  :  IS<i2  :  U7. 
^_M»i>>.rlati<.  m,.-lica  .lesoriptiom-m  Pt  casus  ali.,wot  ostoomulacia.  sisten.s,  Upsala., 

'Thu^.  int(-roste,l  will  (i„.|  the  ,s,ih,i,.r(     ,„r..  fullv  .liscasso.l  in  an  article-  by  one 

vf ;  .^;:  x.\-"  z.  ^^  :;'ri..;"""  -"" " ''- ''-"-'  ^^--^  ^^^  •^•"'•^ 

'  li\i  iHH.k  of  (Ifi.eral  I'athol.  Ry,  t.i>ii<l<>n,  1 :  I9S    \.  A  ('.  Hlack 

desnu'i'  ';".'';""«;•:'.  "'■^•^  '}"-■  """*■*  "• ''"«  ^i^'«ioht  .er  anatoniiscfien  I'e.tandtheile 
uMnun-clilichen  Korpersim  gesumlon  u.  im  kranken  Zustande,  Leipzig  1882 


1014 


THE  BOXES 


m  <■ 

■•  'I 
li. 


'If 


the  weight  is  above  42  kg.  The  largest  newlwrn  infant  on  rttonl 
reported  by  Dubois.'  which  weighed  11.3  kilos  (twenty-'our  |h 
thirteen  and  one-half  ouni-es).  As  u  rule,  giant  children  a-e  still 
When  they  sunive,  the  excessive  si/-  may  l»e  conipeiisatetl  l.y 
gmwth  sul>se<iuently,  l»ut  cKfasionally  such  infants  gn>w  very  fa* 
attain  pulierty  early. 

M»)re  often,  however,  general  macnwomia  lirst  makes  its  npjM'u 
between  the  tenth  and  the  twentieth  year.  us\ially  with  the  (tn: 
pul)erty.  The  abnormality  manifests  "itself  chiefly  by  an  incnn 
the  length  of  the  long  bones,  mainly  of  the  lower  extremities,  I 
some  extent  in  the  tnmk,  so  thai  the  height  is  notably  iiicreas«i. 
increase,  in  weight  is  less  appariMit,  l)eiiig  never  more,  and  UMia',1' 
than  the  increase  in  height  would  warrant.  In  giants  the  head  is 
tivelv  small  and  the  overgrowth  is  dispr<)|M»rtii)nale.  Stigmata  of  itil 
ism,' such  as  kiHX'k-kn«'e  and  genital  hy]M)plasia,  may  \h'  yt 
.Some  cases  are  assixiatetl  wit!  other  devel(i|>mental  <lcfe(ts,  fiicJMl 
hvpertniphy,  lixal  exostoses,  or  cur\e«l  bones.  These  may  U'  nj; 
a.s  examples  of  .^jimplomalic  gij;anlism. 

Much  rarer  is  egscnthl  gigantism,  in  which  the  overgrowth  is  \n 
a  1  symmetrical,  and  the  atTccted  individuals  are  strong  and  inj 
Wu.  perfect. 

The  caases  of  gigantism  are  obscure.  It  has  l)een  attributtHl  l.v 
to  peculiarities  in  tlie  germ  cells.  This  view  is  supporteil  b\  ili 
that  the  condition  is  sometimes  inherittHi,  and,  also,  by  the  obstrv 
of  Engel-Keimers,=  who  has  emphasized  the  view  that  excessive  iiiu 
development,  the  so-called  "athletic"  habit,  is  often  tlue  to  an  al)ii 
predisposition  and  not  to  functional  overactivity.  In  this  conn 
increased  intra-uterine  nutrition  appars  to  play  a  Icailing  n)le. 

Several  facts,  also,  would  indicate  that  irritation  or  excessive  siinii 
of  the  epiphyseal  ends  of  the  bones  tentls  to  prml-ice  overgn)\Mli. 
can  l)e  brought  about  experimentally  by  driving  ivory  pegs  into  th 
of  the  lx)nes  or  by  feeding  young  animals  with  phosphorus  or  j 
(Wegner*).  Elongation  of  the  bones  has  also  l)een  noted  in  com 
with  osteomyelitis,  fractures  of  the  shaft,  tuberculosis  of  the 
superficial  ulcers,  and  <lilated  veins.  Local  hyperostoses  of  tlie 
have  been  known  to  follow  tmuma  and  erysipelas. 

Giant  growth  also  has  l)een  met  with  after  the  acute  inftctivej 
in  childhood,  which  were  apparently  the  exciting  c-ausc. 

( )ther  cases,  again,  appear  to  he  d»'pendent  on  disorders  of  ii 
.secretion.  A  tendency  to  <-xaggerated  growth,  particularly  of  tlit 
extremities,  has  l)een  c'         t  J  in  eunuchs  and  castrated  aninuils. 

There  is  considerable  ground  for  l)elieving,  further,  that 
portion  of  the  cases  of  gigantism  (42  per  cent,  according  t< 


hiri] 
;•  n 


'  Lc3  gros  enf.int.s  au  point  de  vuc  obsttjtricil,  Thf^se  de  Paris,  1S!I7 
'Jahrb.  der  Hamburg  iStaatskrankeiian.'staltcn,  3:  1S94. 
»  Ueber  den  Einflus.s  des  Phosphors  au  don  Organismus,  Virch.  Archiv 
*  Ueitrftge  zurKenntniss  der  ,\kromegaiio,  Zeit.  f.  klin.  Med.,  27.  !■ 


-.■:l 


W4iVr/SH 


101  s 


!  its  i)|)|N>uriiii('i- 
til  the  (iti>(>t  iif 
till  incn'ii-i*-  ill 
ireiiiitifs,  Imi  to 
iiicrfiistHl.  The 
iiid  usually  less, 
the  lit'iui  i>  rtlii- 
;iiiutii  of  iiifiiiitil- 
iiav  Im'  prt'stMii. 
■I'ts,  fiiciiil  iifiiii- 
nav  1h'  rfi'iinltii 


e  iiift'ctivf  frve^ 


Z  ,?„  .^ff!!r  ^■'^-    ""^."''  """^  ^*'?*'  ^^'^  upheld  the  view  that 
tho  two  affection,  are  essentially  the  same  tTiing.    The  same  patholodca 
pr-K^s.  at  work  during  the  growing  period  of  life  will  prtxl^    e^giganSm 
«  a  later  penod.  when  epiphyseal  ossification  is  completed.  acWieX 
It  IS  possible  that  some  at  least  of  the  cases  of  gigantism  which  do  no 


fia.  J7B 


lateral  «..lio-i..     (From  ,h.  SurgicJ  Clinic  of  th.  Montreal  Gener.1  Hospital.) 


r      1  ?  ^•''•f™'^'7«''^s  of  acromegaly  are  nevertheless  dependent  on 
al.u,,rn  al  function  of  the  pituitary  body  (acromegalic  fruste=)!^ 
BtM,les  the  peculiarities  of  growth  and  development  just  considered, 

|J«'!ir.  lie  mM.  et  chir.  prat.,  Januar}'  25,  1895. 
F  .r  a  full  discussion  of  the  general  gubjert  of  Kiirantism   and  ty>f,>mnn»=  ♦    ,v. 

wond  edition,  N.  Y.,  Wm.  Wood  &  Co.,  8  :  1904  :  457.  ^'•' 


^ 


il. 


m 


loin 


THE  BO.VKS 


there  are  others  more  localized  which  die  hrounht  alxMit  hy  al)ii 
static  and  mechanical  influences  exerte«l  upon  the  orpmism  durii 
developmental  priod  of  life.  These  may  arise  both  Ix-fori'  and 
birth  and  fre<iuently  cause  most  pronounced  deformities. 

While  many  of  these  congenital  anomalies  are  probably  to  \te  attri 
to  peculiarities  of  the  j;erminal  cells,  others  are,  at  least  in  many  iiisi 
more  closely  connected  with  intra-uterine  pressim-.    .\mon>i  these 
tions  mav  l)e  mentioned  lOicrocephaly,  micromelia,  the  fusion  of 


Fio.  280 


!i! 


Sc'iiliosi^  with  inarkcil  i>i.-tori..r  .Ii-f..rniily  lkv|'li..-i->i 

polydactylism,  and  the  amputation  of  limbs.  Tlic  factors  usu;ill\  ii 
an'  a  contracted  amniotic  sac,  liands  or  adhesions  traversing'  tin  - 
weight  of  superimposed  iinil)s,  or  a  knotted  innbilical  cord. 

To  a  larfje  extent,  also,  the  develo|)nient  of  llic  liony  cavitir  , 
for  instance,  the  cranium,  the  orbits,  and  tlie  tliorax,  is  dcjn  ici'  n 
the  state  of  development  of  the  contained  orjjans.     .Slumld  tin   !•  1" 
or  otherwise  defective,  the  correspondiiif;  !)ony  part'--  air  li\|i'  .l^i 
defective.    In  this  category  may  be  placed  such  conditions  as  crun 
craniorachischisis,  anencephaly,  spina  bifida,  and    the  like      I 


',  'I 
II 
l« 
ii 
io 
III 


SCOUOSIS 


lot* 


|)res.siire  within  the  Imhiv  cavities  will  also  lead  to  enlargement  of  the 
s:iine.  riiiis,  hydrocephalus  is  an  enlargement  of  the  cranium,  often  with 
s.paration  of  the  hones  and  flattening  of  the  brain  substance,  caused  bv 
excess  of  the  cerebrospinal  fluid. 

Ill  later  life,  t(M),  owing  to  external  influences,  bones  that  were  originally 
w.H-form.Hl  and  developed  may  l)ecome  deformed,  and  this  the  more 
iviidily  (K-ciirs  should  the  bone  from  any  cause  Ix-come  soft  ami  yielding 

Scoliosis.  -One  of  the  most  common  of  these  deformities  is  scoliosis  or 
laf.ral  deviation  of  a  jiortion  of  the  vertebral  column.  .\s  a  rule,  there  is 
(iMViit.m'  of  (he  <lorsal  spine  to  the  right,  with  a  comp-nsatory  deviation  of 

Fla.  281 


lMM..k-kl, 


-liitai.) 


'Ill'  lumbar,  and  soni.times  the  cervical,  jx-rtioii  to  the  left.  This  mav  be 
iiruiiuht  j,l„„„  i,v  excessive  distension  of  one  llionicic  ••avitv,  as  from  an 
•MMatc  or  new-growth,  or  by  contraction  of  the  ciivitv  from'fibroid  indu- 
J;"i"ii  <•!'  liic  lung,  tli(>  iiispissMtion  of  a  pleuritic  exiidate,  or,  again,  by 

'":'[': '■  '.'"«'  I>»''vis  in  an  obli(|ue  position.    It  is  also  met  with  in  Fried'- 

I'li  li  -  .iiaxia  and  the  progressive  myopathics.  Perhaps  the  commonest 
'"111  (-  iiir  taiilty  ineth.Mls  of  standing  or  sitting  in  cliildJKXMl.  In  the  more 
^'■\rrr  .uses  the  deformity  conies  on  <|iii<kly  and  Im-coiiics  extreme,  being 
"'I;  !•  <<>iiibined  with  posterior  curvature  X///)/<,i.v;.v.  Tliere  is  often  with 
iiii~  tuci-e  or  less  rotation  of  the  vertebra-  on  their  vertical  axes.  The  liga- 
iiKii!  >  l)econie  stretched  and  may  calcify.owing  to  the  priKluction  of  osteo- 
I'li}  '•-■     Curvatiiiv  forwani,  or  lonlo.v'.i,  is  also  frequentlv  met  with. 


't 
u 


1018 


THE  B^NES 


Ooz»  Vw*. — Coxa  vara  is  a  condition  of  the  hip-joint  brought  aboi 
imperfect  development  of  the  acetabulum,  or  changes  in  the  head  or 
of  the  femur.  It  is  met  with  where  there  is  abnormal  yielding  o 
bone,  as  in  rickets,  and  leads  to  dislocation. 

Oenu  Valgum. — Genu  valgum  is  met  with  in  children  from  the  se 
to  the  fourth  year,  or  at  puberty.  In  this  condition  the  It'C  forrr 
obtuse  angle  with  the  thigh  at  the  knee-joint.  It  may  be  uiiilater 
bilateral,  and  is  often  met  with  also  in  those  who  are  a  great  deal  on 
feet  ami  who  do  heavy  manual  labor.  It  may  occasionally  \ye  di 
traumatic  separation  of  the  epiphyseal  cartilages  with  dislocation  o 
fragments  and  subsequent  union  in  the  faulty  position,  to  carious  pro*' 
in  the  external  condyle  of  the  femur,  or,  again,  to  arthritis  defonnai 

Talipes  Valgus. — Talipes  valgus  (pea  planus),  or  flat-foot,  is  a  coiul 
in  which,  owing  to  the  stretching  of  the  internal  lateral  and  plantar 
ments,  the  arch  of  the  foot  is  more  or  less  completely  destroyed.  In  .s( 
eases  the  normal  concavity  on  the  under  side  of  the  foot  may  give  ] 
to  actual  convexity.  The  result  is  that  the  foot  as  a  whole  is  tii 
outward,  the  soft  tissues  are  often  reddened  and  swollen,  while  mo 
less  pain  is  complained  of.  The  trouble  is  usually  brought  ai)()ii 
much  standitig  or  by  carrying  weights,  in  the  case  of  those  whose  li 
is  not  i-obust.  It  may  also  be  caused  by  knock-knee  or  rachitic  di: 
of  the  ankle-joints.     Rarely  it  is  congenital. 

Hallux  Valgus. — Hallux  valgus  is  to  Ix;  reganled  as  a  pressure  defor 
due  to  tiie  use  of  improjierly  fitting  boots.  The  great  toe  often  is  U 
to  assimie  a  position  beneath  the  other  toes. 

Abnormal  positions  of  the  articular  surfaces  of  bones  may  ai-^ 
brought  about  by  faulty  positions  of  the  limbs,  as  in  certain  forii 
paralysis,  contractures  of  neuropathic  origin,  or,  again,  by  the  contiiK 
of  scar-tissue  in  fascia  or  tendons.  The  nature  of  talipes  imriin,  t.  vifiii 
and  /.  calcaneus  is  sufficiently  indicated  by  their  names  an«l  calls  t'( 
extendetl  description. 


OIROULATORT  DISTURBANCES. 

Hyperemia. — Active    Hyperemia.— Active    hyperemia    is    met 
in  the  periosteum  and  m?dulla  in  growing  bone,  and,  patlu)li(f;i( 
in  various  forms  of  regeneration  and  inflammation. 

Passive  Hyperemia — Passive  hyperemia  is  found  in  general  w 
stasis  and  whenever  the  free  outflow  of  blood  from  the  bone  i-  i 
fered  with.  Chronic  passive  congestion  appi'ars  to  favor  the  ;.'i  vi 
the  bone  ami  soft  tissues,  as  is  well  seen  in  the  clubl)ed  fingers  ol  !ir 
pulmonary  and  cardiac  disease.  Whether  the  peculiar  disc:;  . 
described  by  Marie,'  and  calletl  by  him  hypertrophic  pulmoiiii<- 1  n 
arthropafhif,  is  of  this  nature  cannot  at  present  be  settled. 

Hemorrhage. — Hemorrhage   into  the   periosteum  or  marrow  i> 
very  uncommon.     It  rarely  attains  serious  proportions,  and  i'"   '<> 

'  R^vue  de  MMecine,  10: 1890: 1. 


ISFLAMMATJONS 


1019 


effused  IS,  as  a  rule,  quickly  absorbed.  It  may  follow  traumatism, 
and  occurs  in  new-growths  and  other  destructive  processes.  The  so- 
called  cephalhemnfomata  are  localized  extravasations  of  blood  beneath 
tlie  periosteum,  -osually  of  the  parietal  bones.    Rarely,  they  are  found 


Fro.  282 


Spatulale  (Hippocralic)  fingers  in  s  cane  of  pulmonary  tuberculosis.    (From  the  Medical  Clinic 
cif  the  Montreal  General  Hospital.) 

in  the  interior  of  the  hone,  leading  to  elevation  of  the  external  plate. 
Pelochial  hemorrhages  are  found  also  in  the  hemorrhagic  diatheses. 
Barlow  s  disea.se,  and  scurvy.  In  Bariow's  disease  the  periosteum  of  the 
loiiK  bones  may  be  dissected  off  from  the  shafts  owing  to  the  extensive 
extravasation  of  blood. 

BmboUsm.— Embolism  as  a  rule  produces  little  eflFect  on  account  of 
he  al)undant  anastomoses  that  are  present,  but,  according  to  Gussen- 
.au.r  end-arterie.s  are  to  be  found  at  the  ends  of  the  diaphyses,  obstruc- 
tion of  which  might  lead  to  ischsemic  necrosis. 

Thrombosis.— Thrombosis  of  the  vessels  is  common  after  trauma  and 
frartiircs,  and  in  the  neighborhood  of  hemorrhages,  inflammatory  and 
nwrt.tic  proces.ses.     It  is  of  no  practical  importance. 

XNTLAMMATIONS. 

Tiie  inflammatory  processes  occurring  in  bone  affect  first  and  chiefly 
hf  ^  ascular  structures,  that  is  to  say.  the  periosteum  and  bone-marrow. 
»(•  may  therefore  distinguish  two  forms:  parioititis  and  oiteomyeUtii 


1020 


TllK  BOSKS 


The  fuinpact  material  of  the  hone  may  l)e  involveil  secondarily  in  <■! 

of  these  conditions  and  usually  in  the  form  of  erosion  and  disintej;ral 
Periostitis    and    Osteomyelitis.— Periostitis    and    osteomyelitis 

not  infretjuently  lomhined. 

Infliimmation  of  hone  may  l)e  brou^iit  about  l»y  local  or  systt 

causes.     As  a  rule,  infective   microorganisms   are  at  work,  hut    i 

agents  and  local  trauma  may  ph 
Fi.:.  2«»  contributory  and  sometimes  a  Iciu 

role,  'i'he  causal  agents  reacli 
affected  part  either  din-ctly  or  tlin 
the  IiUxmI  stream.  The  most  cha 
teristic  form  of  inflammation  is 
acute  osteomyelitis  and  |)eriostiiis 
to  pyogenic  cocci,  but  an  inialoj 
condition  is  (xrasionally  met  wli 
a  c(iin|>lication  of  some  of  the  c 
mon  infectious  fevers,  such  as  ai 
articular  rheumatism,  scarlat 
niciisles,  typiioid,  variola,  rclap 
fever,  dysentery,  ami  e])idenii('  p 
titis.  Here  the  condition  niav 
some  cases,  \tv  due  to  the  actio 
tlie  siHH'iKc  microorganism  of 
primary  disease,  but  perhaps  ii 
frc(|ucntly  is  the  n'suit  of  sccoik 
or  mixe<l  infection  witli  sonic  of 
j)us-f()rming  c<K-ci. 

The  rcsuics  arc  various.  > 
grades  of  inflammation  and  tliosc 
are  early  an<l  efficiently  tn'att'd  i 
heal  with  little  or  no  |  icrccptililccll't 
Much  more  fre<|uciiliy,  however. 
sc(|uela'  are  serious.  These  may 
grouped  under  two  main  lieaiK,  ill 
tegration  and  proliferation.  In  in 
forms  of  acute  ant)  clironie  intl: 
mation  iktwiiIk  of  bone  is  a  inar 
featun",  either  in  the  form  ol'  m  > 
eriKling  prwess  of  resorption  i-n 
— or  as  an  exfoliation  of  hiiver 
smaller  portions  of  the  bone  i  n  im 
—xfiiiiiiftration.  .Short  of  liii^ 
tn'ine  r«'sult,  the  bone  niav  \»'c< 
])orotic,  owing  to  lacimar  n  -iii[iti 
This    results    from    the    ilc  irnc 

ai-lioii   of   the   gninul.ttioii    tissue   in    the    medullary  spaces        =••;/ 

ostt'itix).     In  other  cases,  on  the  contniry,  the  function  of  'n  "   '' 

formation  apin-ars  to  Ix'  stimulated  in  some  way.     Thus,  in 


i-'t>riiiir  rut  IfiiifcitiKiirmlly,  to  >)i<)w 
ran'factifin.  (t«lpn«clprn-i^.;tnil  rit^w-Kruutli 
'II  IwiM*'  fnim  lilt'  periii^ti'Uni.  Vt\M'  nf 
(i>triiMivfliliv.  <  l*.-itliiil<iffiriil  MiiM-uiii, 
Mri;ill    ^rliver^il,v  I 


iiei 


ACUTE  INFECTIOUS  OSTEOMYELITIS  joo] 

IjorluKxl  of  al«ces.ses,se(iue.stra,  and  tul)erculous  areas,  the  bone  Iwt-omes 
(L-nser  ancl  more  compact,  owing  to  the  deposit  of  new  l)one  upon  the 
lral)ecula;  (fWW«ro*/*).  Tlii.s  may  lie  a  primary  condition  in^sonie 
lascs  of  syphihs  and  phosphorus  jjoisoning.  Not  infw,|uentlv,  then-  is 
a  new-formation  of  [mm  in  tlie  shape  of  osteophytes,  or  a  <hffuse  con'- 
.rntric  dep<,s.t,  owms  t.,  excessiye  actiyity  of  the  'pericwteal  osteo«enetic 
aver.  1  his  may  lead  to  iiicrease<l  thickness  of  the  \  ^e  and  to  inore  or 
less  jx-rfect  restoration  of  its  contour  after  exteiisiye  destruction  In 
jrroNvinfr  Imnes,  inflammation  of  the  shaft  of  the  hone,  provided  that  il 
1h-  not  too  severe  and  not  too  near  the  epiphyseal  cartihijie,  may  result 
in  a  marke.1  increase  in  the  length  of  the  hone.  Should,  However  the 
iiinammatory  process  occur  near  or  at  the  zone  of  ossification,  irreKulaiit  v 
in  growth  will  occur,  an<l  should  the  epiphyseal  cartilage  be  separate«*l 
or  (lestroye(J,  growth  will  come  to  a  standstill. 

It  is  hanlly  necessary  to  state  that  inflam:atory  affections  of  bones 
may  extend  to  the  adjacent  tissues  such  as  the  veii'is,  muscles  tendons 
ai..neur.,ses,  and  skin.  In  this  way  l,x-al  ai.scesses  an.l  fist  ■  ar^ 
produced.  Ihrombophlebitis  is  a  dangerous  complication,  inasn.  .'.i  as 
i(  fre<iuently  leads  to  a  dissemination  of  the  infective  .gents  and  inav 
thus  produce  systemic  septicemia. 

A  rath.-r  peculiar  form  of  inflammation  of  the  periosteum  has  In-en 
dexrilKHl  by  Oiher  and  Berg,  'i'he  .iisease  <K-ciirs  more  particularly  in 
vouMg  [H-rsons  and  usually  runs  a  mild  course.  The  siibiH-riosteal  ^xu- 
•lation  is  clear  and  serous,  or  someti.nes  viscid,  containing  fibrin  fat 
ftlol.ules,  and  relatively  few  corpuscles.  It  may  Ik-  combine.!  with  osteo- 
m.v,.|itis.  Ihe  exa  t  etiology  of  tiie  condition  is  not  as  vet  definitely 
mac  If  out. 

Acute  Infectious  OsteomyeUtis. -Acute  infectious  osteomyelitis  iH-loiiffs 
t.)  the  gn.iip  of  septicemi-  infections  an.l  occurs  spontaneously  or 
as  a  complication   of  various  fevers.     The  spontaneous,  or  so-idled 

I'liopathic  form  ..■,  most  commonly  dije  t«.  the  S..,pl,v|„c,Krus  pvoirenes 
amviis  or  a  bus,  and  is  met  with  usually  in  voung  persl.ns.  It  is  A  severe 
atf.rt.on  characteriml  by  great  pain,  fever,  an.l  symptoms  of  consti- 
tiitional  involvement.  The  infection  is  hematoge.H.us,  the  original  point 
of  .Mtrance  of  the  germ  being  usually  .1,  the  skin  or  mucous  membranes 
I  lie  pnmary  wouml  may  have  been  m.  trifiing  that  ail  trace  and  recolkx-- 
iioM  ot  It  may  have  .lisappeared. 

Tlie  pro.;ess  begins  either  in  the  peri.)stcum  .)r  in  the  mclullarv 
'•aimi.  an.l  is  chanHterue.!  by  an  intense  suppurati-  e  an.l  necmtizing 
'I'tlannnation.  Ihe  .hsease  mvolves  usually  the  p^^riosteum  an.l  the 
m-iL'hl.ormg  parts.  The  affecte.1  region  is  sw.>llen.  .ense.  ml.lene.1,  an.l 
ni.Mi,ely  painful.  Ihi  bone-marrow  is  at  first  congested,  pres.  .tini; 
liitcr.  areas  of  hemorrhagic  extravasation,  an.l  later  still,  numerous 
Miiall  hm  .)f  suppuration.  Owing  to  the  confluence  of  the.se  foci  larger 
w  -^^laller  abscesses  nsult,  an.l  the  suppurative  pr.x-ess  mav  extend 
hr.H,.hout  the  medullary  canal  to  the  Havei^^ian  cat.als  and  periosteum 
aiul  .ven  to  the  surface.  S.>metimes  the  epiphy,ses  and  the  joints  are 
muAvvd.     In  milder  cases  the  process  may  terminate  without  such 


m  ill 


1022 


THB  aONtS 


marked  disturbance,  but  usually,  owing  to  the  interference  w'tf 
circulation  due  to  the  pressure  of  the  inflammatory  products,  la  ->; 
smaller  portions  of  the  bone  may  become  necrosed  and  in  time  exfoli 
This  takes  place  both  within  the  bone  and  at  places  where  the  pcrios 
has  been  separated  from  the  underlying  structure.  Large  niussi 
bone  and,  iu  fact,  the  whole  central  pdrtion  of  the  shaft,  may  U' 
sequest.ated  and  necessitate  surgical  interference.  Owing  to  the  o 
rence  of  septic  venous  thrombosis,  metastatic  abscesses  may  for 
various  parts  and  death  is  a  not  infrequent  result.  The  bones  ar 
volved  primarily  in  the  following  order:  femu'^,  tibia,  the  bo;:es  o 
upper  extremities,  the  flat  and  short  boi<es. 


Fia.  3M 


Chninic  osteomyelitis  of  tne  femur.  The  epecimen  shows  great  thickening  i)f  il.c  -I.  ill 
hone,  with  the  formation  of  abscesses.  On  the  left  a  sequestrum  is  well  pliuwn.  In 
Pathological  Mu.»eum  of  McGill  University.) 

In  cases  where  a  bone  is  injured,  as  by  crushing,  .-iplinitiiiij 
fracture,  a  moderate  amount  of  inflammation  !«  set  up  which  in.i  n 
heal.  Should,  however,  infective  microorganisms  be  ciniilaiin^  ii 
bloofUstream  the  injured  region  is  liable  to  become  infected  ninl  i  ci 
tion  similar  to  infective  osteomyelitis  and  periostitis  is  protliw  td  d 
resistentise  minoris).  In  cases  of  compound  fracturt,  iiiff  p.'H 
also  take  place  from  the  externalair. 


PAOBT'S  DISBASB 


1023 


Otoonlc  OitwmyeUto.-Chronic  inflammation  mav  be  the  result  of 
a  preexisting  acute  process  or  may  be  chronic  from  the  start.  The 
latter  is  apt  to  be  the  case  in  tubeiculosis,  syphilis,  typhoid,  and  actino- 
injcosis.  M  the  changes  just  described  as  occurring  in  the  acute  form 
may  occur  here,  but  the  process  is  more  gradual  and  long^ontinued 
Granulation,  suppuration,  and  necrosis  are  marked  features  and  both 
osteoporosis  and  hypercwtosis  occur.  Chrcnic  inflammation  may  also 
arise  by  the  ,  xtension  of  mflammatory  processes  from  the  neighboring 
parts,  as.  for  example,  from  ulcers  of  .ae  skin.  Osteophyte,  may  be 
produced  or  diffuse  hyperostosis.  ^ 

A  peculiar  form  of  chronic  inflammation  that  should  be  hce  mentione<l 
IS  the  phosphonu  necrona  which  attacks  the  jaw  bones  of  *'aose  working 
..   match  factories.    The  process  usually  begins  in  the  lower  maxilla 
and  may  extend  to  the  upper  jaw  and. 
rarely,  to  the  bones  of  the  face.    The  fio  jss 

condition  is  brought  about  by  the  fumes 
of  the  yellow  phosphorus,  which^  being 
(lissolyed  in  the  saliva,  attack  the  gums, 
ami,  if  carious  teeth  be  present,  invade 
the  alveolar  processes.  Infection  with 
microorganisms  from  the  buccal  cavity 
also  plays  an  important  part  In  the 
early  stages  there  is  a  slight  inflamma- 
tion, in  consequence  of  which  the  peri- 
osteum and  bone-marrow  ar.'  imuiated 
aiiii  produce  new  bone,  so  that  the 
jaw  l)ecomes  thickened  and  sclerosed. 
Later,  suppuration  and  necrosis  set  in, 
ami  larger  or  smaller  portions  of  the  bone 
are  sequestrated  and  cast  off.  In  this 
way  the  whole  of  the  lower  jaw  may 
\w  destroyed.  Rarely,  the  prtx-ess  runs 
a  much  more  acute  course. 

We  come  now  to  discuss  two  rare  and 
striking  affections  the  eiiology  of  which 
is  ((tiite  obscure. 

Pagefs  Disease'  (Osteitis  Defor- 
mans).—Paget's  disease  is  a  rare  affec- 
tion found  after  middle  life  and  asuallv 
m  advanced  age.  In  brief,  there  are 
two  opposing  pathological  processes  at 
work,  resorption  and  osseous  hyperplasia. 
In  some  cases,  owing  to  the  absorption 
of  tlie  bone,  the  affection  bears  a  close 
resemblance  to  osteomalacia.    The  dis- 

foTvSl!"  "^'15  P*'"""-  \'-^^"™«f>  character,  which  are  quickly 
followed  by  pathognomonic  cl.  ..ges.    The  bones,  especially  thoSe  sul^ 

•  Med.  Chir.  Trans.,  60: 1877:  37. 


Osteitii  defnr  Jiang.     (Packud.) 


ft 


1024 


THE  BUSES 


(I 


ii } 


jei'twi  to  tlu-  weifjht  of  the  IkxIv,  as  the  spine  nnil  lej;  hones,  Ixv 
curved  and  otherwise  deforuuHl,  wliile  tiiere  inuy  also  l>e  a  consid 
and  irre  'iilur  liyjK'rostosis.  Tlxe  parts  chiefly  atFejteil  are  llie  . 
of  the  lower  extremities,  the  spine,  clavicles,  and  tlie  calvariuin. 
pnK-ess  of  resorption  jtoes  on  iM)th  in  the  sjjonjty  and  conipact  |)art>  i 
lK)ne,  and  leads  to  more  or  less  complete  destruction  of  the  Imiuv  |i 
which  are  replacetl  by  a  fatty,  gelatinous,  or  fihrous  tissue,  poor  in 
(iMtcomyeliiin  fihromi).  Or  the  tissue  may  li(|uefy,  forming  <ysi>. 
sides  tliis,  proliferation  and  new-formation  of  hone  take  place  Im 
the  jieriosteum  and  in  the  marrow,  leading;  ti>  ffn'wi  increase  in  liii' 
and  density  of  the  hone  (osteosclerosis).  As  a  conse(|iU'n(<-  of 
irregular  nixlular  enlargements  are  formed  in  various  parts  nf  liic  l> 
which  may  also  Ik-  enormously  thickened.  Kventuaily.calcificaiioii 
set  in,  and  as  it  InHomes  domiiumt  the  disease  comes  to  an  end.  lli( 
and  Ziegler  ri'gartl  the  disease  as  Iwing  strictly  comparalile  to  nri 
deformans  while  v.  Kccklinghausen  helieves  it  to  In-  allied  to  ostt i:i 

Hjrpertrophic  Pulmonary  Osteo-arthropatby.  The  nam  re  n 
.second  disease  referred  to,  hyj)ertro])hic  pulnu)nary  ostco-arllHi>|i 
is,  if  possible,  still  more  ohscun'.  Attention  was  first  dirccliii  t(. 
^iarie'  and  shortly  after  i)y  Mamhcrger.-  It  was  DrecJM-ly  dcscrilii 
the  former,  who  differentiated  it  from  acromegaly,  to  wliicii  it  lit 
strong  general  resend)lance.  In  the  vast  majority  (»f  ca^cs  the  ili>f 
found  in  those  suffering  from  chronic  pulmonary  or  cardiac  atVntid 

In  a  typical  case  the  hands  and  feet  arc  consjderahly  enlarge  I  »\\ 
hones  of  the  forearm  and  leg  are  also  in(  reased  in  size  towar.l  llnir 
ends.  The  finger  tips  are  cluiihed.  The  cartilages  of  the  juiiii 
enxled  and  the  synovial  fluid  is  increased.  The  princes  in  tiic  ml 
hones  is  a  jK'riostitis  with  scleroMiig  hyi)erplasia  and  a  rart'tyiii!.'  . 
mvelitis.  The  face  and  head  are  not  involved.  Ca^cs  are  often  <  n 
cated  with  tulx-rcnlosis  of  the  spine,  thus  giving  rise  to  dcfonnilic  . 

So  far  as  is  known,  the  disease  appears  to  Ik-  a  chronic  inllanniii 
brought  about  possibly  i>y  the  absorption  of  infective  agents  and  |>nii 
assisted  by  venous  stasis.  The  anah)gy  with  IlippiM  ralic  fingi  r-  -I 
Ir-  remarked  in  this  connection. 

Tuberculosis.  'rni)erculosis  is  the  most  coninion  and  i,,i|ii 
disease  of  i>one.  The  affection  attacks  l)y  preference  ciiildi-cn  :i  id  ' 
persons,  but  is  not  unknown  in  middle  life.  This  is  pnibalil\  t.'  I 
plaineil  in  that  the  boiu-s  of  young  growing  iiulividuals  arc  mcuv  \  i- 
aiul  susceptible  to  ivlatively  slight  injuries,  while  the  <  iinip:iriiii\t  Iv 
circulation  in  the  vessels  of  the  in<Hlulla  also  predispoM-.  AMi 
tuheixniosis  of  the  hones  often  apjM-ars  to  he  a  primary  alVtH;  n 
far  as  the  clinical  manifestations  are  concerned,  yet  thedisca-f  i- ;'!"! 
always  secoiulary  and  an  expression  of  metastasis  from  -oni.  li 
focu.s,  usually  in  the  limgs  or  lymphatic  glands.  This  f'lHU-  i  ■ 
minute  as  to  escape  observation,  or  may  even  appear  to  h~\\'  n 
As  a  rule,  the  infective  germs  are  brought  to  the  part  by  the  '  'I 


Itfvue  de  Modecinc  10:  ISW):  1. 


2  Zcit.  f.  klin.  Mcil  , 


TUBERCULOSIS  jqjj 

oc-CMioruilly  the  dUea*e  arises  hy  extension  from  a  joint  or  other  structure 

through  the  lymph-stream.    The  disease  may  be  acute,  in  the  fom  of^ 
d.«eminated  mifiary  infection,  but  this  is  always  a   eminal  e^t  fnd 
of  l«s  interest  than  the  more  f,«,uent  chronic  forms. 
I  he  tuberculous  process  begias  either  in  the  bone-marrow  or  oeri 

rrhvis     Th:t"'^  "  P^'-r^  '«'  •»"'  ^nceHous  s^^tu"  TJ 
epiphyses     The   bones   most   frequently   involved   are   the   vertebne 
femora,  the  bones  of  the  tareus  and  carous    the  riK.   o^^     vertebrae, 
fhn  okiill     Ti.»  Ai  I  tarpus,  tue  nbs,  and  occasionally 

he  skull.     1  he  disea.se  does  not  tend  to  attack  the  mdulla  exceot    n 
the  case  of  the  phalanges,  metacarpal  and  metataml  bones.  ^ 


Fill.  2gu 


(PatholoBical  Museum,  .McGill  University.) 

Th.-  process  begins  with  the  formation  of  one  or  more  areas  of  tubereu- 

iTv  Sn'^ll '  "'^'''^  ^T'"t"^'  ^^*^"''  ^^  ^'-'-  «^  the  Cy  sSuIture 
Ml  they  finally  fuse.  At  the  same  time  new  foci  of  infiltration  are 
^n^  formed  m  the  neighborhood  of  the  older  areas.    The  bone  t^b^ 


i] 


J... 


Si 


-J 

:  ft 


1026 


THE  BONES 


11 


rounded  or  elongated  yellf  .ish,  necrotic  areas  surrounded  bv  gn 
or  grayish-red,  gelatinous-looking,  granulation  tissue.  In  other  . 
there  may  be  seen  large  areas  of  necrotic  bone  of  a  yellowish-whi 
reddish  color  infiltrated  with  inflammatorj-  ce"s  and  surrounded  by  gi 
iation  tissue  or  caseopurulent  exudation  and  detritus.  A  much 
form  than  this  is  the  one  in  which  the  process  is  so  rapid  that  thi 
very  little  attempt  at  the  formation  of  granulation  tissue.  Ins 
there  is  a  diffuse  ca-wating  process  which  extends  rapidly  throughoii 
bone-marrow.  OccBsionallv  w«lge-shapc<i  areas  of  necrosis  and  c 
tion  are  found,  the  hnwtl  Imwc  of  the  w«lge  l>eing  situated  towun 
articular  surface.    This  suggests  that  the  c«)ndition  is  brought  uIm.i 

Kh..  im 


Tuberculous  dactylili"  (»pin»  vento«).     (From  the  Surgical  Clinic  of  (he  51. .mm 
Gent^ral  Hospital.) 

infarction,  a  view  that  is  supported  by  the  experiinciits  »<i  ^ 
The  articular  surfaces  of  hone  have  licen  shown  to  contain  »>nil-ar 
and  these  probably  liecome  occluded  by  infective  emboli  or  In  a 
bination  of  embolism  and  thromlxisis. 

The  results  of  the  process  are  various.  Small  foci  undoul)i.ill 
heal  by  the  softening  and  aljsorption  of  the  destroyed  ti>-^n<, 
is  gradually  replaced  by  connective  tissue,  marrow,  or  bone.  ' !  1  it- 
cavities  may.  however.*  remain  and  become  delimited  by  dvnv.  f 
tissue  or  a  zone  of  tuberculous  granulation  tissue.  In  neartv  ;!l  c 
compensatory  process  of  the  nature  of  a  new-formation  of  1m)' •  I'V 
sition  takes  place.     In  other  cases  rarefaction  occurs  in  the  cei '    1  p 


if  (he  M..iiiiTiil 


TUBERCULOUS  PERtOSTrrfs  ^q^ 

of  the  bone  so  that  the  central  canal  becomes  enlarwd,  and  with  th» 

Z\^V»J^  resorption  and  concomitant  apposition  of  bone  mWy  aUo 
uJ^!^  ^u"  P"«'^"'"  P'«*-  In  many  ii^sTances,  especially  in  tS 
^^T'  "if  »'"'^»"'«  become  th-^ken^  and  sclerosS^     ^ 

Tub«ulo«  »«l-UtU.-Tube«uloa,  periostitis  mar^'primary  or 
secondary  o  tuben..uloiu.  osteomyelitis  an\l  arthritis.  ^VpSS^^J 
l)c  localized  in  the  form  of  an  area  process  may 


fio. 


of  tuberculous  granulation  or  a 

ruseous  node,  or  may  extend  over 

the  whole  surface  of  the   \nme. 

When    the    inflammation     has 

!«turted  in  the  deeper  parts  there 

ma/  he  direct  communication  with 

the  exterior.     If  the   process  do 

not  tend    to  heal,  it    goes    from 

had    to   worse,   the    tultertiilous 

foci  caseate  and  s<iften,  and  the 

infective  agents  are  cnrriwl  along 

ihe  tissue  spaces  and  lymphatics, 

to  invade  the   muscles   and    the 

bicMwl vessels     ami    possibly     the 
joints    by    a  steadily  advaiuiiig 
pnK-ess  of  granulation  and  case- 
ation.    In  this    waA-  large    cold 
alisivsses  or  cuseolil>n)id  iumIuIcs 
are  formed.     In  advanced  case.>. 
tile  |)r(K-ess  may  reach  the  surface, 
giving  rise  to  tul)erc-ulous  sinuses 
and  fistuhe  which  discharge  j-ase- 
"iis  pus.     With  this  there  is,  us  a 
rule,  more  or  less  extensive  suix-r- 
licial  erosion  of  the  hone  with  for- 
mation of  new  hone  from  the  osteo- 
(tenetic  layer  of  thej)criasteum.  In 
the  case  of  tie  curfjus  i»nd  tarsus 
more  than  one  hone  ant.    everal 
joints  are  usually  involve*!  in  an 
extensive  destructive  process. 

In  tuberculosis  of  the  vertebra-  those  fmm  the  seventh  dorsal  to  the 
wojul  lunibar  are  the  ones  .usually  involved.     The  process  Ijegins  supei- 

dt  -v^  „  H '^  '"  '"r'^u  '^'  l'?"^'-^  °^  '^'  '■''''^"''  '^'  ligaments  are 
d«tr;ned,  and,  owing  to  the  weight  of  the  body,  the  spine  may  collapse, 
fo  nung  an  angular  cur^•ature  (Pott's  disease).  The  vertebral  canal 
may  uv  opened  up  and  compression  of  the  con!  from  tuberculous  deposit 
0^  pr-ssure  of  the  dislocated  bones  may  result,  giving  rise  to  a  spkstic 
E  ■  ""■  x^  prevertebral  cold  abscesses  are  occasionally  fomed, 
"hi.  1,  may  burrow  most  extensively.    The  usual  coui^  is  for  the  abscess 


Tuberculiiun  pmsion  of  the  vertrbne.     (From 
the  Patholncical  Muwum  of  McUill  University.) 


N 


I! 


lOK 


THE  BONES 


I'' 


to  exte!id  retitmeritoneally  downward  into  the  pelvis.  It  tends  to 
below  Poupart^  ligament' or  lower  in  the  thi^h  (/»»<>«*  ab»ef»»),  or,  n 
may  excavate  the  gluteal  region  ami  extend  Inu-kward,  disset-tini 
soft  tissues  away  from  the  sacrum.  In  one  case  which  we  section.- 
abscess  discharged  into  the  trachea.  Here,  amphoric  breath  s< 
and  metallic  tinkling  were  heard  in  a  limited  area  near  the  spin. 
dently  due  to  the  presence  of  air  in  the  abscess  cavity.  A  tuben 
abscess  may  extend  through  the  sacrosciatic  notch,  giving  rise  tr  s 
toms  of  obstinate  sciatica.  Should  the  disease  heal,  the  defo 
usually  remains.  Tulierculosis  of  the  atlas.  axi.s,  and  the  lm.se  i 
skull  is  rare,  but  is  of  importance,  since,  when  the  ligaments  are  destr 
a  sudden  strain  may  cause  dutlocation  and  the  odontoid  procexn  t 
atlas  is  then  driven  forcibly  into  the  medulla,  causing  instant  death. 
process  more  often  than  not  does  not  completely  heal,  but  grui 
extends,  giving  rise  to  .secondary  infection,  amyloid  disease  and  ex 
tion.  In  some  cases  the  tulierrle  bacilli  l)ecome  dissemiimtetl, 
the  lungs  a.id  other  distant  parts. 

SyjJlUii.— The  syphilitic  manifestations  in  Ixinc  vary  consL  • 
according  as  the  disease  is  congenital  or  awjiiired.  In  the  first 
the  affection  manifests  itself  at  the  line  of  ossification  of  the  lonj;  1 
usually  the  femora.  The  lesion  is  really  a  siKiific  oitMcbon 
The  line  of  calcification  is  broader  than  normal,  more  irrcgulur,  n 
a  whitish  or  whitish-yellow  color. 

Microscopically,  the  zone  of  ossification  is  irregular,  the  iKHic-tnili 
vary  in  thickness,  sometimes  containing  islets  of  cartilage,  and  th«'  ii 
lary  spaces  are  irregular  in  size.  I n  otiier  ca.ses  the  pnxess  ()f  ossiHi 
is  still  further  interfere*',  with;  the  cartilage  is  soft  and  .swollen;  lli 
physes  tnav  l>e  enlarge<l.  owing  to  proliferation  of  the  cartilage,  :ini 
l)e 'separated  from  the  shufi  l.y  an  exteasive  soft,  grayish-yellow,  n 
dish  zone,  in  which  are  necrotic  areas.  In  advanml  ca-ses  the  ej)!! 
may  be  more  or  less  comj)letely  .separated  from  the  diaphysis.  Tin 
ference  with  the  normal  process  of  ossification  leads  toasomc\vli;ii 
acteristic  form  of  dwarfing. 

In  the  acquired  form  of  the  disease  the  characteristic  lesKni 
gumma,  which  may  be  situate«l  in  the  periosteum  or  marrow.  I'iri 
gummas  are  much  the  commoner.  Here,  at  first,  we  see  a  liwi 
.somewhat  flattene<l,  .swelling  of  gelatinous  appearance  and  ehi  tu 
sistency.  I..ater,  this  may  a.ssume  a  more  grayish  appiir.iii(( 
liecome  firmer,  owing  to  the  presence  of  granulation  tissue.  I  )ry ,  \vl 
necrotic  areas,  not  unlike  caseation,  with  more  or  less  fibroM  .  :ii 
quently  met  with.  As  the  process  heals  it  leaves  a  dense,  lil)r  .11 
At  the' points  where  the  periosteal  gummas  are  situated  tlur.  nn 
siderable  erosion  and  caries  of  the  underlying  bone.  This  pr. .  i> 
occur  in  anv  part  of  the  skeleton,  but  is  most  commonly  met  "I'li 
calvarium. '  It  begins  in  the  external  layer,  may  extend  l.-  i'  < 
and  the  inner  table,  finally  reaching  the  dura.  According  to  tic 
of  the  disease,  the  destruction  of  the  bone  may  be  almost  idi  r,b 
or  furrows  and  excavations  may  be  produced,  or,  again,  lair  pf 
of  the  calvarium  may  become  exfoliated. 


ry  consii.  nililv. 
II  the  first  ciis*', 
!  the  loii);  Imhips, 
'  otteocbondritii. 
ir«'giilitr,  and  ot 


1029 


*1 


P.rM»itiii.  witn  a«itmctiv«  ialUmiution  (<»t»p„™l.)  utmniag  tb«  tnnul  ua  WmponJ  br  .. 
.upp.««lly  Uu.  to  whlU..     (from  ,h.  P.,holo,i«J  Muimn  rf  Mco" uS^ ,  ' 

Kio.  MO 


^yphiliU,  o.t*,po«»i.  of  th.  clvmrium  with  p.rfo«Uon.  du.  to  multipl.  ,uom„ 
(From  the  Paiholofical  MiiMum  of  McOill  Univ««ity.) 


1030 


THE  BONES 


fypWMtie  OftMiiqrelltis. — Syphilitic  osteomyelitis  is  rare  in  the  I 
bones  but  b  met  with  occasionally  in  the  phalanges  and  the  diploe  of 
cranial  vault.  Gelatinous  or  fibrogelatinous-looking  foci,  often  of  a  so 
what  purulent  character,  are  formed,  of  a  grayish-yellow  color,  in  \vl 
the  bone  is  becoming  necrotic.    In  the  neighborhood  the  less  affe< 


Flo.  391 


Sclerosis  u(  the  calvsrium,  of  syphilitic  origin.  Note  the  thicknefn  of  the  sfunifi.'  -f 
(at  the  lower  p»rt  of  the  picture),  which  ii  sIki  denee  mod  ivory-like.  (P»thologi.i»l  .Mui 
McGill  University.) 

bone  shows  a  tendency  to  hyperostosis.  Under  proper  mediciitinn 
disease  m.ay  come  to  a  standstill  and  finally  heal.  The  granuhil  i  ;  ti 
disappears'  the  caseoid  detritus  is  absorbed,  dead  bone  is  seque.st iv  i' d 
cast  off,  and  any  defects  are  either  filled  up  by  new  bone  or  bri  i  •  •!  i 
by  connective  tissue.    The  bone  in  the  neighborhood  frequenti    i  •  :n 


MADURA  FOOT 


1031 


dense  and  sclerotic,  and  of  a  texture  and  hardness  resembling  ivory. 
In  all  forms  of  this  affection  osteoplasia  is  a  marked  feature,  and,  in 
fact,  m  one  type  of  periostitis,  may  dominate  the  anatomical  picture. 
It  should  be  mentioned  that,  where  large  masses  of  bone  are  being 
sequestrated,  inflammation  may  extend  to  the  soft  tissues  and  skin  so 
that  inflammatory  exudation  and  necrotic  material  are  discharged 
externally  with  the  formation  of  suppurating  sinuses. 

Actinomycosia.— This  is  usually  found  in  the  ma.xilla;,  vertebrse,  and 
bones  of  the  thorax.  Infection  usually  takes  place  through  the  alimentary 
tract.  The  mfective  agent  is  the  ray-fungus  (actinomyces  bovis),  which 
seems  to  be  frequently  present  on  grass  and  hay.  The  disease  has  been 
known  to  follow  pncking  the  gums  with  a  needle,  or  may  invade  the  alveolar 
process  through  decayed  teeth.  The  infection  may  also  enter  from  the 
mum  and  appendix,  whence  it  spreads  to  the  retroperitoneal  tissues 
thence  to  the  ilium.  At  first  a  periostitis  is  produced  and  the  fungus' 
gradually  extends  into  the  interior  of  the  bone,  which  is  rarefied  and 
inhltrated  with  granulation  tissue.  There  is  considerable  destruction 
of  the  bone.  Macroscopically,  the  affected  structures  are  involved  in 
a  granulating  necrotizing  process.  By  proper  methods  the  rav-fungus 
can  be  detected  in  the  inflammatory  tissues. 


m 


Flo.  292 


Mycetoma.     Fungus  surrounded  by  n  dense  accumulation  of  leukocytes.     X  300. 
(Dr.  Hyde's  ca."e:  fri)m  a  phot.imicrograpli.) 

Madura  Foot.— Madura  foot  is  a  disease  of  the  bones  of  the  tarsus 
clos,  ly  resembling  actinomycosis.    The  infective  agent  is  a  fungus,  in 


!.     18 

r.    a 


H 


JM^ 


1032 


THE  BONES 


some  cases,  the  mycetoma  pedis,  an  organism  allied  to  the  actinomy 
in  other  instances  an  aspergillus  has  been  found.  The  disease  is  ii 
common  in  India,  but  a  few  instances  have  been  met  with  on  the  Ameri 
continent.    One  case  has  been  reported  in  this  country  which  is  rem; 


Fu.  39S 


Osseous  lesions  in  mycetoins.     (Hyde.) 

able  in  that  it  occurred  in  a  person  who  had  spent  his  whol'  li 
America.'  The  lesions  produced  are  similar  to  those  in  actiiiomyc 
leading  to  rarefaction  and  destruction  of  the  aflfected  bones,  with  luiint 
discharging  sinuses,  the  pus  from  wliich  contains  the  specific  .  ga 
(vide  also  p.  924). 


'  Adami  and  Kirkpatrick,  Trans.  Assoc.  Amer.  Phys.,  10  ; 


1805 


ATROPHY 


1033 


Lep».— In  leprosy,  granulomas  containing  bacilli  may  be  found  in 
the  periosteum  and  bone-marrow,  causing  more  or  less  osteoporosis  and, 
where  an  extremity  is  involved,  mutilation. 

VarioU.— According  to  Chiari,'  in  variola  an  osteomyelitis  may  be 
found  characterized  by  the  formation  of  multiple  minute,  yellowish  foci 
with  gray  centres,  varying  in  size  from  that  of  a  millet-seed  to  that  of  a 
ijplit  pea. 

Microscopically,  these  consist  of  epithelioid  cells,  a  few  leukocytes,  and 
a  fibrinous  exudate  with  central  necrosis. 

Parasites. — Eckinococcus  and  Cyaticercus  cellukuiw  have  been  met  with 
forming  cysts.  ' 

UTB0OKB88IVE  M£TAMORPH08E8. 

The  structure  of  the  bony  framework  of  the  body  is  in  health  under- 
gomg  constant  change.  In  the  child,  while  there  is  a  certain  amount  of 
breaking  down  of  the  substance  of  the  bone,  vegetative  ant'  productive 
forces  are  pretlominant,  with  the  result  that  tlie  bone  increases  in  size 
and  strength  unt"  it  attains  its  perfect  structure.  In  the  adult,  breaking 
down,  or  resorption,  as  it  is  called,  also  goes  on,  but  is  compeasated  by 
a  contmuous  deposit  of  bone  by  the  process  of  apposition.  In  the 
aged,  however,  resorption  is  in  e.xcess,  so  that  the  bone  l)ecomes  smaller, 
lighter,  and  more  fragile.  Lacunar  resorption,  both  under  normal  and 
pathological  conditions,  is  brought  about  bv  the  agencv  of  large,  niulti- 
iiucleated  cells,  the  osteoclasts  (myelopla.xes),  situated  in  the  periosteum 
and  bone-marrow.  These  take  up  their  position  upon  the  bony  trabec- 
iilie  and  gradually  erode  their  way  into  the  structure,  forming  excava- 
tions, calle<l  Howship's  lacunte. 

Atrophy.— In  the  rapid  resorption  of  the  bone  characteristic  of 
certam  «liseases,  the  osteoclasts  are  greativ  increased  in  number  and 
he  closely  packed  together.  The  result  of  this  is  that  the  surface  of 
the  bone  becomes  rough,  eroded,  and  irregular.  Should  the  process  come 
to  an  end,  the  projecting  ridges  are  absorlied,  there  is  a  deposit  of  ne.. 
Imne  m  the  hollows,  and  the  surface  of  the  bone  again  becomes  sniootl. 
Should  the  resorption  be  mast  marked  ne.xt  the  medullarv  cavitv,  the 
external  appearatu  .•  <.f  the  bone  is  not  altere<I,  but  the  cavitv  is  enlarged, 
the  tral)eculffi  betonie  gradually  thinner,  and  niav,  in  part-  disappear 
{exmitrw  atrophy).  When  the  process  begins  'externally,  the  bone 
becomes  gradually  thiimer  and  local  defects  are  manifested  {concentric 
atrophy).  In  jther  cases  the  compact  substance  of  the  bone  becomes 
porous,  owing  to  the  widening  of  the  Haversian  canals.  This  is  known 
as  aiteoporosia.  According  to  Pommer,=  atrophv  of  Inne  may  be  a 
relative  matter,  that  is  to  say,  the  amount  of  lacunar  resorption  does  not 
ext.-ed  the  normal,  but  there  is  a  diminished  deposit  of  new  bone  bv 
api-ositjon,  so  that  the  bone  becomes  smaller,  or,  again,  the  atroohV 
mu;  l)e  aKsolute.  *^  ^ 

'  Ziegler's  IJuitrtige,  !):  1891. 

'  Ueber  die  Osteoklastentheoric,  Vircli.  Arrhiv,  02:  1883:  449. 


MU^t 


1034 


THB  BONES 


Atrophied  bones  are  light  and  fragile,  easily  broken  or  sawn.  'I 
medullary  substance  will  vary  in  appearance  according  to  the  extent 
the  affection.  It  may  be  hyperplastic,  presenting  the  appearance 
lymphoid  naarrow,  fatty,  or  the  fat  may  be  replaced  by  a  semitranslucc 
gelatinous-looking  substance  (serous  atrophy).  As  a  consequence  of  i 
excessive  resorption  of  the  solider  portions,  the  bones  become  bril 
and  unable  to  support  their  accustomed  burden,  nnd  may  readily  fracti 
(tymptomaiic  otteojaathyrosia,  fragUitcu  oatium).  Atrophy  of  bone  n 
arise  as  a  senile  or  marantic  change,  from  pressure,  djsuse,  or  fn 
neurotrophic  disorders. 

FiQ.  2S4 


Atrophy  "'  the  bodies  of  the  vertebrs  from  the  pre»9Ure  of  an  aneurism. 
Muaeum.  McGill  University.) 


(Patli..l"tri.al 


Senile  and  Uarantie  Atrophy. — Senile  and  marantic  atrophy  inav  :itr 
the  skeleton  as  a  vhole,  but  the  former  is  apt  to  involve  iiiorr  ( 
tensively  the  flat  bones,  the  calvarium,  the  scapulw,  and  tlic  \>A\ 
The  process  begins  d  the  points  which  are  devoid  of  muscular  :i!i.ii 
ments.  The  atrophy  may  be  concentric  or  excentric,  and  the  boic  in 
also  become  more  porous.  The  facies  so  characteristic  of  old  iiL'e 
due  to  atrophy  of  the  maxillae,  the  alveolar  processes  of  whii  h  in 
disappear  entirely.  In  the  case  of  the  calvarium,  the  whole  of  tin  oui 
table  and  the  diploe,  or  even  portions  of  the  inner  table,  may  be  lif  i  rovi 


ATROPHY 


1035 


In  some  instances  there  is  a  deposit  of  new  bone  on  the  surface  of  the 
inner  table.  This  b  most  frequently  seen  in  the  frontal  bone.  The 
vertebra  becomeporous  and  diminished  in  size,  so  that  the  bodily  height 
is  diminished.  The  dorsal  curvature,  so  often  seen  in  elderly  people,  is 
due  largely  to  the  absorption  of  the  anterior  portion  of  the  intervertebral 
disks. 

Fio.  aM 


Uarefaction  of  tlie  «h»ft  of  the  humerus,  due  to  cuvinnms.     (Pathologi'  im, 

HcGill  University.) 

Pressure  Atrophy.— Atrophy  from  pressure  is  of  course  local.  A 
familiar  instance  is  the  depression  in  the  bones  of  the  chlvarium  due  to 
the  Pacchionian  bodies.  Hvdrocephalus  and  intracranial  growths  lead 
to  atrophy  of  the  calvarium.  Pressure  atrophy  is  also  brought  about  by 
anfurisms,  tumors,  scars  in  the  skin  and  subcutaneous  tissues,  the  pressure 
of  tiie  umbilical  cord  on  the  embryo. 

Inflammatory  Atrophy.— Atrophy  may  also  follow  inflammation. 

Atrophy  from  Dlsnie.- Atrophy  from  disuse  L«  met  with  especially  in 
the  limbs,  as  in  amputations,  fractures,  chronic  arthritis,  joint  and  bone 
influinmations. 


t    a' 

k 


m 


kf  Mn 


1036 


THE  BONES 


HraropAthie  Atrophy. — ^The  neuropathic  forms  result  from  some  is- 
order  of  the  central  nervous  system,  as  dementia  paralytica,  talies 
dorsalis,  syringomyelia,  anterior  poliomyelitis.  In  many  cases,  however, 
the  atrophy  is  attributable  to  disuse  as  well  as  to  disease. 


Fia.  2M 


Til'  femur  and  tibia  of  an  idiot.  i«liowiiig  tlie  iiimple  atropliy  uf  disuse,  'llic  coiitrii-t  iti  -ize 
betwet-n  the  shaft  and  the  extremities  of  the  hone?  is  marked.  CFmrn  the  Palhoh>Bif;tl  -Mii-fura 
of  McGill  UniverMly.) 

Death. — Deatli  of  bone  takes  two  forms— caries  and  necrosis.  (  aries 
is  a  slow  disintegration  of  the  bone  into  fine  and  almost  imper- 
ceptible particles,  and  is  analogous  to  suppuration  of  the  soft  ti^^ue.s. 
Necrosis  may  be  compared  to  gangrene  and  is  death  of  bone  <k  <  iirriii,; 
en  masse.  Caries  is  practically  always  due  to  inflammation.  .\i<  ro.sis 
may  be  due  to  inflammation,  interference  with  the  proper  circuLiii'Hi  of 
the  part,  traumatism,  or  chemical  and  thermic  agencies.  A^  i  rule, 
when  a  portion  of  a  bone  dies  it  becomes  separated  from  tlic  in  :iltiiy 
part  by  a  zone  of  reactive  inflammation,  where  resorption  ami  exfolia- 
tion is  actively  going  on.  In  such  cases  the  necrotic  portion  Ls  (•riaed 
a  sequestrum. 


• "  ■' 


HALISTERESIS 


1037 


HalisteresiB.— A  striking  and  important  retrogressive  change  some- 
times found  in  bone  is  halisteresis,  a  condition  in  which,  while  the  organic 
substance  of  the  bone  remains  comparatively  unaltered,  there  is  a  notable 
diminution  in  the  amount  of  lime  salts,  so  that  the  bone  becomes  soft 
iind  yielding.  The  process  may  be  restricted  to  a  small  area  in  a  bone, 
us,  for  instance,  in  the  neighborhood  of  a  tumor,  or  may  be  more  widely 
spread  throughout  a  whole  bone,  or  even  the  greater  part  of  the  skeleton. 
The  more  extensive  affection  is  commonly  known  by  the  name  of  oit«o- 
malaeia  (mollities  assium,  malacosteon). 

The  pathological  changes,  here,  coasist  in  the  main  of  decalcification 
of  the  old  bone,  with,  at  the  same  time,  a  tendency  to  the  formation  of 
new  bone,  which,  however,  remains  imperfectly  calcified.  The  process 
of  decalcificaticn  begins  at  the  periphery  of  the  bone-traliecuhe  and 
(iradually  extends  to  the  deeper  parts.  The  line  of  demarcation 
l)ftween  the  normal  and  the  altered  bone  is  sometimes  even  and  con- 
tinuous, or  may  be  irregular  with  excavations,  like  Howship's  lacunie. 
FrMjuently  there  is  formed  an  intermeiliate  zone,  where  the  lime  salts 
arc  not  completely  absorl)ed  but  remain  in  the  tissue  in  the  form  of  a 
crumbling  detritus  preliminary  to  their  removal.  In  the  course  of  the 
disease  the  original  bone  canals  liecome  enlarged,  and,  following  upon 
tlie  absorption  of  tlie  salts,  new  canals  an*  ft)rnied  in  the  groimd  sul)- 
stance.  The  matrix  itself  may  ap{)ear  to  be  homogeneous,  or  mav 
present  a  finer  or  coarser  fibrillation.  Some  of  the  bone-corpuscles 
may  be  preserved  but  many  are  atrophied  or  have  disappeared,  leaving 
siiiall  cavities.  In  some  cases  there  is  a  formation  of  new  osteoid  tissue, 
which  for  a  long  time,  or  perhaps  permanently,  remains  uncalcified.' 
This  new  tissue  may  Ik;  quite  dense,  containing  only  a  few  spaws,  or  it 
may  present  a  laminated  or  fibrillafed  structure  with  large  corpuscles. 
O-iteoclasts  and  Howship's  lacuna>  are  not  more  numerous  than  in  normal 
bone.  The  condition  of  the  marrow  varies.  It  may  be  reddish,  with 
friaiit  cells,  yellowish  and  fatty,  gelatinous,  or  even  fibroitl.  Hemorrhages 
and  pigment  are  commonly  found  in  the  marrow. 

.Vs  would  l>e  expected,  such  changes  in  the  structure  and  consistence 
of  the  bones  lead  to  marked  interference  with  their  function.  The 
l)()m's  are  no  longer  able  to  support  the  weight  of  the  body  or  oppose 
miiMular  contractions,  so  that  curvatures,  fractures,  and  indentations 
arc  not  uncommon.  The  bone  becomes  so  soft  that  it  is  wax-like  and 
is  readily  cut  with  the  knife  (nxtcomulacia  ccrea).  In  other  cases  resorp- 
tion of  the  bone  is  so  excessive  that  there  is  a  huge  medullary  cavity 
witli  a  mere  shell  of  hone  beneath  the  periosteum,  so  that  the  bone  is 
liflhl  and  brittle  (ontmmnlaciit  fmgiUs).  When  the  vertebral  column  is 
involved,  lonlosis,  kyphosis,  and  .scoliosis  are  frequently  met  with,  with 
all  tiiat  this  implies.  The  clavicles  and  ribs  may  be  much  deformed, 
anri  the  thorax  is  flattened  from  side  to  side,  the  anteroposterior  diameter 
iH-inir  increased.  In  the  pelvis,  owing  to  the  weight  of  the  hotly  and 
the  jiressure  of  the  femora,  the  acetabular  regions  are  driven  in,  the  pubes 
IS  iiiished  forward,  while  the  promontory  descends.  The  tuberosities 
of  1  lie  ilia  are  more  or  less  approximated.    The  cavity  of  the  pelvis  is 


1088 


THE  BOSES 


thus  greatly  reduced,  a  deformity  which  ia  of  the  greatest  importance 
in  regard  to  the  auestion  of  parturition.  Not  only  is  there  deformity,  but 
the  bones  actually  shrink,  so  there  is  a  double  reason  for  the  production 
of  a  contracted  pelvis.  In  the  lower  extremities  there  is  at  first  an 
exaggeration  of  the  natural  curves  of  the  bones,  but  later  there  are  more 
acute  curvatures  or  twists.  In  the  femur  the  greatest  deformity  is  found 
just  below  the  trochanter.  Where  bending  or  fractures  have  taken  place 
there  is  an  attempt  at  repair  by  the  formation  of  new  osteoid  ti.s.sue 
along  the  concave  side  of  the  curvature  or  at  the  site  of  the  fracture. 

The  true  cause  of  osteomalacia  is  quite  obscure.  The  disease  in 
found  both  in  the  old  and  in  the  young,  but  is  most  common  between 
the  third  and  fourth  deaule.  It  is  usually  met  with  in  women,  especially 
in  those  who  are  pregnant  or  unusually  prolific,  while  it  is  only  rarely 
found  in  men.  It  is  noteworthy  that  the  affection  is  endemic  in  certain 
localities,  such  as  the  Rhine  valley,  Westphalia,  Flanders,  and  northern 
Italy,  although  cases  are  not  unknown  in  other  parts  of  Eur()|H>.  It 
appears  to  be  rare  on  the  North  American  continent,  Dock'  only  finding 
record  of  ten  cases.  Among  the  direct  exciting  causes  the  most  important 
b  pregnancy,  which  in  the  majority  of  instances  initiates  the  affection 
or  leads  to  relapses  and  exacerbations. 

Numerous  theories  have  been  advanced  to  explain  the  condition. 
Some,  like  v.  Winckler,  think  that  unhygienic  surroundings  and  nuxles 
of  life,  unsuitable  or  poor  food,  insufficient  clothing,  repeated  ]>»>(;- 
nancies,  or  prolonged  lactation,  are  the  important  predisposing  causes. 
Hanau's  observation,  that  in  25  to  30  per  cent,  of  puerperal  women, 
osteophytes  and  osteoid  tissue  are  present  in  the  cranial  bones,  sunj^'e.sts 
that  osteomalacia,  at  least  in  puerperal  cases,  may  be  due  to  an  exa;;- 
geration  of  a  physiological  process.  That  there  is  some  coniiettion 
between  the  disease  and  the  genital  apparatus  would  seem  to  l)e  indi- 
cated by  the  fact  that  it  is  sometimes  cured  by  removal  of  the  ovaries. 
On  these  grounds  Fehling  has  enunciated  the  theory  that  osteonialacia 
is  a  trophoneurosis  due  to  reflex  irritation  from  the  ovaries.  In  view 
of  the  frequent  existence  of  hyperemia  of  the  bone-marrow,  v.  Re(  klin);- 
hausen  is  of  the  opinion  that  the  disease  is  due  to  a  local  irritation  and 
stimulation  of  the  bloodvessels  of  the  bones.  Virehow  also  iK-litvcd  the 
condition  to  be  of  an  inflammatory  or  hyperemic  nature.  Otiurs,  like 
Volkmann,  think  that  in  addition  to  circulatory  disturbances  tlure  i.s 
some  abnormality  of  the  nerve-supplj  ih  the  medulla.  Examination  of 
the  central  nervous  system,  however,  does  not  reveal  any  speciid  evi- 
dence of  this.  It  used  to  be  thought,  too,  that  an  excess  of  lactic  acid 
in  the  blood  was  the  caase  of  the  solution  of  the  calcareoas  suits  i  if  the 
bone.  It  is,  however,  not  the  ca.se  that  there  is  an  excess  of  tlii.  Mil). 
stance  in  the  blood  in  osteomalacia,  nor  has  it  been  found  pii>-iliie  to 
produce  the  disea.se  in  experimental  animals  by  feefling  tlitni  with 
this  acid. 

'  Amer.  Jour.  Med.  Sci.,  109: 1895:  449. 


HYPERPLASIA 


1(W 


PKOOBIUITI  MITAMOlPHOnS. 

While  under  ordinary  circumstances  bone  may  be  regarded  aa  the  most 
stable  and  unchanging  tissue  of  the  body,  waste  and  repair  are  to  some 
extent  always  going  on.    In  the 
adult  these  two  ',.;■  XMing  processes  '""•  *" 

are  almost  perfectly  balanced,  so 
that  for  a  time  at  least  the  volume 
and  the  texture  of  the  skeleton 
remain  constant.  On  occasion, 
however,  regenerative  processes 
may  become  more  active,  as,  for 
example,  in  the  process  of  repair 
of  bone  after  injuries,  and  some- 
times result  in  an  excess  of  growth 
over  and  above  the  obvious  needs 
of  the  organism. 

HypeipUflia. — The  causes  un- 
derlying hv-perplasia  of  bone  are 
often  obscure.  Some  forms,  such 
as  leontiasis  ossea,  local  and  gener- 
aiizetl  gigantism,  are  congenital 
and  primary,  being  apparently  due 
in  the  main  to  excessive  or  dis- 
ordered nutrition  during  prenatal 
existence.  Much  more  commonly 
the  process  is  acquired  and  aecond- 
nri/.  A  common  example  of  this 
is  the  repair  that  takes  place  after 
fnictures,  and  the  increase  in  length 
and  thickness  of  bones  in  certain 
ra^es  of  inflammation  and  t-iuma- 
tisin.  Experimentally,  increase  in 
the  length  of  bones  has  been  pro- 
diK-ed  by  driving  ivory  pegs  into  the 
growing  end  of  the  bone.  In  other 
cases,  hj-perplasia  seems  to  be  due 
to  chemical  substances  circulating 
in  the  blood.  Thus,  the  exhibition 
of  |>hosphoriis  and  arsenic  (GieS,' 

Kassowitz.'  Maas,'  Wegner*)  stimulates  bone  production  in  experimental 
animals. 


Ill 


Fracture  of  the  humerus  wifi  the  formation 
iif  an  enormoui  permanent  eallua.  The  patient 
from  whom  this  specimen  was  taken  was  a 
lunatic,  who  kept  his  arm  in  almost  constant 
motion.  As  a  consequence,  splints  could  not 
be  kept  properly  applied.  (From  the  Patho- 
logiosl  Museum  of  HcGUl  University.) 


'  i;iiiHu88  des  Araens  auf  den  Organismus,  .\rch.  f.  cxper.  Path.,  8: 1877. 

'  Zi'it.  f.  klin.  Med.,  7:  1884:  .36. 

'  Tageblatt  d.  Leipsiger  Naturforschenere.  1872. 

'  I  'her  den  Kinflti.«R  des  Phosphors  auf  den  Organismus,  Vireh.  Archiv,  56: 1872 : 1 1 . 


1040 


THE  BONES 


"'In  this  category  ulso  may  be  placed  those  hypertrophies  of  the  bone 
and  soft  tissues  associated  with  disorders  of  internal  seiretion,  a<i,  for 


Fio.  3M 


Normal  nkull.  Skull  (mm  •  vu«  of  arrDincgaly.    (Onburni;.) 

Kio.  209 


New-growth  of  onteophytes  about  the  hip-joint,  the  result  of  chronic  arthriti" 
the  Pathological  Muaeum  of  McGill  Vnivcrrity.) 


fi 


CALLUS 


1041 


example  in  acromegaly.  An  increase  in  the  length  of  the  bones,  par- 
titularly  thiMc  of  the  lower  extremities,  is  frequently  observed  also  after 
castration. 

Pn»'  >ngetl  passive  congestion  seems  also  to  favor  overgrowth  of  tissue, 
as  i  .i.e  clublied  fingers  of  those  suffering  from  chronic  pulmonary  and 
ciiniiac  affections. 

Bony  hyperplasia  is  s  ....nes  also  compensatory,  for  example,  the 
ttf'll-known  enlargement  of  the  fibula  in  ununited  fracture  of  the  tibia. 

The  overproduction  of  bone  may  manifest  itself  in  several  ways.  - 
\yhen  a  Iwne  becomes  enlarged,  either  as  a  whole  or  in  part,  the  condi- 
lioii  is  termed  hyperontoaia.  Again,  when  the  density  of  bone  is  incre&sed 
owing  to  the  formation  of  new  trabeculie  and  the  deposit  of  an  excess 
of  lime  salts,  so  that  the  structure  becomes  more  compact,  we  speak  of 
mtrimleroau.  Both  conditions  may  be  combined.  Local  outgrowths 
of  bone  are  calle«l  o»ieophytea  or  ezosiosea.  These  may  be  seen  in  the 
nt'ijrhliorhood  of  inflammatory  processes,  and  at  the  points  of  insertion 
of  the  tendoas  where  these  are  subjectetl  o  excessive  muscular  traction. 
Einmtoaea  are  hx-al  new-format i<jns  of  l)one  withii.  the  spongiosa.  It  is 
haril,  however,  in  some  cases  to  draw  Jhe  line  l)etween  local  h,v]>erostoses 
uiiil  true  tumor-formation. 

Oallos  (sec  vol.  i,  p.  557).— When  a  Injne  is  fracturetl  or  splintered, 
a-i  from  .some  traumatic  caase,  regenerative  processes  are  initiated  in 
till'  |)eriosteuni  and  l)one-marrow,  which,  provided  that  the  process  be 
not  complicated  i>y  infection  or  senile  or  other  cachexia,  lead  in  the 
course  of  a  few  weeks  to  consolidation  and  more  or  less  perfect  repair 
of  the  injury. 

hi  the  ordinary  course  of  events,  immediately  on  receiving  the  fracture, 
thtif  are  more  or  less  tearing  and  bruising  of  the  neighboring  soft 
tissii  s,  together  with  extravasation  of  blood.  A  moderate  amount  of 
inHamtnation  sets  in,  with  effusion  of  fluid  and  infiltration  of  leukocvtes 
int<i  the  structures  in  the  neighlwrhood  of  the  injury.  This  subsides  in 
from  five  to  six  days.  About  the  second  day  the  cells  of  the  periosteum 
ami  bone-marrow  show  signs  of  proliferation  in  that  they  are  enlarged 
and  their  nuclei  are  undergoing  karyokinesis.  In  the  ne.xt  few  davs 
the  number  of  the  proliferating  cells  is  greatly  increased  and  the  endo- 
thiliiiin  of  the  blotnlvessels  now  begias  to  take  part  in  the  process, 
<o  that  ai)out  the  fourth  day  the  osteoblastic  layer  of  the  periosteum  is 
wiiM-rfeil  into  a  vascular  germinal  tissue.  Under  the  microscope  this 
eoiHists  of  large  polymorphous  cells,  containing  frequent  mitotic  figures, 
emhtilded  in  a  partly  homogeneous,  partly  fibroid,  stroma.  After  the 
fourth  day,  the  germintl  layer  begins  to  be'differentiated  into  chondroid 
and  osteoid  tissue,  whicl ,  in  turn,  is  rapidly  converted  into  bone.  After 
the  hipse  of  a  week,  the  ends  of  the  fractured  bone  are  emliedded  in  a 
lar};i  number  of  young  osteophytes  a  1  osteoid  spicules.  In  this  way 
i»  (iimiuced  about  the  injuretl  region  a  spindle-shaped  sheath,  or  natural 
>piiiit.  called  the  external  callus.  A  prolongation  of  this  litween  the 
ends  of  the  fractured  portions  constitutes  the  irUermediary  calliu.  Simi- 
larly A  callus  is  formed  within  the  cavity  of  the  boae,  if  one  of  the  hollow 


1043 


THE  B0SS8 


■IH 


ill 


bones,  constituting  the  internal  or  muelogenic  eattut.  Thli  is  prr 
by  the  osteoblasts  which  are  grouped  into  masses  and  are  traiwf 
into  osteoid  and  eventually  into  oaseous  tissue.  In  the  neighborh 
the  fracture<l  portion  the  periosteal  germinal  layer  may  be  con 
in  part  into  hvaline  cartilage  and  in  part  into  fibroui  connective 
which,  in  time,  is  transformed  into  bone.     In  the  course  of  from 


Ki<i.  30O 


Fiu.  301 


unii 
(From  1 
University./ 


•ura  of  the  (cmur,  Bbowinc 

inn  of  the  eeotnl  ranal. 

al    MuMum  of    McGill 


Femur;  ununited  fncture  through 
tn^hsnter;  excnnve  jrowlhot  callu 
the  Pntholoiical  .Muwum  of  Mriii 
•ity.) 


three  weeks  the  fractured  ends  are  more  or  less  completely  n 
The  amount  of  callus  resulting  from  this  proce-ss  varies  coii>i( 
at  times,  being  dependent  on  individual  idiosyncrasy,  the  coikI 
the  bone,  the  nature  of  the  fracture,  and  the  amount  of  deforuiiiv 
In  addition  to  the  formation  of  new  tissue,  and  to  som«>  im< 
chronous  with  it,  an  opposite  process  is  at  work,  namely,  n''( 
The  fractured  ends  become  somewhat  rounded  off  and  splintt  is 


TUMOIU 


1043 


wpwated  frmn  the  nuiin  mass  are  abwrbed.  The  callus,  which,  at  the 
ftid  of  the  aixth  or  seventh  week,  consists  of  a  rather  soft  and  porous 
lionv  subflUnce,  is  gradually  converted  into  denser  bone  by  means 
i>r  lacunar  resorption,  the  formation  of  medullary  spaces,  and  the 
thickening  of  the  trabeculie  through  the  agency  J  the  osteoblasts.  In 
this  way  the  permanent  or  drfiniiivt  coi/iw  is  substituted  for  the  temforary 
otie.  In  the  course  of  months  or  years,  according  to  the  amount  of 
tmumatum  and  deformity,  the  permanent  callus  is  still  farther  modi- 
fied. Excess  bone  is  removed  and  the  weak  spots  an  strengthened 
until  a  more  or  less  perfect  return  to  functional,  if  not  anatoniKal,  in- 
tegrity is  complete.  In  severe  dislocations  of  the  parts  the  medullary 
cavity  of  the  bone  is  not  usually  restored. 

The  process  as  just  described  may  be  materially  modified  by  cerUin 
untov.urd  factors.  Thus,  infection,  inflammation,  or  necrosis  may 
delay  the  union  of  the  fragments,  or,  again,  the  co-  'ition  of  senility  or 
cachexia  may  prevent  it.  \Mien  two  bones  are  ii  lue  proximity  and 
one  only  is  broken,  the  resulting  callus  may  involve  i  le  uninjured  bone, 
producing  a  gynmtoais.  m  fracture;!  near  or  involving  a  joint  an  exuber- 
ant fumiation  of  ixsteophytes  may  lead  to  nnkylosia  of  the  joint.  Should 
the  .separated  fragments  be  impmperly  replaced,  be  too  far  apart,  or 
should  a  large  amount  of  Injne  Iw  destroyed,  or,  again,  should  muscle 
or  fascia  inter\ene,  the  parts  may  fail  to  unite.  Should  the  fragments 
be  united  immovably  by  fibrous  tissue,  the  condition  is  known  as  patho- 
loi/ical  »ynde»vu)»is.  In  other  cases  fibrous  union  takes  place,  leading 
to  the  estabiishmetit  of  a  false  joint,  ptevdarthroiis.  In  still  other  ca.ses 
a  true  joint,  with  a  more  or  less  perfect  approximation  to  the  ball  and 
socket  type  with  a  capsule,  may  be  formed — nearlhroais. 

As  might  l»e  expected,  the  process  of  healing  is  completed  more 
quickly  in  children,  taking  place  in  from  two  to  three  weeks  in  those 
under  two  years  of  age,  v.hile  in  adults  it  may  take  dix  to  eight  weeks. 
As  we  have  already  seen,  it  may  be  much  pruiunged  and  even  fail 
to  occur. 

Tumon. — ^The  tumors  that  develop  primarily  in  the  bones  belong 
to  the  connective-i  ^sue  group  and  origi  late  from  the  periosteum,  the 
bone-marrow,  or  tiic  cartilage.  In  accoruance  with  their  genesis  they 
assume  the  type  of  fibroma,  myxoma,  lipoma,  angioma,  cbondroju,  osteoma, 
myeloma,  sarcoma,  and  various  admixtures  thereof.  The  secondary' 
tumors  are  usually  various  forms  of  carcinoma. 

Like  that  of  tumor-growth  generally,  the  etiology-  of  the  neoplasms  of 
bone  is  somewhat  obscure.  Traumatism,  however,  such  as  a  fracture 
or  Mow,  seems  to  play  a  relatively  important  part  (callus  tumoi-s),  as 
floes  also  inflammation.  Irregularities  in  ossification  were  believed  by 
\  ir<  liow  to  account  for  the  chondromas,  especially  those  arising  in  the 
neJKlihorhood  of  the  epiphyseal  sutures. 

Tlie  primary  tumors  are  usually  solitary,  but  occasioiuilly  assume  tnc 
fonn  of  multiple,  isolated,  and  independent  growths.  The  presence  of 
tumirs  in  bones,  especially  when  of  the  malignant  type,  leads  usually  to 
conMiierable  lacunar  resorption  of  the  stnicture,  so  that  the  bone  may 


1  jHHHJ^^^Bi 

■5. 

1 

■■■ 

1044 


THE  BONES 


become  greatly  deformed.  Besides  this,  there  is  often  a  production 
new  bone  from  the  periosteum,  owing  to  the  stimulation  of  the  ost 
genetic  layer,  with  the  resMlt  that  the  new-growth  may  be  more  or  1 
completely  enclosed  within  a  bony  shell.  Not  only  so,  the  cells  of 
tumors  and  of  their  supporting  stroma  show  a  peculiar  liability 
undergo  metaplasia  into  bone,  and  a  more  or  less  perfect  osseous  frai 
work  may  be  produced  within  the  growth.  Sarcomas  and  carclnoi 
are  most' likely  to  manifest  this  tendency.  The  ground  substance 
some  cases  also  undergoes  petrifaction.  i 


Fro.  302 


Spindle-celled  periosteal  Mromna  of  the  Imnd.     (Kmni  the  surgical  clinic  of  ihe  .M.  Ml 

(ienoral  Hospital.) 

Sarconu.— The  most  important  and  frequent  of  the  prinian  \w 
of  bones  is  the  sarcoma.  Of  this  there  are  two  varieties,  the  niiirl'>i 
and  the  periosteal.  The  former  are  rapidly  growing  tumors  wlir  h 
to  produce  great  rarefaction  and  expansion  of  the  shaft  of  the  'in 
bone.  Microscopicallv,  they  are  giant-celled,  round-cellt-d.  pii 
celled,  and  alveolar.  'They  are  dealt  with  more  at  lengtli  rWv. 
(see  p.  234  et  seq.).  •     i     „   i 

The  periosteal  sarcomas  are  usually  of  spindle-  or  mi.\ed-c<  .1   ! 


Sarcoma 


1045 


but  occasionally  are  composed  of  round  cells.  'J'hey  may  be  found  in 
any  part  of  the  skeleton,  but  are  mast  frecjuent  near  the  ends  of  the  long 
bones,  in  the  upper  maxilla,  and  on  the  shoulder  girdle.  The  denser 
forms  are  closely  allied  to  the  fibromas,  and  the  two  conditions  may  pass 
almost  imperceptibly  one  into  the  other.  The  term  epulis  is  applied 
clinically  to  either  a  fibrous  or  fibrosa r- oih!(!,'«  ixriosteal  new-growth 
in  the  buccal  and  nasal  cavities. 


KiG.        I.! 


Spindle-celled  aorccjiiia  .if  ihv  iiiriostrum.     Wiiickel  ijbj    ,\i..  (i,  withfjut  rirular. 
the  dillectiiin  of  Pr.  A.  <1.  Niihcills.) 


(Fmm 


c  of  the  M-'htif.nl 


Periastea!  .sarcomas  ari.se  iif  first  on  one  side  of  the  bone,  and  tend 
gradually  to  envelop  it.  The  underlying  bone  becomes  rarefied  and 
(itstroyed,  or  may,  on  the  contrary,  lie  transformed  into  very  dense 
tissue.  The.sc  tumors  fre<|Uently  j)riHluce  bone  in  the  form  of  plates  and 
spicules  of  osteoid  ti.ssue  without  calcification  (osteoid  samnna).  In 
other  cases  a  (leaser  anastomosing  framework  of  bony  processes  is  pro- 
duced from  which  finer  spicules  and  plates  grow  out  in  a  radiating 
manner  into  the  substance  of  the  softer  tissues  {osteosarcoma,  ossifying 
mmma).  Cartilaginous  and  sanomatous  growths  may  be  combined 
{rliiindrosarcoma),  or  cartilage,  bone,  and  sanoma  (choiidroosteosnrcoma). 

.\n  important  clinical  tyjX"  in  the  giant-celled  sarcoma,  which  origi- 
nates on  the  alveolar  process  or  in  the  antrum  of  Highmore.  It  is 
siiKill,  firm,  and  relatively  slow  gmwing,  and  is  one  of  the  least  malig- 
nant forms  of  the  sareomas,  sintr  when  removed  it  does  not  always 
recur. 

Macroscopically,  it  is  dense  and  fibrous  and  of  sessile  form.     On 


1046 


THE  BONES 


::iJikr 


•M.k 


section  it  is  of  a  brick-red  color,  owin^  to  the  fact  that  hemorrhage  into 
its  substance  is  common.  Microscopically,  it  consists  of  fibrous  tissue, 
with  masses  of  spindle  and  multinucleated  giant  cells. 

The  myeloma  is  a  peculiar  and  interesting  tumor  of  bone  described  at 
length  elsewhere  (p.  236). 

Osteoma.— Of  the  benign  growths,  perhaps  the  conmionest  is  the 
osteoma.  It  is  not  always  possible  to  draw  the  line  between  osteo- 
phytes and  hyperostoses  of  inflammatory  origin  and  tumors  proper. 
The  true  osteomas  are  usually  found  in  early  childhood  or  durinR  tlie 
developmental  period  of  life,  and  may  even  be  inherited.  Especially 
when  the  exostoses  arc  :aultiple,  or  derived  from  cartilage,  it  is  likely 
that  they  are  due  to  some  aberration  in  the  growth  of  the  skeleton,  for 
in  such  cases  other  disturbances  of  development  are  apt  to  be  present. 
Osteomas  are  formed  from  the  periosteum  (exostoses)  or  from  the  bone- 
marrow  (enostoses).  They  may  arise  also  by  metaplasia  from  fibrous 
tissue  or  cartilage. 

According  to  their  structure,  osteomas  may  be  divided  mto  two  forms, 
one  composed  of  den.se  compact  bone — osteoma  eburneum;  the  other 
formed  of  cancellous  bone — osteoma  spongiosum.  Small  exostoses  are 
rounded,  conical,  nodular,  or  fungoid  in  appearance,  while  the  larger 
ones  are  bulbous,  warty,  irregular,  or  even  pectinate.  The  fibrous 
exostoses  develop  especially  in  connection  with  the  bones  of  the  skull 
and  the  flat  bones  of  the  trunk,  and  the  cartilaginous  ones  at  the  diaphy- 
seal ends  of  the  long  bones.  Occasionally,  in  the  case  of  exostoses  near 
a  joint  one  sees  a  closed  membranous  sac  resembling  a  bursa,  and 
structurally  similar  to  the  synovial  membrane,  associated  with  the 
tumor  (exostosis  hursata).  This,  rarely,  contains  free  bodies,  and  is 
supposed  to  be  derived  from  the  cartilage  of  the  joint  or  a  misplaced 

"rest."  ^      ,.  ,        ,    u 

The  enostoses  are  found  most  frequently  m  the  diploe  of  the 
calvarium  and  in  the  bones  of  the  face. 

Chondroma.— Chondromas  are  lobulated  tumors,  composed  usually 
of  hvaline  cartilage,  and  are  enveloped  in  a  fibrous  capsule  which  sends 
prolongations  into  the  substance  of  the  growth.  They  are  asunlly  due 
to  some  disturbance  in  the  development  of  the  growing  bone  ^vh(•reby 
portions  of  the  primitive  cartilage  become  displaced.  They  may  origi- 
nate in  the  periosteum  and  medulla  as  well  as  from  the  cartilage.  A(  ( ord- 
ing  to  their  position  on  the  surface  of  the  bone  or  within  its  mtenor, 
we  may  make  a  division  analogous  to  that  of  the  osteomas,  into  rv<-hon- 
dromas  and  enchoiidromas.  They  are  found  most  frequently  in  ,  hildren 
and  young  growing  persons,  and  may  be  congenital.  As  a  rule  th.v  are 
multiple,  and  are  met  with  most  commonly  on  the  bones  of  th.'  liancis 
and  lower  extremities,  less  frequently  on  the  trunk,  and  -still  more 
rarely  on  the  calvarium.  They  are  particularly  liable  to  underi;.)  ntro- 
gressive  manifestations,  such  as  fatty  and  mucinous  <Kk'  '^ •'«•"" 
(myxochondroma)  calcification,  and  liquefaction,  with  the  form  I'l-not 
cysts.  Metaplasia  into  bone  not  infrequently  takes  plact  ."»"'- 
chondroma,  osteochondroma).    Sarcomatous  transformation  is  al     nniet 


1048 


THE  BONES 


•1     ■    "'•    '* 


'   Lipoma. — Lipomas  are  extremely  rare.    They  have  L.-'cn  known 
arise  from  the  periosteum,  and  are  often  associated  with  striated  nnisc 
fibers  (Sutton). 

Angioma. — Pure  angioma;  are  also  excessively  rare,  but  have  he 
described  in  connection  with  the  vertebrae  f.  irchow),  the  calvariui 
femur,  sternum,  and  palate  (P^an).  Combinations  of  angioma  \vi 
endothelioma,  chondroma,  and  osteoma  have  also  been  recorded. 

Fio.  305 


Section  from  ■  hemangio-emiotlielioma  <if  Ixinr.  n,  large  vascular  spare',  filled  with  .ijtl 
cytea  and  surrounded  by  large,  clear,  cubical  endothelial  cells,  which  in  parts,  as  at  e.  Icriu  i 
masses;  6.  stroma;  d,  larger  and  c,  smaller  bloodvessels,      iDrieraen.) 

The  secondary  tutors  of  the  bone  are  the  carcinoma  and  sarcoi 
The  latter  are  rare  and  usually  of  the  melanotic  variety.  Tlie  \>i 
thelial  angiosarcomas,  more  especially  those  of  the  thyroid,  kiiliu\ ,  a 
suprarenal,  are  particularly  liable  to  produce  metastases  in  tlie  lnn 
which  take  the  form  of  vascular  pulsating  growths,  strongly  sut:<;(-.li 
aneurisms. 

Carcinoma  arises  by  the  direct  extension  of  a  .ircinoniii,  of  i 
adjacent  soft  parts  or  by  metastasis,  and  forms  either  a  diffused  iiitilt 
tion  or  a  nodular  growth.  Metastatic  carcinoma  is  .said  to  lie  w 
frequently  secondary  to  carcinoma  of  the  breast,  prostate,  tiiMi 
and  bronchi.  The  bones  involved,  according  to  v.  Reckllnf;li nii 
are,  in  order  of  frequency,  the  vertebrre,  femur,  ribs,  sternum,  Innnir 
and  cranium.  The  secondary  deposits  are  usually  to  be  found  in  ili 
parts  of  the  bones  which  are  subject  to  the  greatest  traction  or  yn  ■  ,\: 
Retrograde  metastasis  to  the  head  of  the  humerus  is  occasioiiiill  i 
with  in  carcinoma  of  the  breast. 

Carcinomatous  infiltration  is  usually  associated  with  a  mark.l  fi 


T5 


104d 


»n  known  ui 
riated  nnisc  Ic 


liferation  of  the  periosteum  and  bone-marrow,  while  the  bone  itself 
undergoes  lacunar  resorption  and  finally  disintegration.  Occasionally, 
the  process  of  lacunar  resorption  is  associated  with  the  formation  of 
new  osteoid  tissue  devoid  of  lime  salts  (carcinomatous  osteomalacia)  or 
ii'ue  bone.  In  this  ca.se  the  medullary  spaces  of  the  osteoid  or  bony 
substance  are  infiltrated  with  carcinoma  cells. 


Fio.  aod 


lleii  nitli  ti>lhri- 
as  al  e,  li'Mu  luliii 


I,  kithu'v,  iind 

in  the  lnme.s 

jly  .suj.'<;«>linf,' 


Seciinfiary  carriiinma  of  the  head  of  the  humeriu.     (From  the  Pathoiogieal  Mtiaeum  of 
McGill  University.) 

Cysts. — Cysts  are  usually  due  to  softening  of  portions  of  solid  tumors, 
as  tlie  chondroma,  myxoma,  and  sarcoma.  Colliquative  cysts  are  some- 
times also  found  in  osteomalacia  and  osteitis  deformans. 

True  cystomas  are  rare  except  the  variety  known  as  the  dentigerous 
('■iMoma  found  in  the  maxilla.  This  is  supposed  to  originate  in  the  mis- 
placed matrix  of  a  tooth. 


ri 


THE  JOINTS  AND  CAETILAOIS. 


.V  joint,  or  diarthrosis,  is  an  association  of  two  or  more  bones  in  such 
a  way  that,  while  they  are  closely  appro,  imated  and  held  together  by 


1050 


THF  JOINTS 


a  capsule,  they  are  separated  by  a  space  so  as  to  permit  a  certain  amount 
of  movement  The  capsule  is  composed  of  dense,  imyielding,  fibrous 
tissue,  lined  by  a  soft,  thin,  and  vascular  membrane  covered  with  flattened 
cells,  known  as  the  synovial  membrane.  The  cavity  contains  a  small 
quantity  of  limpid  fluid,  the  synovia. 

Pathological  changes  affecting  the  joints  may  originate  in  the  synovial 
sac  and  extend  to  the  articular  cartilage,  the  ends  of  the  bones,  and 
even  to  the  surrounding  soft  tissues,  or  arise  by  extension  from  the 
neighboring  structures. 


OOXOWITAL  AMOMALIIB. 

The  anomalies  of  development  occurring  in  the  joints  are  practically 
those  of  the  bones  themselves.  When  certain  bones  are  absent  or 
abnormal  the  associated  joints  are  necessarily  affected.  Of  interest 
from  the  point  of  view  of  orthopedic  surgery  are  such  conditions  as 

Fio.  307 


Double  club-foot  (talipn  v»ru»).     (From  the  turgiMl  clinic  of  the  Montreal  Genersl  Hn 


iiital.) 


genu  valgum  and  v*nun,  morbus  coxa,  duWoot,  spinal  ctiTTatures,  and 
dMocationi.  Some,  at  least,  of  the  cases  of  club-foot  appear  to  hv  due 
to  antenatal  affections  of  the  spinal  cord,  e.  g.,  anterior  poliouivi  litis. 
Genu  valgum  is  occasionally  a  stigma  of  general  infantilism. 

Congenital  Luxation.— Congenital  luxation  most  frequently  involves 
the  hip-joint.     It  is  due  to  hypoplasia  of  the  acetabulum  and  liead 
of  the  femur,  or  to  abnormal  positions  of  the  limbs  and  ex.' 
pressure  during  intra-uterine  life. 


INFLAMMATIONS 


1061 


OIROULATOBT  DUTtTKBANOIS. 

These  are  comparatively  unimportant.  AetiT*  hyptremia  is  met  with 
in  the  early  stages  of  inflammation.  PasiiTt  hyparemia  occurs  under 
the  same  conditions  as  elsewhere. 

Hamoiriitc*  into  a  joint  cavity  is  usually  due  to  trauma,  such  as  a 
sprain,  contusion,  dislocation,  or  fracture.  It  may  also  occur  in  the 
hemorrhagic  diatheses  and  as  a  neuropathic  manifestation.  Small 
effusions  quickly  disappear,  larger  ones  are  oartly  absorbed,  and  the 
remaining  portions  are  substituted  by  fibrou  tissue  derived  from  the 
proliferation  of  the  cells  of  the  synovial  membrane.  The  cells  lining 
the  synovial  sac  also  proliferate  and  may  extend  over  the  clot.  In 
severe  cases  the  clot  may  not  be  entirely  absorbed  and  may  break  loose, 
forming  one  variety  of  "  floating  l)ody"  .n  the  joint.  Not  infrequently, 
consii'rable  reactive  inflammation  is  set  up,  leading  to  the  production 
of  adhesions  and  fibrous  ankylosis. 


DirLAMMATIONS. 

Acute  inflammation  of  the  joints  may  involve  first  and  chiefly  the 
synovial  membrane — acute  synovitis — the  cartilages — chondritis — etc. 
In  severe  cases  not  only  the  joint,  but  the  bones  and  soft  tissues  may 
be  involved — oitoitia  and  periarthritis. 

Acnte  Arthritis  and  Synovitis. — These  disorders  may  be  produced 
by  direct  trauma  or  the  extension  of  inflammatory  processes  from 
structures  near  the  joints.  In  many  cases  there  is  a  hematogenic  origin. 
As  examples  of  the  first  form,  punctured  wounds,  gunshot  injuries,  and 
the  like  may  be  cited;  of  the  second,  the  joint  changes  in  infective 
osteomyelitis;  of  the  third,  the  polyarthritis  of  acute  inflammatory  rheu- 
matism. The  hematogenic  forms  are  in  the  vast  majority  of  cases 
due  to  infective  microorganisms,  and  are  found  in  such  conditions  as 
inflammatory  rheumatism,  septicemia,  gonorrhoea,  scariatina,  measles, 
tv-phoid  fever,  pneumonia,  erysipelas,  and  dysentery.  In  the  diseases 
just  mentioned,  the  inflammation  of  the  joints  is  in  some  cases  due  to 
the  specific  microorganism  of  the  disease  in  question,  but  not  infre- 
(juently  to  secondary  infection  with  pus-producing  cocci. 

In  the  milder  grades  of  inflammation,  and  in  the  early  stages  of  the 
severe  forms,  the  synovial  membrane  is  congested  and  swollen,  especially 
about  the  folds,  and  there  may  be  occasional  small  extravasations  of 
tilood,  with  exudation  of  thin  yellowish  fluid  containing  a  few  delicate 
flocculi  of  fibrin  (leroni  synovitis,  hydrops  artienli).  This  form  is  apt  to 
l><>  lighted  up  by  trauma,  such  as  sprains  or  contusions,  floating  bodies 
iti  the  joints,  and  occurs  also  in  the  lighter  grades  of  inflammatory  rheu- 
matism, gonorrhoea,  and  osteomyelitis.  Swelling  of  the  joint  results, 
« ith  possibly  some  redness.  In  more  severe  cases  the  exudate  is  more 
al)undantly  fibrinous  (lynovltii  leroflbrinoM),  and  in  some  instances 
t'le  exudate  may  be  mainly  fibrin,  with  but  little  fluid  (lynbvitii  Hbrinosa 


1052 


THE  JOINtS 


sive  liecft).  In  other  cases  the  effusion  may  become  purulent  or  ma; 
have  been  purulent  from  the  start  (qnwTitii  pomltnU,  •mnrama  artieulij 
Here  the  synovial  membrane  is  thickened  and  swollen,  infiitratei 
with  inflammatory  products,  and  covered  with  a  fibrinopurulent  o 
purulent  deposit,  while  the  cavity  of  the  joint  contaiiis  a  variable  quantit; 
of  turbid  fluid.  In  the  severest  forms  the  synovial  membrane  may  h 
partially  destroyed,  and  the  articular  cartilages  undergo  fatty  degenem 
tion,  fibrillation,  and  ultimately  necrosis.    The  whole  joint  may  in  tini 

Fia.  308 


Chniriic  nsteoarthritin  of  the  knw  m  a  li./rie.     iFrom  the  P»thcilo«;io»l  Museum  uf 
McGill  University.) 

Ijecome  disorganized.  The  process  frequently  extends  to  the  cxiin,r 
ends  of  the  bones,  the  soft  tissues,  and  along  the  lymphatics.  The  |>i 
may  burrow  widely  along  the  lines  of  least  resistance,  and  gmcr. 
infection  may  be  set  up.  Osteomyelitis  or  lymphangitic  al)s<tsst 
sometimes  also  result.  This  form  is  the  one  most  commonly  seen  a^ 
pomplipation  of  pyemia,  measles,  scarlatina,  and  puerperal  infecti  !: 

Acute  synovitis  and  arthritis  frequently  heal,  leaving  little  ci  ti 
trace,  or  may  pass  on  into  a  chronic  condition.  Not  infrequ'  il; 
where  there  has  been  necrosis  of  the  structures  composing  tlif  hi 
more  or  less  fibrous  proliferation  takes  place  in  the  process  of  i. ;  a 


OOUT 


1053 


and  osteophytic  outgrowths  may  form  about  the  joints,  so  that  ankylosis 
occasionally  results. 

A  peculiar  form  of  polyarthritis  is  occasionally  met  with  in  children, 
which  is  apparently  of  an  infective  nature.  It  runs  a  low  febrile  course, 
and  the  joint  manifestations  are  accompanied  by  enlargement  of  the 
lym]  t-nodes  and  spleen.     It  is  known  as  Btill't  diiMia. 

AiJiritii  Urlca. — Arthritis  urica  (gout,  podagra)  is  a  form  of  acute 
inflammation  due  to  the  deposit  in  the  joint  and  adjacent  structun> 
of  salts  of  uric  acid,  together  with  phosphate  and  carbonate  of  lime 
and  i'i^ipuric  acid.  These  salts  are  precipitated  in  the  form  of  fine 
needles  und  granules,  not  only  in  the  cells  and  matrix  of  the  cartilages, 
liut  also  in  the  r^novial  membranes,  ligaments,  and  soft  tissues.  This 
leads  to  irritation  and  inflammat  <ry  infiltration,  with  the  exudation 
nf  a  serous  fluid  into  the  joint.  The  metatarsophalangeal  joint  of  the 
great  toe  is  first  involved,  but  other  joints,  as  those  of  the  fingers,  hands, 
and  knees,  may  be  involved.  It  is  characteristic  of  the  dis(;ise  that 
it  tends  to  relapse  and  in  time  leads  to  chronic  changes  in  the  joints. 
Between  the  acute  paroxysms  the  pain  and  swelling  subside,  but  the 
chalk-like  deposit  still  remains  upon  the  cartilages.  In  severe  or  pro- 
longed cases  the  articular  cartilages  eventually  undergo  necrosis  and 
(iisintegrate,  the  synovial  membrane  becomes  thickened,  and  the  salts 
may  l)e  deposited  in  such  quantities  as  to  form  concretions  (chalk- 
f/o/iM,  tophi).  The  tendons,  periasteum,  and  Iwnes  may  l)e  similarly 
involved.  The  deposit  may  be  so  great  that  the  .soft  parts  necrose 
and  the  chalk  presents  externally.  Ulceration  and  abscess-formation 
are  common.  Wiile  the  joint-changes  constitute  a  striking  picture 
ill  the  disease,  they  form  only  one  aspect  of  the  affection,  which  is  a 
systemic  one,  due  to  disordered  metabolism.  Arterial  sclerosis,  digestive 
disorders,  skin  eruptions,  and  degenerative  changes  in  the  kidneys 
are  frequent  accompaniments. 

Chronic  Inflammations. — In  the  present  state  <if  our  knowledge  it  is 
impossible  to  make  an  entirely  satisfactory  classification  of  the  chronic 
morbid  processes  affecting  the  joints.  There  are,  it  is  true,  certain 
l)road  generalizations  which  enabl'  us  to  differentiate  anatomically 
several  forms  in  a  rough  way,  but  ail  po^ible  combinations  and  inter- 
mediate gradations  exist.  Yet  we  are  often  in  the  dark  as  to  the 
etiological  factors  at  work  in  certain  cases,  and  even  when  these  are 
known,  they  at  times  give  rise  to  widely  differing  anatomical  pictures. 

In  general  we  may,  perhaps,  divide  these  processes  into  the  inflamma- 
liirij  and  the  degenerative.  The  former  group  includes  those  due  to  all 
forms  of  infection,  traumatism,  gout,  and  toxic  causes.  The  latter 
embraces  the  senile  and  neurotrophic  forms.  Inasmuch  as  in  the  latter 
grmp  the  inflammatory  featur-j  are  comparatively  trifling  and,  indeed, 
SI  inetimes  in  abeyance,  it  is  open  to  debate  whether  they  are  properly 
to  lie  regarded  as  inflammatory  or  whether  they  should  not  be  classed 
with  the  retrogressive  metamorphoses.  The  leading  fomts  will  be 
fi'ind  in  the  accompanying  table: 


1054 


THB  JOISTS 


A.  Infl»i.ini»tory 


Chronic  ArtbritU 


(a)  Exudativ* 


(I.  Arthritb MTOM. 
3.  Arthritia  puruknta 

3.  Arthritii  uriea. 

4.  gpMifie:    tub«rcul<> 

■ia,  lypbilu,  aetin 
omyeoMs. 


.  B.  Degenerative 


(b)  Productive    or 
hyftrpUutie 


(a)  SttuU  . 


ankylop 
rheumat 


1.  ArtbritU 
etiea. 

2.  Arthritia 
ica. 

,3.  Arthritia  deformani 

Arthritia  uleeroaa  lioei 

I  1.  Tabee  donalia. 
„  ^  .,  ,  i  •  •  2.  Syriwtomvelia. 
(b)  Sewrolrophte in  |  3   Acutoanterior  polic 

I.        myeliti*. 


OhroBie  8«rau  Arthrttii.— Chronic  serous  arthritis  is  a  somewha 
sluggish  affection  chi  -acterized  by  the  effusion  of  a  thin  serous  exudatt 
The  affection  results  from  an  acute  or,  more  often,  a  recurring  synovitis 
The  knee  is  affeited  most  frequently,  and  next,  the  shoulders,  hips 
and  eUwws.  The  lesioas  may  be  bilateral  or  unilateral.  The  effusio 
in  some  instanc-es  may  be  so  great  that  the  synovial  membrane  is  force 
out  through  the  fibers  of  the  capsule  in  the  form  of  hernial  protrusions 
The  changes  in  the  synovial  membrane  and  the  cartilages  are  ofte 
comparatively  trifling  but  in  long-standing  cases  the  capsule  may  Ik 
come  thickened  and  ^^rtilages  fibrillated.  The  folds  and  frin>,'e 
of  the  sv.iovial  meml>-.  .»e  are  enlarged  and  vascularized,  and  soint 
times  extend  as  a  panniis  over  the  articular  surfaces.  The  affectio 
frequently  follows  exposure  to  cold  in  those  of  a  rheumatic  tendency 
but  often  also  traumatism,  as  in  contusions,  sprains,  and  the  incarcen 
tion  of  synovial  fringes  or  free  bodies  in  the  joint. 

Chronic  SnpparatiTa  Arthritii. — Chronic  suppurative  arthritis  resuli 
from  hematogenic  infection,  traumatism,  or  the  extension  of  disea> 
from  the  adjacent  parts.  The  cavity  of  the  joint  is  filled  with  purulei 
ir  seropurulent  fluid,  and  there  is  a  deposit  of  fibrin  and  pus  on  tli 
synovial  membrane  and  the  surface  of  the  cartilages.  The  cartilafj* 
show  cloudiness,  fibrillation,  and  various  grades  of  degeneration,  amouir 
ing  sometimes  to  necrosb.  The  synovial  membrane  and  the  capsule  ai 
infiltrated  with  inflammatory  products.  Not  infrequently,  the  inHun 
mation  extends  to  the  bone  and  the  surrounding  soft  tissues.  In  th 
way  caries  and  necrosis  may  be  brought  about  and  abscess^fomiatic 
in  the  capsule  and  its  neighboriiood.  Healing  takes  place  by  the  exfolii 
tion  of  (kad  bone  and  cartilage,  the  absorption  of  the  exudate  and  1 
discharge,  the  production  of  new  bone  from  the  periosteum  and  Um 
marrow.    Fibrous  and  bony  ankylosis  not  infrequently  result. 

Obronie  Ctonty  Arthritto.— Chronic  gouty  arthritis  has  been  sufiici.  iit 
referred  to  in  discussing  the  acute  form. 

TnbercnloiU.— Tuberculous  arthritis,  in  so  far  as  the  dime 
features  are  concerned,  may  occur  as  a  primary  disease.    In  tlii     a 


TVBERCVLOaia 


1055 


ilceroia  lieea. 


the  infection  is  hematof^nic  in  origin.  How  tliis  ia  brought  about  ia 
not  clear,  but  it  is  possible  that  the  bacilli  of  tuberculosis  may  enter 
at  some  point  in  the  respiratory  or  alimentary  tracts,  and,  without  causing 
a  local  lesion  at  the  point  of  invasion,  may  on  occasion  be  carried  to 
some  distant  point,  as,  for  instance,  a  joint.  It  is  much  more  probable, 
however,  that  there  is  some  local  focus,  either  obvious  or  concealed, 
from  which  the  infection  proceeds.  As  has  be  -^  demonstrated  con- 
clusively by  the  experiments  of  SchUller  and  Krause,  among  others, 
a  slight  injury  to  a  bone  or  joint  will  detenr  ine  the  localization  of  the 
germs  at  that  point.  In  the  majority  of  cases,  two-thirds  according 
to  Krause  and  Kttnig,  the  affection  of  the  joints  arises  by  the  extension 
of  previously  existing  tuberculous  disease  of  the  bones.  In  discussing 
tuberculosis  of  bone,  it  was  pointed  out  that  the  disease  most  frequently 
occurs  at  the  ends  near  the  epiphyseal  junction,  so  that  involvement 
of  the  joint  is  readily  brought  about.  In  other  cases  it  is  probable 
that  infection  takes  place  bjr  way  of  the  lymphatics.  The  progress 
of  the  affection  is  characteristically  sluggish,  and,  while  ofi  t  unattended 
by  distressing  subjective  symptoms,  may  in  time  lead  to  destruction 
and  complete  disorganization  of  the  joint.  The  disease  is  pre^minendy 
one  of  the  developmental  period  of  life,  for,  according  to  Gibney,  about 
84  per  cent,  of  cases  are  found  in  persons  under  fourteen  years  of  age. 

It  usually  begins  by  the  production  of  minute  tubercles,  which  in 
course  of  time  increase  considerably  in  size  and  number.  In  acuie 
miliary  tvberculont  of  the  synovial  membrane,  which  is  but  one  mani- 
festation out  of  many  of  a  systemic  distribution  of  the  bacilli,  com- 
paratively few  tubercles  ma;  be  produced,  and  there  may  be  little  or 
no  inflammatory  reaction  of  any  moment  in  the  joint. 

In  other  cases,  where  the  foci  are  more  numerous,  the  synovial  mem- 
brane b  reddened,  swollen,  infiltrated  with  inflammatory  products,  and 
is  converted  into  a  soft  greyish-red  granulation  tissue  containing  abun- 
dant tubercles  {arthUis  granulosa).  There  is  frequently  an  exudation 
into  the  joint  cavity  of  a  serous  {hydrops  articuli  tuberculosvs),  sero- 
fibrinous, fibrinopurulent,  or  purulent  exudate  (empycema  tvberculosum). 
More  or  less  abundant  shreds  and  flakes  of  fibrin  cover  the  granulation, 
and  the  so-called  "rice-bodies"  (corpora  oryzoidea)  may  be  foimd  in 
the  joint.  These  bodies  are  smooth,  soft,  and  rather  elastic,  of  a  gelati- 
nous, whitbh  or  grayish-white  appearance.  On  section  they  present 
a  concentric  lamination.  They  are  supposed  to  be  derived  from  fibrin 
or  bits  of  synovial  fringe  that  have  become  detached  and  have  under- 
gone hyaline  degeneration.  The  synovial  membrane  may  undeigo 
a  simple  inflammatory  proliferation  and  may  extend  into  the  joint 
ill  the  form  of  folds  or  villi  of  an  oedematous  or  gelatinous  appearance. 
Op,  again,  there  may  be  papillary  'n  oolypoid  thickenings  of  the 
membrane.  Tubercles  situated  beneatn  the  sy^r.ial  membrane  may 
in  the  course  of  their  growth  invade  the  cavity  of  the  joint  (arthritis 
nodosa  or  tuberosa).  In  other  cases  the  tubercles  are  extremely 
minute,  perhaps  not  visible  to  the  naked  eye,  nd  the  membrane  b 
only  slightly  thickened.    A  layer  of  vaacular  granulation  tissue  b 


1066 


THE  JOISTS 


formed  from  the  synovial  mc  and  spwads  gradimHy  over  the  artinilii 
.urfaces,  converting  the  cartilage  into  coniM^ctive  tiiwue  {aynomta  ,^w 
nota).  In  cases  where  the  gianulation  tissue  exten<U  to  tlie  tarliluK. 
and  remains  in  contact  with  them,  disintegration  and  nlMorptioii  »f  I h 
cartilage  tak-.'s  place,  with  destruction  of  the  cartilage  «flls  and  tl. 
invasion  of  the  cell  capsules  with  inflainnmtory  leukwytes.  l-.»t.i 
the  cartilage  mav  be  invaded  by  vessels,  ami  uiulergoes  a  {wtcliv  mi 
mucinoas  degeneration  or  U  converted  into  loose  fibrous  tissue,  bium 
ta.KH)uslv.  resorption  of  the  neighboring  bone  may  take  pluc-e.  lli 
advanciiig  laver  of  the  granulation  tissue  ewroaches  uiK)n  t!ie  nUori. 
at  the  ec^  of  the  cartilages,  gradually  dissecting  them  away  fnHn  tl, 
deeper  Vmictures  and  finally  extending  to  the  l)one  ami  the  mwliiilai 
cavity.  The  medullary  substam*  loses  its  fat  and  is  <onvert«l  ml 
a  vascular  lymphoid  marrow.  ,      .  .      ,  ■         ■ 

.\.s  a  confluence  of  these  changes,  the  joint  l^^-omes  enlarp.  .i.i 
presents  a  pile,  smooth,  rather  shin/  anpearance  {wh,e  «»•</<». 7 
Sooner  or  later,  the  process  extends  from  the  cartilage  and  Ikmh-  k.  tl 
surrounding  soft  tissues.  Caseoas  mxlules  are  foriiie.1  which  coalc, 
and  break  down  int..  tubereulous  or  "col.l"  abscesses.  lltpt-  uu 
enlarge  and  burrow  their  way  to  the  surface,  and  hstuJ.c  result.  I 
ioint  mav  lie  disorganized  to  such  an  extent  that  disl<Kution  of  tl 
lK>i.es  fakes  pla<  e.  When  the  pnK-ess  tends  to  heui.  nu.ncrous  ost.- 
phvtes  are  pn«l.ue(l  in  the  neigiiborhood  <.f  the  .liseas«Ml  purt.  ai 
fibrous  or  fibroiisseous  ankylosis  may  result. 

(Comparatively  few  bacilli  are  to  !«  found  in  the  effusion,  I. iit  it 
iLsuailv  possible  to  produc-e  tulierculosis  in  susceptible  aiiiinals  .y  tl 
injection  of  the  flui.L  Further,  as  the  studies  of  Urtigau  have  .i.-iiu, 
strated.  bacilli  mav  l.e  .letected  in  a  joint,  even  where  the  disease  I, 
apparently  healed,  and  may  be  of  a  comparatively  high  grade  of  vn 
lence  Thus,  the  disease  may  !«  disseminated  to  <lisfaiit  parts  or  l.n 
out  again  after  months  or  years.  The  joints  usimllv  affeetnl  an-  t 
hip  vertebne.  knee,  ankle,  shoulder.  cUk.w.  tarsus,  and  cari.us. 

SypWlii.  — In  congenital  syphilis  an  extulative  arthritic,  «smhu.i 
with  thickening  of  the  capsule  and  disintegration  of  the  .artilM- 
(Kcurs  as  a  primary  affection  or  follows  osteochondritis,  (.imiu.;.^ 
neighboring  parts  may  extend  to  the  joint.  ,     ■       .. 

In  acfiuired  s\-philis  the  joint  changes  may  appear  during  the  ihti 
of  eruption  or  in  the  later  stages.  In  the  first  event  then;  is  pr.«hH 
a  diffuse  serous  synovitis,  not  unlike  that  of  acute  rheumatism.  Kan 
a  similar  state  of" things  may  be  observe.1  in  late  syphilis,  but  it  i>  in. 
common  to  find  gummatou-s  infiltration  of  the  capsule  with  thuk.  n 
of  the  capsule  and  synovial  sheath,  together  with  erosion  an.l  lil-nl 
tion  of  the  cartilages.  These  changes  may  be  primary  or  w.r. 
secondary  to  specific  inflammation  of  the  periosteum  and  \mnvny.nn 
Aetinomy«»»i«— P"™"y  actinomycosis  of  the  joini.s  is  in.|.i- 
The  affection  usually  arises  by  metastasis  or  extension  from  ne.-h  ■ 
ing  parts.  The  cervical  vertebrse.  the  elbow,  the  tibiotarsal,  ani  n 
joint  have  been  found  involved. 


ARTHKITIS  DEFORMANS 


1057 


Artbrttli  ukytepMilM  ehroaiM  is  a  peculiar  anatomiiil  fumi  of 
arthritis  due  to  various  etiological  causes,  l^ie  inain  features  are  the 
formation  of  adhesions  between  the  cartilages  with  vascularization  ami 
fibrous  transformation  of  the  cartilages.  'Vhr  condition  may  result 
from  acute  exudative  inHammation,  and  tuberculosis  or  other  chn>ni«' 
destructive  affectiuiLs. 

In  the  earlv  stages  the  synovial  membrane  is  lomewhat  injected  anti 
thickened,  while  the  surface  of  the  cartilages  i.<  'lugh  and  fibrillated. 
The  cartilages  are  here  atnl  there  vascularized  anu  e  opposing  surfaces 
lire  more  or  less  adherent.  The  deeper  layers  of  the  cartilages  are  also 
gradually  converted  into  medullary  spaces  through  resorption  brought 
iiiiout  by  the  encroachment  of  the  sul>chondral  nie<lullary  sulMtance. 
.S«»me  of  the  islets  «)f  cartilage  thus  isolated  may  in  time  \ie  converte*! 
into  bone.  Thus,  the  cartilages  are  gradually  tmasfomied  into  a  va.scular 
lihrous  or  fibroiisseous  tissue.  The  joint  cavity  is  traversed  by  clense 
Kbroas  hanos  and  is  converted  into  a  number  of  small  spaces,  iNiunded 
by  dense  fibrous  tissue  and  containing  synovial  fluid.  In  verv  advanced 
iiises  the  whole  of  the  articular  cart'laeie  i  lay  disappear  and  \>e  replace<l 
l)y  fibrous  tissue,  so  that  the  origif  "  cture  of  the  joint  l)ecomes  well- 
nigh  unrecognizable.  Not  only  s  i  he  newly  forme<l  fibmus  tissue 
may  in  time  be  converte<l  into  .ass  of  spongy  bone  unil  complete 
iisseous  ankylosis  result. 

Poljrarthritii  Olironiea  Shtnmatiea.  The  disease  commonly  known 
iis  chronic  rheumatism,  or  polvarthritis  chronica  rheumatica,  is  of  some- 
vvliat  uncertain  etiolog_v.  It  is  found  commonly  in  old  persons,  ami 
may  result  from  repeat^l  attacks  of  aiute  rheumatism  or  may  come 
i>n  insitliously.  It  usually  Itegins  in  the  phalanges  or  metacarpal  and 
(iiq>al  l>ones,  but  the  larger  joints,  such  as  the  knees  and  ankles,  are 
'H>t  infretjuently  involved.    The  disease  is  iLsually  steadily  progressive, 

ronic  in  its  course,  occasionally  with  acute  exacerbations,  and  leads 
Hi  more  or  less  limitation  of  movement.  Proliferation  of  Ijonc  is  rather 
marked,  .so  that  the  affection  presents  a  rliwe  resemblance  to  arthritis 
ilt'formans. 

Arthritis  Daformant. — Arthritis  deformans  (rheumatoid  arthritis,  rheu- 
matic gout,  arthrite  s^-he)  is  a  rather  common  disease  of  the  joints, 
I  haracterized,  on  the  one  hand,  by  degenerative  changes  in  the  articular 
cartilages  and  bone,  and,  on  the  other,  by  a  marked  prtxluction  of  new 
lione.  The  dLsease  may  he  monarticular,  but  is  more  usually  poly- 
articular. It  has  been  known  to  follow  repeated  traumatic  insults, 
fractupes,  or  infectious  disea.se,  or,  rarely,  is  spontaneous.  The  affection 
l«';:in3  usually  in  the  third  decafle  of  life  or  later,  and  may  run  a  chronic 
loiirse  for  many  years,  with  occasional  acute  exacerbations.  It  has 
Ixin  known,  however,  to  attack  young  children.'  Women  are  more 
ciiiiimonly  affected  than  men  (1  to  5).  The  etiology  is  quite  obscure. 
S  iinc  have  regarded  it  a.s  neuropathic  in  nature,  on  the  analogy  of 


ir 


XichoUs,  Rheumatoid  Arthritis  in  Young  Children,  Montreal  Medical  Journal, 
lS9«-97:97. 
67 


1058 


THE  JOINTS 


Charcot's  joints.  This  is  supported  by  the  fact  that  muscular  wasting. 
contractures,  glossiness  of  the  skin,  and  paresthesia  are  frequently 
observed.  Others  regard  it  as  a  degenerative  process,  a  mark  of  actual 
or  premature  senility.  Certain  recent  observers  have  found  in  the 
synovial  fluid  of  these  cases  cocci,  which  they,  on  experimental  grounds, 
lilieve  to  be  specific.  The  proof  of  this,  however,  is  not  as  yet  conchi- 
sive  Considering  the  fact  that  certain  cases  begin  acutely  or  present 
acute  exacerbations,  it  is  not  impossible  that  some  at  least  are  infective 
in  nature.  The  close  relationship  to  gout,  which  used  to  be  insistea 
upon,  is  now  no  longer  accepted.  Lately,  the  view  has  been  advanced 
that  arthritb  deformans  b  due  to  a  toxin  of  enterogenous  nature. 

Anatomically,  the  lesions  produced  may  be  summed  up  as  dcpenera- 

tion  of  the  cartilages,  together  with  the  formation  of  new  bone-marrow 

and  osteophytes.     Considerable  deformity  of  the  joints  results    with 

more  or  less  complete  limitation  of  movement.    The  superficial  layers 

of  the  articular  cartilages  become  fibrillated  and  fissured,  while  in  the 

deeper  parts  there  are  areas  of  necrosis  and  softening.     Further,  owing 

to  some  stimulation,  the  bone-marrow  begins  to  proliferate  and  a  new 

vascularized  marrow  invades  the  deeper  layers  of  the  cartilage  ami 

grows  into  the  degenerated  areas  just  referred  to.    The  inter%ening 

cartilage  that  remains  is  gradually  converted  into  osteoid  tissue  and 

eventuallv  into  »)one.    Sometimes  there  is  an  overgrowth  of  the  cartilage, 

leading  to  the  formation  of  nodular  excrescences,  which  may  in  time 

project   into  the   medullary  spaces.    Coincidently  with   the  changes 

nist  described,  the  joint  capsules  and  the  synovial  membranes  beioine 

thickened.     Occasionally,  the  folds  and  fringes  of  the  latter  encnmth 

upon  the  joint  cavity  and  are  infiltratetl  with  fat,  forming  the  soK'alled 

lipoma  arbarescens.     Small  portions  of  the  altered  synovia   membrane 

may  be  converted  into  cartilage  or  bone.    Should  these  break  loose 

they  form  free  bodies  in  the  joint.     In  the  bone  itself  noteworthy  changes 

take  place,  in  the  form  of  resorption  of  the  trabeculse.  resulting  m  .on- 

siderable  loss  of  substance  and  alterations  in  the  shape  of  the  hone 

In  course  of  time  the  newly  formed  osteoid  tissue  in  its  turn  undergoes 

similar  retrogressive  changes.    The  marrow  of  that  part  of  the  hoiu 

near  the  joint  loses  much  of  its  fat  and  is  converted  into  gelatinous  oi 

lymphoid  marrow.     If  the  resorption  of  the  bone  be  extensive  it  may 

be  more  or  less  substituted  by  gelatinous  fibrous  tis.sue.    In  "tlu-: 

cases  the  marrow  softens  and  liquefies,  producing  small  cysts.     lli< 

tissues  bounding  these  cysts  may  proliferate  and  produce  new  Urn 

bv  metaplasia.  ...  .        .         t  .i„ 

'In  couree  of  time  extensive  changes  in  the  size  and  contour  ..f  th 
bone  take  place.  In  the  case  of  the  hipjoint,  for  example,  the  m-H 
of  the  femur  is  more  or  less  shortened,  the  head  is  enlarged,  and  no.Ma 
excrescences  or  osteophytes  form  about  it  and  around  the  edpc  ..f  Hi' 
acetabulum,  ^\^lere  the  cartilage  is  completely  abwrbed  tla-  "M".«< 
bone,  owing  to  pressure  and  friction,  becomes  flattened,  sraootli.  i.iK 
ebumated.  Where  cysts  in  the  bone  are  laid  bare  by  erosion,  im  r-ila 
grooves  and  depressions  are  formed  and  the  bony  surfaces  not  n     •" 


PLATE   XV 


X-rny    Photograph    of    the    Hand,    showing    the   >>hnnqes    in     the 
bones    resulting    troni    rheiirnntoifl    nrlhritis. 


Tile*  <  l(Hl(>CMIi<  III   <>I    the    iihiilaii^le^*    vvMIt   «'ri»»4iiMi   .iiui   i)»«t«*i  ipiiylii 

I  ii.li.ti  .  >  vvtli-  i«ff    \v»*il    ~»*en. 

il'n.iii   111,   I  ir.l.-\'.  Iliiii.-.  \l..riii.:.l  llrtiii.il  ll..-|.il.il  I 


fr:'*i^  -'■:-4.-'    h  ■*  ■ 


ARTHRITIS  CHRONICA  ULCEROSA  SICCA 


1060 


tact  are  covered  by  extensions  of  the  synovial  membranes.  In  this 
way  marked  deformity  of  the  articulations  results.  Ankylosis  is  a 
common  event  due  to  thickening  of  the  capsule  and  the  formation  of 
bony  outgrowths  in  the  capsule  and  along  the  edge  of  the  bone.  A 
common  deformity  is  the  ulnar  deflection  seen  in  the  fingers.  Dis- 
locations of  varioas  kinds  occur. 


Fio.  300 


Spondylitii  deformalii;  curvatun  o(  the  •pine,  with  anliyloaia  due  to  Kubperinsteal 
oateoceneaiii.     (Patholociral  Muaeum,  McOill  Univeraity.) 

Arthritis  deformans  oftenest  attacks  the  hip-joint  and  the  knees,  but  is 
frc(|uently  found  in  the  shoulders  and  elbows  and  in  the  smaller  joints  of 
the  hands  and  feet.  When  the  vertebral  column  is  involved  the  condition 
Is  known  as  spondylitis  deformans.  This  often  leads  to  bowing  of  the 
trunk  forward,  with  limitation  of  movement. 

Arthtitif  Chronica  UlMroM  tUeea.— Arthritis  chronica  ulcerosa 
sicca,  or  senile  arthritis,  is  in  some  ways  not  unlike  arthritis  deformans, 
hilt  the  degenerative  side  of  the  process  is  more  marked  while  the  pro- 


w 


1060 


THE  JOINTS 


liferation  of  bone  and  cartilage  b  less  obtnisive.    As  >ts  name  implies, 
it  is  found  in  advanced  life,  and  is  to  be  regarded  as  a  degenerative 
process   resulting   from   deficient   nutrition.    It   occasionally   follows 
riieumatic  and  other  inflammatory  disturbances,  and  has  been  known 
to  occur  where  the  bones  have  been  kept  for  a  long  time  in  one  position. ; 
In  other  cases  it  is  a  neurotrophic  disturbance.    Most  commonly  the  i 
hip-joint  is  affected  (morhut  coxa  senilis),  but  the  shoulder,  elbow,: 
finger-joints,  and  patella  may  be  attacked.  i 


Via.  310 


CUroof.  joint.     The  illustration  .how,  .1-.  very  well  the  hyperextenwon  of  the  le.  on  .I.-  iW. 
l^rll^  of  the  joint.     (From  the  Medici  Clinic  of  the  Montr..!  G«..r.l  Ho.p,.al  . 

The  lesions  found  consist  in  fibrillation  and  Assuring  of  the  arti.  nla 
cartilages  with  some  superficial  erosion.  At  the  periphery,  when  th 
synovial  membrane  is  attached,  the  cartilage  undergoes  gelatinou.. ... 
fibrous  transformation,  and  may  even  disappear.  In  advanced  rasf.  .n 
whole  of  the  articular  cartilages  may  be  lost,  so  that  the  underljm^  =  .^ 
is  laid  bare.  This  in  turn  may  be  eroded,  or  become  compacte.  n 
eburnated.  The  capsules  and  synovial  membranes  are  frequent  y  tin  - 
ened,  leading  to  capsular  ankylosis.    Occasionally,  instead  of  this    i 


CHARCOTS  JOISTS 


1061 


fibrous  bonda  undergo  uecrcsis  and  disintegration.  Calcification  and 
amyloid  transformation  are  sometimes  to  be  noti'"Kl  in  the  degenerating 
cartilage,  in  the  fibrous  capsule,  and  adhesions. 

MrarvpatUe  Joiiiti. — The  neurotrophic  changes  in  joints  are  of  con- 
siderable clinical  interest  and  importance.  They  are  found  chiefly  in 
tabes  dorsalis  {Charcot's  joints),  syringomyelia,  anterior  poliomyelitis, 
compression  and  destruction  of  the  spinal  cord,  and  after  the  severance 
of  nerves.  As  a  rule,  the  condition  comes  on  quickly,  without  pain,  and 
leads  to  great  e:.'<irgement  of  the  joints,  owing  to  the  accumulation  of  fluid 
within  the  synovial  sac.  Degenerative  changes  are  in  excess  and  quickly 
bring  about  disintegration  of  the  joint.  Besides  this,  there  are  atrophy 
of  the  ends  of  the  bones,  and  sometimes  osteoporosis,  with  erosion  and 
thickening  of  the  membranes.  Spontaneous  luxation  is  common.  In 
tabes,  the  lesion  b  found  chiefly  in  the  lower  extremities,  in  the  knee  or 
hip,  but  the  shoulder,  elbow,  and  smaller  joints  of  the  hands  and  feet 
do  not  escape.  The  condition  is  single  or  multiple.  In  syringomyelia 
the  lesion  occurs  chiefly  in  the  upper  extremities,  depending  upon  the 
site  of  the  disease  in  the  cord. 

PftrasitOS. — Echimx^x.-cus  disease  may  invade  the  joints  from  the 
neighboring  parts. 


RITR00EI8BIVS  METAMORPHOSIS. 


Degenerative  changes  may  affet't  the  articular  .surfaces  or  the  investing 
membranes. 

Degeneration.  —  Fatty  Degeneration.  —  Fatty  degeneration  of  the 
cartilages  is  not  uncommon.  It  occurs  in  general  marasmus  and  as  a 
senile  change,  from  interference  with  the  circulation,  ami  from  inflam- 
mation.   The  fat-globules  are  deposited  within  the  cells. 

B^raUne  DegeneratioB. — In  hyaline  degeneration  the  capsule  may  be 
involved  as  well  as  the  cartilage  and  its  cells.  The  cartilage  is  con- 
verted into  a  homogeneous  semitranslucent  mass,  or  breaks  up  into 
flakes. 

Amyloid  tnuufonnation  is  also  met  with. 

Mucoid  Degonen^on. — The  so-called  mucoid  degeneration  is  a  peculiar 
change  found  principally  in  the  costal  cartilages  of  old  persons  and  also 
upon  the  articular  surfaces  of  the  long  bones.  The  cement  substance 
of  the  cartilage  liquefies  and  the  flbrillie  of  the  matrix  are  dissociated 
or  separated  into  bundles,  giving  the  cartilage  a  curious  fibrillated 
structure.  In  advanced  cases  the  cartilage  may  break  up  into  clumps 
or  fine  granular  detritus.  The  cartilage  cells  are  in  part  destroywi, 
but  those  remaining  proliferate,  so  that  small  clusters  may  be  seen  lying 
within  the  same  limiting  membrane.  At  first  the  cartilage  is  gray  and 
(itiiisparent,  but  later  becomes  strt-aked,  opaque,  ur,  if  calcification 
(K-cur,  dense  and  white.  The  softening  may  proceed  to  such  a  d^pree 
tliat  cysts  filled  with  fluid  are  formed.  The  process  of  softening  is 
frequently  met  with  in  old  age,  and  is  an  important  feature  in  connec> 


1062 


THE  JOINTS 


tion  with  chronic  arthritis.  If  the  degenerated  areas  are  near  the 
medullary  cavity  or  the  perichondrium,  vessels  may  grow  into  them  with 
proliferation  of  cells,  so  that  the  destroyed  parts  are  substituted  by 
fibrous  tissue,  bone-marrow,  and  eventually,  in  some  cases,  with  bone. 
Besides  the  mucinous  changes,  cartilage  may  undergo  a  retrograde 
metaplasia  into  fibrocartilage  and  fibrous  tissue.  This  b  common  in 
connection  with  chionic  inflammation. 

Mecroi^  and  Oariei.— Necrosis  and  caries  of  the  cartilage  occur 
with  suppurative  and  other  forms  of  inflammation. 

Pigmentation.— Pigmentation  of  the  cartilages  is  usually  due  to  the 
absorption  of  the  hematoidin  from  blood  effused  within  the  cavity. 

Oehronoilt  is  a  peculiar  and  rare  condition,  in  which  the  cartilage 
assumes  a  brownish  or  blackish  hue.    The  cause  is  unknown. 

Inflltntion.— In  gont  there  is  a  deposit  within  the  cartilages  and  the 
capsule  of  needles  of  urates.  The  capsule  of  the  joints  may  undergo  all 
the  degenerative  changes  just  described  as  affecting  the  cartilage. 

nUURIU  AHD  THIIB  SIPAIB. 

WTien  a  cartilage  b  injured  there  b  invariably  more  or  less  degenera- 
tion of  the  specific  cells  in  the  form  of  swelling,  vacuolation,  albuminous 
and  fatty  degeneration,  and  even  necrosb.  The  regenerative  power 
of  cartilage  b  slight,  and  only  in  rare  cases  and  in  young  persoas  is 
new  cartilage  formed.  The  repair  b  made  by  cartilage  or  bone.  In 
the  event  of  fracture,  restoration  b  brought  about  by  proliferation  of  the 
t«Us  of  the  perichondrium  producing  fibrous  tissue  and  bone.  In  the 
case  of  the  articular  cartilages,  any  loss  of  substance  b,  as  a  rule  only 
imperfectly  made  good.  Here  repair  takes  place  by  means  of  fibrous 
tissue.  Portions  of  the  articular  and  semilunar  cprtilages,  if  they  break 
loase,  may  become  free  in  the  joint  cavity. 

.Joints  mav  be  injured  by  pnneture,  contwdon,  torrion,  dislocation, 
snblazation,  or  fracture  of  the  bones  within  the  capsule.  The  amount 
of  injury,  of  course,  varies.    The  capsule  may  be  crushed,  pulled  upon, 

or  actually  torn.  .         .  .  ,  ■    ,       i 

In  a  dislocation  the  end  of  one  of  the  bones  forming  a  joint  is  fmiml 
in  an  abnormal  position  outside  the  capsule.  In  subluxation  the  dislo- 
cation b  only  partial.  In  some  cases,  the  articular  cartilages  or  the  in.l 
of  the  bone,  may  be  injured  or  fractured  (complicated  dislocation). 

The  results  of  such  accidents  depend  largely  upon  whether  mf.r- 
tion  takes  place  or  not.  In  the  more  trifling  injuries  recovery  tak.s 
place,  and  restoration  of  function  is  eventually  complete.  In  sev.r.  r 
traumatism  the  changes  initiated  are  not  unlike  those  occumng  m  triK  - 
ture  of  the  bones.  Immediately  following  a  dislocation  or  intracapsiihir 
fracture  there  is  more  or  less  abundant  hemorrhage  into  the  joint.  I  .;ii'i . 
inflammation  sets  in.  The  capsule  and  surrounding  parts  become  swoll^i 
oedematous,  infiltrated  with  inflammatory  products,  and  there  ma\  '»■ 
effusion  into  the  synovial  cavity.  In  simple  non-infected  cases  the  luti'"- 
mation  rapidlv  reaches  its  height  and  then  resolves.    The  effused  !•  - 


INJURIES  AND  THEIR  REPAIR 


1063 


and  the  inflammatory  exudate  are  absorbed.  In  rare  cases  it  happens 
that  portions  of  the  coagulum  may  persist  and  become  organized,  forming 
one  variety  of  "free  bodies"  in  the  joints.  When  the  dislocation  is  re- 
duced, the  tear  in  the  capsule  is  repaired  by  the  formation  of  a  cellular 
material  which  in  time  becomes  differentiated  into  dense  connective  tissue. 
Should  fracture  have  taken  place,  it  heals,  as  do  ordinary  fractures  of  bone 
and  cartilage.  In  time  the  joint  may  return  to  its  normal  anatomical 
condition  and  function  be  perfectly  restored.  Should  reposition  not  be 
effected,  the  capsule  and  ligaments  contract,  the  articular  surfaces 
waste  away,  the  joint-cavity  is  invaded  by  fibrous  tissue,  and  the  dis- 
used muscles  atrophy.  The  end  of  the  dislocated  bone  will  atrophy 
or  become  attached  in  its  abnormal  situation  by  fibrous  tissue.  Should 
it  rub  against  a  bony  surface,  a  new  articulation  in  the  form  of  a  shallow 
socket  is  in  time  produced.  This  is  in  part  due  to  pressure  atrophy. 
Round  about  the  newly  formed  groove  the  bone  proliferates  and  forms 
a  ring.  In  this  way  a  more  or  less  perfectly  functionating  joint  is 
produced.  Useless  muscles  atrophy,  others  become  elongated,  and  the 
soft  tissues  in  time  adapt  themselves  to  the  altered  condition  of  things. 
In  some  cases  a  new  capsule  b  formed  by  the  proliferation  of  celb 
derived  from  the  original  capsule  or  from  the  soft  tissues  in  the  neighbor- 
hood. If  the  dislocated  bone  be  not  movable,  partial  or  complete 
fibrous  or  fibrous  and  osseous  union  takes  place  (ankylosis). 

Where  a  joint  is  resected  the  result  varies  according  to  circumstances. 
The  ends  of  the  bones  at  the  point  of  injury  become  rounded  off  and 
a  proliferation  of  connective  tissue  fron  the  periosteum  and  bone- 
marrow  takes  place,  so  that  the  two  en  ';  are  united  by  fibrous  bands, 
in  which  bone  sometimes  develops.  If  the  parts  be  kept  at  rest,  a  strong 
immobile  union  takes  place.  If,  however,  motion  be  kept  up,  designedly 
or  otherwise,  a  new  joint  results.  In  young  persons  articular  cartilages 
may  be  formed.  In  time,  the  parts  return  in  a  considerable  degree 
to  their  normal  appearance  and  a  capsule  secreting  synovia  may  even 
be  produced. 

As  a  result  of  injuries  and  some  forms  of  inflammation  a  joint  may 
become  fixed — ankylotis.  If  completely  immobile,  the  condition  is 
called  true  or  complete  ankylosis;  if  partially  movable,  false  or  incompUte 
ankylosis.  Ankylosis  is  usually  brought  about  by  the  proliferation 
of  fibrous  tissue  into  or  around  the  region  of  injury.  Should  the  intra- 
articular cartilages  be  preserved  in  whole  or  in  part,  they  sometimes 
undergo  direct  metaplasia  into  fibrous  tissue  or  fibrocartilage,  or  into 
mucinous  tissue,  which  gradually  becomes  fibrous.  In  some  cases 
the  newly  formed  fibrous  tissue  is  trifling  in  amount  and  the  ankylosis 
is  produced  mainly  by  cartilage  or  bone.  In  other  crses  the  ankylosis 
is  due  to  fibrous  tissue  or  cartilage  and  bone  intermingled.  In  still 
another  class  of  cases,  the  interference  with  mobility  is  due  to  some 
cause  outside  the  capsule  (extracapsular  ankylosis),  such  as,  abundance 
of  osteophytes,  for  example,  in  arthritis  deformans;  thickening  and 
contraction  of  the  capsule;  adhesions  of  tendons;  the  formation  of 
bony  bridges;  contractions  and  paralyses  of  muscles. 


1064 


THE  JOINTS 


VROOUUIVI  MRAMOBPHOUf . 

MetepluU.— The  phenomenon  of  metaplasia  is  frequently  exempli- 
fied in  the  case  of  cartilage.  Cartilage  is  rather  an  inert  tissue,  and 
when  destroyed  is  apt  to  be  replaced  by  fibrous  tissue  or  occasionally 
bone.  Ordinary  hyaline  cartilage  in  th-  joints  may  be  transforniod 
into  fibrocartilage  or  fibrous  tissue  in  certain  cases  of  inflammation. 
Mucinous  metaplasia  is  very  common.  Transformation  into  bone 
occurs  both  in  inflammation  and  as  a  senile  change. 

Hypeipiuia.— Hyperplasia,  both  of  the  cartilages  and  the  connective 
tissue  of  joints,  is  a'frequent  event  in  most  forms  of  chronic  inflamma- 
tion, especially  in  tuberculosis  and  arthritis  deformans.  Not  only 
may  the  fibrous  capsule  and  its  synovial  lining  be  diffusely  thic'.rened, 
but  new  cartilage  and  bone  may  be  developed.  The  cartilages  may 
also  be  diffusely  thickened,  or  not^olar  and  papillary  excrescences  may 
be  formed.  Overgrowth  of  the  cartilage  is  seen  also  in  the  hyperplastic 
form  of  that  rare  disease  called  by  Kauffmann  chondrodystrophia  fcDtalis. 

Tomors.— Primary  tumors  of  the  joints  are  rare.  A  curious  form 
is  the  so-called  lipoma  arbareseani,  which  is  rather  common  in  cases  of 
tuberculosis  and  arthritis  deformans.  Here  the  synovial  membrane 
becomes  thickened  and  hypertrophic,  and  is  thrown  into  numerous 
folds  and  papillse,  in  which  fat  is  subsequently  deposited.  Sarcoma 
mav  originate  in  the  capsule. 

The  secondary  involvement  of  a  joint  by  tumors  of  the  adj.xcent 
parts  is  not  uncommon. 


INDEX. 


Abiotrophy,  521 

Abortion,  878 

Abwew  of  lungs,  301 ,  303 

uf  mammary  gland,  N85 

retrumammarj-,  884 

tuboOvarian,  851 
AcanthoHU  nigricans,  908 
Achlorhydria,  358 
Achomlruplasia,  1010 
Acid-fast  Willi,  307,  757 
Acne  of  sebaceous  glands,  976 
Acrochordon,  957,  976 
Acromegaly,  684,  1041 
Actinomycosis  of  bones,  1031 

of  buccal  cnvity,  388 

of  cerebrum,  559 

of  Fallopian  tubes,  847 

of  heart,  149 

of  intestines,  443 

of  joints,  1056 

of  kidnev,  758 

of  liver,  476 

of  lungs,  318 

of  mammary  gland,  888 

of  muscles,  987 

of  oesophagus,  401 

of  pericardium,  140 

of  pharynx,  59S 

of  pia-arachnoid,  548 

of  skin,  924 

of  spleen,  228 

of  stomach,  412 

of  thyroid  gland,  691 

of  tonsil,  395 

of  vulva,  813 
Acute  yellow  atrophy  of  liver,  460 
Addison's  disease,  701,  951 
Adenocele,  895 
Adenoids,  393 
Adenolvmphocele,  210 
Agnath'ia,  381 
Ague-cake,  226 
Agvria,  526 
Amhum,  949 
Air  embolism,  55 
Mbini<<m.  «27.  908 
Albuminuria,  726 
Alopecia,  909 
Amaatis,  883 
Amnion,  878 
Amotio  ntinte,  644 


Amyelia,  527 

Amyloid  bodies  of  prostate,  794 

^  myotrophic  lateral  aclerusis,  59U 

.inasarca,  106 

Anastomoiiis,  34,  37 

Anemia,  aplastic,  94 

of  choroid,  632 

of  heart,  145 

of  liver,  456 

pernicious,  92 

of  spinal  cord,  596 

of  retina,  637 

secondary,  91 

of  skin,  912 
Anencephaly,  524, 526 
Aneurism,  189,  196 
Aneurismal  varix,  199 
An^na  Ludovici,  396 
Angioneurotic  cedema,  113 
of  mamma,  884 
of  skin,  910 
Anidrosis,  973 
Aniridia,  628 
Ankylosis,  1043,  1051,  1053,  1054,  1057. 

1059,  1063 
Anophthalmia,  607 
Anorchidism,  799 
Anorexia  nervosa,  306 
Anthracosis,  307 
Anthrax,  925 
Anuria,  723 
Aorta,  atheroma  of,  194 

atresia  of,  144 

stenosis  of,  144 
Aortitis,  193 
Apneumatosis,  283 

Apoplexia  pulmonum  vascularis,  285 
Apoplexy,  cerebral,  78 

of  uterus,  827 
Appendicitu,  444 
Arcus  senilis,  624 
Arsvria,  526,  631,  763,  951 
Arfainencephaly,  526 
Arrhythmia  of  heart,  125 
Arteriectasis,  197 
Arteries,  190 
Arteriolith,  192 
Arteriosclerosis,  175,  184.  194 
Arteritis,  191 
Arthritis,  acute,  1051 
chronic,  1053 
deformans,  1057 
A«»te*,107 


1066 

AaeitM,  ehyUform,  lU 
ehyloua,  lU 

pwudoehvloiM,  111 
AaphyxU,  283 
AstMtoMt,  97ft 
Aathma,  343 

AitomU,  381  ,   „       ,„. 

Atexia,  bendiUry  ee.ebcUar,  596 

looomotor,  ASS 
Atexie  paimplMlU,  694 
AtelMtM^  365^383, 290 
AteleioM.  1006 
Atetemyelia,  636 
AteloproMpia,  'SI 
Atherain*  of  •orU,  194 

of  wbMCouf  eyiU,  976 
Atteti*  of  aorta,  144 

of  Fallopian  tubes,  843 

of  pulmonanr  valve,  144 

of  uterus,  823 

of  vagina,  816 
Atrophy  of  auditory  nerve,  650 

of  choroid,  636 

of  Fallopian  tubes,  847 

of  heart,  150 

of  Icidney,  769 

of  liver,  478 

of  lymphatic  glands,  215 

of  mammary  gland,  888 

of  muscles,  988 

of  ner\-es,  603 

of  optic  ner\-e,  648 

of  ovaries,  852 

of  pancreas,  499 

of  prostate,  795 

of  retina,  644 

of  skin,  948 

of  vulva, 813 
Auditory  nerve,  atrophy  of,  6S0 
tumors  of,  051 


INDEX 


Balanitis,  788 
Balanoposthitis.  788 
aspergillina,  788 
Ball-thrombus,  70 
Barlow's  disease,  1019 
Bedsores,  948 
Belching,  349 
Beri-ben,  601 
Bile,  the,  363 
Biliary  calculi,  491 
cirrhosis,  471 
Bladder,  urinary,  abnormal  contents  of, 
778 

calculi  in,  779 

circulatory  disturban    »  of,  775 

conicenitai  anomalies      774 

cystitis  oi,  775 

degenerations  of,  779 

dislocations  of,  774 

diverticula  of,  774,  780 

hypertrophy  of,  779 

paracystitis,  776 


Bladder,  urinary,  pararitea  of,  778 
periey»titU;776 
piUnuetio,  778 
Uphills  of,  777 
tuoareulosis  of,  777 
tumors  of  "80 
Blastomycetie  demuktitis,  930 
Blood  pbteleta,  101 
Blushing,  36 
Bone-marrow,  331 
Bones,  acromegaly  of,  684 
aetinomyeoais  of,  1031 
atrophy  of,  1033 
callus  of,  1041 
earieaof,  1020, 1036 
chondrodvstrophia  foptalis,  1010 
clubbed  ringers,  1018, 1041 
coxa  vara,  Tolb 
I        cretinism,  1006 
eysU  of,  1049 
dwarfism,  1006 
enostosis  of,  1041,1046 
epulis  of,  1045,  1047 
exostosis  of,  1041,  1046 
gigantism,  1013 
balisteresis,  1037 
haUux  valgus,  1018 
'         Howship'slacunff,  1033, 1037 
byperostoHS,  1041 
hvpertrophic      pulmonary      osteo- 

luthropathv,  1018, 1024 
kyphons,  1017,  1037 
hiontiasis  ossea,  1013 
1         leprosy  of,  1033 
!         lordons,  1018,  1037 
I         Madura  foot,  1031 
'         nearthrosis,  1043 

necrosis  of,  1020, 1036 
osteitis  of,  1019 
osteogenesis  imperfecta,  lOU 
osteomalacia,  1037 
osteomyelitis,  1020 
osteophytes,  1041 
o«teopon>'  s,  1033 
osteopaatlivrosis,  1013,  1034 
osteosclercMis,  1021,  1024,  1041 
periostitis,  1020 
phosphorus  necrosis  of,  1023 
pseudarthrosis,  1043 
rickeU,  1007 
scoliosis,  1017,  1037 
sequestration  of,  1036 
syndesmosis,  1043 
svnostosis,  1043 
'         syphilis  of,  1028 

tuberculoos  of,  1024 
variola  of,  1033 
Borborygmi,  350 
Bowman's  theory,  716 
Brachy  gnathia^j^  38 1 
Bromiciroina,  973 

,  Bronchial  occlusion,  242,  280 

i  Bronchiectasis,  261,  276,  279,  2S1 
i  Bronchiolitis  exudativa,  242,  278 
I  Bronchitis,  276 
I  Bronchoeele,  691 


INDEX 


1007 


Drrucbolithi,  37V 
Bptnchopneumonia,  301 
Bv  bo,  indolMit,  214 

virulent,  an,  918 
Bulwnie  plaiue,  214 
BulbomyelitSi,  5M 
BvnitU,  1001 


Cachbxia  itmmipnv*,  677 
CkiHon  diaeaae,  S6,  fi74 
Calcification,  44,  75  I 

Calculi,  biliary,  491  | 

pancreatic,  498  { 

ueputial,  790, 814  i 

MkUvary,  396  { 

urinary,  779  , 

CaUua,9S),1041  \ 

Canalisation,  74 
Cancer  atrophicans,  900 

en  cuiraaae,  902 
Cancrum  orii,  383 
Canitiee,  971,  972 
Capillary  emboliam,  50 

thromboni,  70 
Caries,  390,  1020,  1036 
Camincation  of  lungs,  326 
Carotid  body,  677,  711 
Caruncle,  urethral,  782, 784 
Cavernitis,  788 
Cavemoma,  483 
Cataract,  651 
Cephalhematoma,  1010 
Ceiebellar  aUxia,  hereditarj-,  595 
Cerebral  ajjoplexy,  78 
diplegia,  535 
nulsy,  infantile,  535 
Cerebrum  and  cerebellum,  actmomycosis 
of.  559 
eiiculatorv  disturbances  of,  551 
congenita)  anomalies  of,  523 
encephalitis,  555 
parasites  of,  567 
retrograde    metamorphoses   of, 

560 
syphilis  of,  559 
trauma  of,  567 
tuberculosis  of,  559 
tumors  of,  563 
Chalicoeis,  307 
Chancre,  789 

Chancroid  of  penis,  790,  918 
of  skin,  789 
of  vulva,  813 
Chareot-TiCyden  crystals,  243,  278 
Charcot-Neuniann  crj-stals,  233 
Charcot's  joint,  1061 
ChemosU,  106,  609 
Chcync-Stokes  respiration,  253 
Chimney-sweep's  cancer,  808 
Chloasma,  950 
Chlorosis,  90 
Cholangitis,  480 
Cholecystitis,  490 


CholeUthiaria,  491 
Lliolara  asiatiea,  435 
CholeatMtoma,  548,  563,  663 
ChoDdradystrophia  fveulis,  1010 
Cbordee,  783 
Chordoma,  540 
Chorea,  Huntingdon's,  562 
>  Chorio-epithelioma  malignum,  8<2 
Choroid  albinism,  632 
anemia  of,  632 
atrophy  of,  636 
choroiditis,  633 
eoloboma  of,  632 
detachment  of,  636 
hemorrhage  in,  633 
hyperemia  of,  632 
svpbilis  of,  636 
trauma  of,  637 
tuberculoBis  of,  636 
Choroiditis,  633 
Chromatophoroma,  966 
Chromidroeis,  974 
Oiylifonn  ascites,  HI 
Chylocele,  805 
Chylous  ascites.  111 
1         hydrothorax.  111,  325 
I  Chyluria,  727 
Cirrhosis,  biliary,  471 
i         of  liver,  466 
j         of  mammip,  886 
1         pericellular,  471 
'         portal,  466 
I  Cleft  palate,  381 
i  Clitoris.  436, 4^4 
'■         comu  cu»       um  of,  814 
elephantir      of,  814 
hvpertrophy  of.  810 
Clubbed  fingers,  1018,  1041 
Cocc^-geal  gland,  685,  713 
Colitis,  436,  444 
Cobboma  of  choroid,  632 
I         of  eye,  608 
I         of  optic  ner^-e,  646 

of  retina,  637 
Colpohyperplasia  cystica,  818 
Comedo,  975 

Compression  of  lungs,  291,  326 
:  Concato's  disease,  335.  791 
Condyloma  of  penis,  791 
i         of  skin,  956 
I         of  \-ulva,  812 
'  Congestion  of  optic  nerve,  646 
Conjunctiva,  chemosis  of,  609 
conjunctivitis,  609 

acute  catarrhal,  610 
mpmbranous,  611 
purulent,  610 
follicular,  612,  613 
granular,  612 
papillary-,  612 
Parinaud's.  61 1 
phtvctiFnulosa,  U13 
variolous,  611 
vernal.  6i3 
cysts  of,  615 
eczema  of,  613 


1068 

CenjaiMtiv*,  ImnonluMp  in,  009 

byperemuk  of,  tiOO 

taproay  of.  014 

odenuof,  009 

pinguacuk,  Olfi 

pt«n-cium,  015 

■ymblepbmron,  017 

lyphilteof.eu 

tuMreukMU  of,  614 

tumon  of,  616 

xeroMiii  of,  614 
CoiMtipktion,  351 
Contraction  of  itomach,  407 
Cor  viUoHum,  138 


ISDWX 


Coreetupia,  KtH 
Conipa,  arci 


Conipa,  arcua  aciiiUit,  024 
deoeneratioiM  of,  t>25 
embryotoxiin,  BIS 
faceUt,  vau 
herpes  of,  022 

hy  Jruphthalmus  anterior,  <>  i  s 
keratitis  619 
bulkiaa,  621 
intt>r8titial,  620 
kiTutomatacia,  323 
keratoniVCOKis  tsijergiliinn  '.24 
inarKinal,  621 
neuniparalvtic,  621 
phlyctenulur,  622 
piuictata,  624 
ulcerativ  e,  622 
vaacutar,  621 
K'proity  <>(,  624 
leukoma  of,  620 
nebula  of,  620 
(lannuH  of,  021 
,;igi  lentation  of,  625 
stapiivloma  anterior,  620 
xypraiis  of,  624 
tUDerculonis  of,  624 
Corneal  facet,  620 
Conm  cutaneum,  814,  052 
Corpora  anivlacea,  321,  794 
or>zoidea,  1001,  1055 
fi3r>  za,  264 
Coughing,  251 
Coxa  vara,  1018 
Craniurachiachiais,  524 
Crnnioschisi*,  524 
Ctaniotuiicii,  1009 
Cniv.-craw,  932 
Cretinism,  1006 
Curschmann's  spirals,  243,  278 
Cuixa  laxa,  958 
Cj'anotic  induration,  30 
of  kidney,  733 
of  lungs.  286 
of  spleen,  223 
Cyclencephalv,   526 
Cyclitia,  630.  631 
Cyclopia,  264.  607 
Cystitis,  775 

Cystosarcoma  phyUodes,  899 
Cysts  of  conjunctiva,  615 
of  K-mphatic  glands,  210 
of  maiiunary  gland,  888,  903 


CysU  of  ovaries,  8SA 
of  pAoerma,  Au:< 
of  penia,  793 
of  prosUte,  7U5 
of  ivtina,  044 
of  thymus  glaiwl,  IHW 
tuboikvariau,  843 
of  vagina,  819 


I  > « I   rr'h  disease,  955 
IV     -mutism,  673 
l)e(  iliitus  of  ii'siifihagU",  VYi 
.1  skin,  IMS 
I.  viiitis,  80« 
,  .  u.    lemtiou  oi  bladiier,  779 

I  if  VMfT.    .■      fl  . 

Ill  f:      ii'iin.iu-i.,  160,  100 

u   ■..      ,  »^i».  150 

.>(  !.  iiiey,  7!») 

(I    1  .intN,  UKil 

..I  !.>er,  478 

o   !!  i.gs,  321 

i.>  I;,  .i,|)liatic  glands,  215 

oi  miwles.  (t02 

of  rt'tiiia,  644 
Deglutltiuii,  343,  345 
Dementia  piiriil>  tica,  561 
iJennatitis.    Sir  Skin. 
IH'rmatugraphia,  933 
Dermatolvsis,  9.58 
I  )em>atoniyco»is.  927 
Ik'rmatoinvoititis,  983 
Dermoids,  ":«7.  3!»,  610,  802 
I)iabetes  insipidus,  722 

melUtu»,  .TOO 
Diabetic  gangrene,  949 
Diarrhcea,  350 
i)ia«tematomyeliH.  .533 
I)ige8tiuti.  mechanicH  of,  343 
Digestive  ferments,  uction  of,  354 
Dilatution  of  heart,  131,  1.56 

of  intestines,  423 

of  oesophagus,  397,  398 

of  stomach,  407 
Diphtheria  of  bronchi,  278 

of  conjunctiva,  611 

of  external  auditory  meatus,  660 

of  u-sophagUH,  400 

of  pharynx,  394 

of  stomach,  410 

of  vagina,  818 

of  vulva,  812 
Diplomvelia,  533 
Dislocations  of  bladder,  774 

of  joints,  10.50,  1062 

of  ovaries,  849 
Disseminated  sclerosis,  562 
UiverticuUt  •)f  bladder,  774,  "SO 

of  intestine,  423 

Meckel's,  422 

of  oesophagus,  398 

of  perkardium,  136 

of  stomach,  404 


INDtX 


1060 


DivertleuU  of  uteru»,  820 
Dru|  nMbw,  <M7 
UuctiM  arterinaua,  1-14 
DuodenitU.  443 
"  IhMt-liodiM."  102 

llyHOiimOSK 
Dvaentary,  43a 
lIvniMra,  2A1 
D^atriehUHa,  613 


Ea«,  extortuil,  ftS6 
intemal,  H71 
mi<i(ll«,  tWi 
hr^hynuixx*,  7H,  91 1 
fxhiimcoocui)  tliiwBKi-  "i  blailiU-r.  778 
of  boneii.  !(•;« 
of  bronchi,  '^I* 
(if  liver,  477 
nf  liiiiR,  32(1 
i>f  lymphatic  chuimfU,  21)4 

elnnilii.  21,5 
of  iiHHliaHt  ilium,  33*1 
of  meningT!'.  5t>7 
of  miisclcH,  «»t7 
of  inyocanii    n,  I-tO 
of  ovary,  W. 
of  ppricanliuin,  1  H 
of  pitiiitiir   IkhIv,  T'i'.t 
of  pipiim'.     ;i 
of  pnwlttti'.  7H5 
nf  Milocii.  22S 
of  thyroid  iilnrxl.  •«•! 
of  tunica  vaniiialis  te»ili»,  M)7 
of  iitinm,  832 
Ecthyma,  iUS 
Ectopic  gPMtHtioii,  H70 
Fkiicma  of  conjuiictiv  ;i-.  HIS 

of  Nkiii,  IKl"! 
EIophantiiiniH  <•(  rlitiiri>    ^1  I 
ii('iin)iiiiil'>»8    ''<','i 
of  penis.  71)2 
of  Hcn)lmii,  .S»H 
of  Kkin.  tWi.3 
of  vuivii    .H14 
Ei<  imlixm.  17.  4K 

,.f  liv.T      J.W 

of  huiK.  2S« 
Erabrviitoxoii    (ilH 
EniplivMoma,  (.ulrwonarc,  237,  2'J2 
Enoephaliti.?,  ■'hV> 
Ei>cpphak)cele,  .524,  52,5 
Encephalonialacift   -5.54 
Encephalomvelitis.  5541 
Eminrteritis  obliternui,  liKJ 
Endi    'rditis,  Ifii 
End       .xiium.circulatorvdinturbances 

ino 

congenital  anomalies  ol.  I.ii* 
degeneration*  of,  166,  1»W 
endocarditis,  161 

acute  verrucoie,  162 
ulcerative,  163 


Endocardium,  endocarditln,  ehmnie,  IM 
heOMtoma  of,  160 
■elcriMiiof,  KiA 
•yphilM  of.  167 
tnunMtiimof,  Iflk 
tubMeukMia  of ,  167 
Endometrltii,  83H,  829 
Entcritia,  430 
Enteroeyitonw,  401 
Enterohtha,  451 
EntemplegU,  423 
Ent«ropto(ii»,  406 
Entmpmn,  U13 
Eoainophilia,  77 
EpheliiW  OSO 
EpicanthuN,  607 

Epidemic  cerefimapinal  nieniii«iti<'.  541 
Epididynnitix,  7!»9 
K.piHclcniia,  626 
Epiiitaxiii,  79,  264 
E[>itheliom».     multiple    lienign    cy»lic, 

<«I4 
Epulis,  3»W,  HM5, 1(47 
ErpitiMii,  .591,  947 
Enuiion  of  otomach.  416 
Erv'Kipelan,  (t2« 
Erythema,  «10,  914,  <«7 
Er'ythraama.  "W 
Erythrocytes,  si 
ErytlironielalpB,  2<> 
Eu-il^:  hian  tuU'.  WA 
ExBiilt'omata,  041 
Exophthalmic  noitre,  690,  609 
Exophthalmos,  t>.V4 
Extrovention  of  bladder.  771 
Eye,  anophthalmia,  <i<t7 
cololMima,  6(W 
cyrlopia,  607 
rxopnthalmoH.  6,54 
claiiconia.  6.50 
nvdrophthalmiiH,  ti()7 
livlanosiH,   627 
microphthalmia,  607 
lutnophthalmitiH.  625,  t>:{2 
permstent  hv    loid  artery,  60S 
phthixinbullii.  tk<2 
sympathetic  ophthahnitis,  (ki2 


F.\LLoi'H\  tiilieM,  actimimycowr.  " 
atre.sia  of,  S43 
atrophy  of.  H47 
c«>np>nii  il  anom.ilies  of, 
foreign  I   idieH  in.  S47 
hematowilpinx,  844 
of,  hydrops  profluens    «^3 

hydrosalpinx,  8-t 
ivpertnipliy  in       , 
paraailf^  of,  84. 
physop>  osalpinv-,  94'' 
pyoaalpinx,  845 
riptuic  of,  84 ! 


.847 


»2 


1070 


INDEX 


Fallopiui  tube*,  HilpingitU,  S44 
aalpingooele,  843 
typhilu  of,  846 
tutierculotis  of,  846 
tuboOvarian  cyit,  843 
tumors  of,  84/ 
Fat-embolism,  54 
Fat-necrosis,  372,  497,  500 
Favus  of  naib,  973 

of  skin,  927 
Fibroids  of  uterus,  834 
Fibrosis  of  heart,  146 
Fistultp  of  uterus,  827 

of  vagina,  816 
Flexions  of  uterus,  822,  825 
Foptus,  abortion,  878 

ectopic  gestation,  879 
lithokelvphos,  881 
lithopedion,  879 
maceration  of,  879, 881 
papyraceus,  879 
Foot,  perforating  ulcer  of,  949 
Foreign  bodies  in  Fallopian  tubes,  847 
in  heart,  149 
in  uterus,  833 
in  vagina,  819 
Frambesia,  926 

'•  Kree-lnxliea"  in  peritoneal  cavity,  51 1 
in  joints,  999,  102S,  1051,  1058 


Galactooki.e,  903 
Oalactophoritis,  886 
(ianKlion  rrepitans,  1001 
Gangrpnp,  45 

fiospital,  917 

of  lungs,  :)0l 

of  skin,  049 

of  vulva,  813 
Gas-embolism,  56 
Gastric  juice,  ;1.55 
GastritiH,  1(K) 
Gastromalacia,  414 
General  paralysis  of  insane,  5(11 
Genu  valgum^  lOlS 
Gerontoxon,  624 
Gigantism,  1013 
Glanders  of  kidnev,  759 

of  livvr.  482 

of  lungs,  319 

of  lymphatics,  204 

of  muscles,  987 

of  nasal  cavity,  266 

of  skin,  026 

of  spleen,  228 

of  testis,  803 
Glaucoma,  6,50 
Gh'nard's  disease,  406 
Goitre,  RS8,  692 
Gonorrha-a,  7S2 
Gout,  999,  10,53 
Graves'  disease,  689,  690,  099 
Guinea  worm,  932 
Gynecomastia,  888 


Hair,  alopecia,  909,  971 
canities,  972 
hypertrichoris,  709,  972 
monilethrix,  972 
trichorrhexis  nodosa,  972 
Hair  balb  in  stomach,  413 
Hairy  tongue,  387 
Halistereos,  1037 
Hallux  valgus,  1018 
Hanot's  cirrhosis,  470 
Harelip,  381 

Heart  (myocardium),  anemia  of,  145 
atrophy  of,  IfiO 
actinomycosis  of,  149 
degenerations  of ,  146,  ISO 
dilatotion  of,  131,  156 
fibrosis  of,  146 
foreign  bodies  in,  149 
hy-peremia  of,  146 
inflammations  of,  147 
myomalacia,  145 
parasites  of,  150 
rupture  of,  154 
segmentation  of,  152 
sv-philis  of,  149 
trauma  of,  149 
tuberculosis  of,  149 
tumors  of,  158 
Hematemesis,  79,  40S 
Hematidrosis,  79, 974, 91 1 
Hematocele,  79.  869 
ilpmatocolpos,  816 
Hematoidin,  80 
Hematoma  of  endocardium,  160 

of  uterus,  827 
Hematometra,  820 
Heraatomyelopore,  574 
Hematopericardium,  79,  136 
Hematosalpinx,  826,  843,  844 
Hematothorax,  79, 325 
Hematuria,  79,  770,  778 
Hemochromatosis,  470,  481,  951 
Hemocnnia,  102 
Hemoglobinuria,  727 
Hemolvmph  glands,  209 
Hemolysis,  68.  89 
Ilemophilia,  81 
Hemoptysis,  310 
Hemorrhage.  76 

into  choroid,  633 
into  conjunctiva,  607 
into  Uver.  458 
into  oesophagus,  399 
into  retina,  639 
into  skin,  911 
into  spinal  cord,  574 
into  suprarenal  glands,  701 
into  svnovial  sacs,  1051 
Hemorrhoids,  429 
fIemoci.^prin,  SO 
Hemosiderosis,  481 
Hepar  lobatum,  475 
Hepatitis,  459  , 

Hepatoptons,  406,  455 


INDEX 


1071 


Hereditery  cerebelUr  ataxia,  595 

Hernia  of  inteitines,  425 

Herpes,  26,  776,  789,  934,  945 

Heterochromia,  627 

Heterotopia  of  spinal  cord,  533 

Hiccoughing,  349 

HidradenitU,  974 

Hidroeystoma,  974 

Hippoeratic  fingers,  1018 

Hirschsprung's  disease,  423 

Hodgkin's  dueaae,  2t7 

Hospital  gangrene,  917 

Hottentot  apron,  811 

Housemaid's  Icnee,  1001 

Howship's  Ukcuna-,  1033 

Huntingdon's  chorea,  562 

Hutchinson's  teeth,  381 

Hyaloid  urtery,  persistent,  608 

Hyalosetoritis,  m,  473,  509 

Hydatidiform  mole,  876 

Hydramnios,  878 

Hydremia,  21 

Hvdroa  vacciniforme,  938 

Hydrocele,  106,  805,  806, 865 

Hydrocephalus,  106,  525,  527, 528, 1017 

H'ydrometra,  826 

Hydromyelocele,  525 

Hydronephrosis,  759,  771 

Hydrophthalmos,  607 

ilvdrops  articuli,  1051 

foUicularis,  853 

profluens,  843 
Hydrorrhachis,  525,  529 
Hydrorrhira  gravidarum,  871 
Hydrosalpinx,  84;i 
Hydrothorax,  106,  325 
Hygroma  buncr,  1001 
Hyperehlorhydria,  358 
Hyperemia,  24 

of  choroid,  632 

of  conjunctiva,  609 

of  heart,  145 

of  lungs,  285 

of  retina,  638 
Hyperidroms,  973 
Hyperinoals,  85 
Hypernephroma,  705,  768 
Hyperonychia,  908,  073 
Hyperpiesis,  180 
Hvpertrichusis,  909 
Hypertrophy  of  bladder,  779 

of  rlitoris,  810 

of  Fallopian  tubes,  847 

of  heart.  155 

of  intestines,  451 

of  kidney,  764 

of  mammary  gland,  888 

of  muscles,  995 

of  prostate,  795 

of  stomach,  416 

of  uterus,  833 
HyphldrosM,  973 
Hypinosis,  85 
Hypophysis,  683.  705 
Hypopyon,  620,  624,  625,  630 
Hyiterocele,  822,  826 


ICHTHTOaiS,  907 

Icterus,  371,  489,  951 
Ileitis,  444 
Impetigo,  917, 945 
Infantile  cerebral  palsy,  535 
Infantilism,  1005 
Infarction,  39,  288 
Insufficiency  of  heart  valves,  168 
Intermittent  claudication,  174 
Intestines,  circulator>-  disturbances  of, 
429 
colitis,  430,  444 
congenital  anomalies  of,  422 
dilatation  of,  423 
diverticula,  acquiretl,  423 
enteritis,  430 

acute  catarrhal,  431 
desquamative,  431 
dvsenter}-,  432 
follicular,  431 
membranous,  432 
paratyphoidal,  430 
tuberculous,  439 
tvphoidal,  430 
hernia  of,  425 
intestinal  Hand,  451 
intussusception,  424 
megacolon.  423 
obstruction  of,  428 
stenosis  of,  424 
tumors  of,  451 
volvulus  of,  425 
Intussusception,  424 
Inversion  ol  .itcrus,  822 
Irideremia,  (i08,  628 
IridochoroiditiH,  630 
Iridocyclitis,  630 
Iritis,  629 

plastic,  620 
serous,  6:S0 
suppurative,  630 


JofNTS,  ankylosis  of,  1043,  1051,  10.53, 
10.54,1057,  1059,  1063 
arthritis,  acute  gonorrhoeal,  1051 

gouty,  1053 

purulent,  1052 

rheumatic,  10.51 
chronic  actinomycotic,  1056 

ankylopoetic,  1057 

deformmg,  1057 

gouty,  1054 

neurotrophic,  lOCl 

riieumatic,  1057 

serous,  1054 

syphilitic,  ia56 

tuneiculous,  1054 

ulcerating,  1059 
degenerations  of,  1061 
echinococctis  disease  of,  1061 
injuriM  of,  1063 


1072 

Joint*,  luxation  of,  1050, 1062 
ocbronoms,  1062 

genarthritia,  1051 
tiU's  diieaae.  1063 
tumon  of,  1064 
"white  welling,"  1066 


Kakkb,  601 
Keloid,  958 
Keratitis.    5«  Cornea. 
Keratodermia,  952 
Keratomalacia,  623 
KeratomycowB  aspergiUina,  6^4 
Keratoacleritis,  626 
Keratosis,  657,  956 
Kidney,  actinomycosis  ol,  7S» 
anomalies  of,  728 
atrophy  of,  759 
degenerations  of ,  .60 
glanders  of,  759 
hypertrophy  of,  764 
infarct  of,  733 
infiltrations  of,  762 
inflammations  of,  735 
leprosy  of,  759 
parasites  of ,  769 
pelvis  of,  parasites  of,  lli 
pyelitis,  771 
tuberculosis  of,  772 
tumors  of,  773 
of  pregnancy,  744 
syphilis  of,  758 
tuberculosis  of,  7.55 
tumors  of,  764 
Koplik's  spots,  382.  941 
Kraurosis  yulva-,  813 
Kupfer's  cells,  10/. 
Kyphosis,  1017 


Labia,  810 

Ijicing-lobe  of  bver,  4M 

I.,aennec'8  cirrhosis,  400 

I.andr\'s  paralysis,  579 

Laryngitis,  269 

Lateral  sclerosis,  .587 

Tx-ns,  650 

Untigo,  950 

I^eontiasis  ossea,  '01^ 

I,eproBV  of  bones,  1033 
ofconjunctiva,  614 
of  cornea,  624 
of  epididymis,  902 
of  kidney,  769 
of  lymphatics,  204 
of  lymph-nodes,  215 
of  nasal  cavity,  2G8 
of  peripheral  nerves,  mi 
of  pleura,  331 
of  diin,  923 


ISDSX 


Leproqr  of  apinal  eord,  881 

of  spleen,  228 

of  testU,  802 
I^ucoderma,  960 
Leukemia,  98,  216 

of  liver,  467  ,    ,,0 

of  lymphatic  glands,  JIS 
Leukocytes,  94 
Leukocvtosis,  96 
leukoma,  620 
Leukopathia,  908,  98» 
Uukoplakia,  387,  402 
Uchen,  9.39,  946 
Liebermeister's  grooves,  45.'i 

H^rXrascens,  1^0,1038 

retroperitoneal,  51/ 
Lithokelyphos,  881 
Lithopeaion,  879 
Livedo.  910  . 

Liver,  actinomjwsis  of,  47t» 
amyloid,  479 
anemia  of,  4.'i6 
atrophy  of,  478 
cirrhosis  of  ,465 
cloudy  swelling  of,  478 
congenital  anomalies  ol,  4&) 
degenerations  of,  478 
embolism  of,  4.')8 
lattv  changes  in,  478 
glanders  of,  482 
hemochromatogis,  4*0,  481 
hemorrhaEB  of,  458 
hemosiderosis  of,  4X1 
hepatitis,  acute,  4.59 
hepatoptosis,  4.'>5 
lacing-lobe  of,  456 
leukemia  of,  4.'>7 
Liebermeister's  grooves  of,  4.>.> 
necroses  of,  481 
ni:tr.;eg,  450 
oedema  of,  4.58 
parasites  of,  477 
perihepatitis,  472 
pigmentation  of,  -180 
psputlocirrhosis  of,  472 
syphilis  of,  476 
tropical  abscess,  4_(H 
tuberculosis  of ,  4/4 
tumors  of.  48;< 
I>ochiometra, '  26 
Locomotor  at_.v.j,  JvW 
lAmlosis,  1018       _ 
Ludwig's  thcor>-.  (10 
"Lumrv-jttw,"  .38<. 
Lungs,  abscess  of,  .101 ,  •«!■» 
actinomycosis  of._.llN 
nnthracosisof,  :«)7 
apneumstosis  ot,  2>W 
atelectasis  of,  283,  290 
bronchopneumonia.  301 
camificatioii  ot,  32fi 
chalicosis,  307 
compression  of,  291 .  32« 
congeniUl  anomalies  of ,  .i8.l 
degenerations  of,  321 


INDEX 


1073 


f ,  455 


r,2S3 


Lungs,  embolism  of,  289 
emphysema  of,  257,  292 
gangrene  of,  301 
Klanders  of,  319 
hemoptysis  of,  310 
hepatization  of,  298 
hvpeiemia  of,  :2S5 
hypostatic  pneumonia,  302 
iiiauntion  of,  286,  305 
infarction  of,  288 
cbdema  of,  284 
parasites  of.  319 
peribronchitis,  301 
pigmentation  of,  286 
pneumonia,  295 
pneumonokonioas,  305,  307 
pneumonuraalncia,  321 
pseudotuberculosis,  317 
siderosis,  307 
syphilis  of,  318 
tuberculosis  of,  307 
tumors  of,  322 
Lupus,  919 

er%'thematosus,  940 
of' vulva,  813 
T^ymphadenia,  216 
Lymphadenitis,  210,  212 
Lymphangiectasis.  107,  204 
Lymphangitis,  203 
Lymphatic  system,  103,  208 

glands,  adeiiolymphocelc,  210 
atrophy  of,  215 
bubo,  acute,  211,918 

indolent,  214 
bubonic  plague,  214 
cysts  of,  210 
degenerations  of,  215 
Ivmphadenia  of,  21  ti 
Hodgkin's  d'  case, 
leukemia,  218 
Ivmphosarcomii,  218 
Ivmpdadenitis,  210 
acute,  210 

bubonic  plague,  21 1 
catarrhal  or  simple,  2 
fibrinous,  212 
hemorrhaKic  2\'- 
suppurative,  211 
chronic,  212 
leprosy,  215 
syphilis,  214 
tuberculosis,  212 
parasites  of,  215 
status  lymplmticus,  209,  698 
tumors  of,  218 
Lymphocytosis,  97 
l,vm|>horrhaRia,  204 
l.viiipliosiircoma,  218 
l.vmph-scrotum,  808 
I. vmph- varices,  210 


MvrKWHKiLiA,  207,  387 
Macrogencsy,  1013 
08 


216 


Macrogfcnsia,  207,  387 
Macrosomia,  1U13 
Macrostomia,  381 
Macrotia,  655 
Madura  foot,  924, 1031 
Malacosteon,  1039 
Mastication,  343,  345 
Mammary  gland,  abscess  of,  885 
actinomycosis  of,  888 
angioneurotic  csderaa  of,  884 
atr<.phy  of,  888 

circulatory  disturbances  of,  884 
congenital  anomalies  of,  883 
cysts  of,  888,  903 
galactocele,  903 
galactophoritis,  886 
gynecomastia,  888 
hypertrophy  of,  888 
mastitis,  885 
milk-fistulap,  885 
paramastitis,  884 
parasites  of,  903 
retromammary  abscess,  884 
syphilis  of,  887 
chancre,  887 
diffuse  mastitis,  888 
Kumma,  887 
thelitis  of,  885 
tuberculosis  of,  886 
vicarious  menstruation,  884 
witch's  milk,  883 
Mastitis,  acute,  885 
chronic,  886 
Ciircinomati>sa,  X86 
Measles,  911 

Meckel's  dix<rticulum,  422 
>Iedia8tiniti«  :131 
Mediastino-|«ricarditiF,  140,  335 
Mediastinum,  congenital  anomalies  of.  334 
inflammations  of,  334 
parasites  of,  336 
syphi      of,  33.'> 
tuben  alosis  of,  335 
tumors  of,  336 
10    Megacolon,  423 
Megaloblasts,  88 
Megalocytes,  88 
MogalophthalmoR,  618 
Melanosis  oculi,  627 
Meleiia,  79,  408 
Menibrana  tympani,  662 
.M<5ni4re's  disease,  672 
Meningitis,  cerebral,  536 

epidemic  cerebrospinal,  544 
syphilitic,  547 
tiiterculoiis,  545 
spinal,  .570,  572 

cerebrospinal,  544 
]  syphilitic,  .573 

tuoerculous,  572 
'  Meningocele,  52 1 
Meningo-encephalili.-.  .>42,  546 
Meningo-encephnlixrle.  .525,  52ti 
Meningonivelitis,  .57!) 
Menorrhagia.  79.  S28,  869 
iMesaortitis  syphilitica,  17S 


1074 


INDEX 


Metritis,  SJI.STO,  871 
Metn.rrlmKia.7)I..S_27  80» 
Micrencephaly,  '<i' 
Microbrachiu*.  iOO.') 
Microcephaly,  •■'"7,  'tlO.5,  1016 
MicrocytOh,  SS 
Micronyria,  ";28,  .t.35 
Micnxnastia.  SKii 
MicnimeUis,  HWS,  101 1! 
Microphthalmia,  007,  »)18 
Micropus,  1005 
Microsimiia,  1005 
Microstomia,  381 
Micrirthelip,  883 
Micn)tiu,  <»5 
Milium,  '.>76 
Milk-fistuUr,  S85 
MilkHp.>t»,  141 
Mitral  viilve  inaufhciency,  Ivn 

stenosis,  lt>8 
Moenckel)crg'8  sclerosis,  180 
Mollities  ossium,  1037 
MoUiiscum  contflgiosum,  965 
Monilethrix,  972 
Mor'<'is  coxa-  senilis,  1000 
Morphd-a,  923 
Mortification,  44  . 

Multiple  h<"nign  cystic  epithelioma.  9(i4 
Mummification,  993 
Muscles,  actinomycosis  of,  987 
atrophy  of,  9S8 

circulatorv  distiirbaiio-s  ol,  981 
congenital  anomalies  of,  980 
degenerations  of,  992 
glanders  of,  987 
hvpcrtmphy  of.  9i)5 
nivositis,  982,  !>83 
myotonia  congenita,  0«>.") 
(MiniMites  of,  1W7 
polymyositis,  983 
priniarv  myopathy,  990 
pseudohypertrophy  ol,  991 
syphilis  of,  980 
tiilierculosis  of,  985 
tumors  of.  9!M> 
MvBstlieiiia  gravis,  t'»80 
Mvcetoma  j^dls,  924 
Mvcosis  a^pcrgillina,  279 
Mveloblasts,  94 
Mvelocvstocele,  .'525,  520 
M'veloc\tes,  95,  98 
Mveloma,  235,  2:«,  574,  1040 
Xlyelomatosis,  2:10 
M'vocarditis,  147 
Myocanlium     142.     See   Heart. 
Mvomalacia,  145 
Myopathy,  primary,  i)90 
Myositis,  982 

o.*iticans.  983 
Myotonia  congenita,  995 
Myringiti:<.  (Mi2 


Nails,  fnvus.  973 

hyperonychia,  973 


Nails,  leukopathia,  972 
onychia,  973 
on'ychogryphosis,  973 
onychomycosis,  973 
paronychia,  973 
.Nanosomia,  1005 
Nasal  polyps,  267 
Neaithrosis,  1043 
Nebula,  020 

Necrosis  of  bones,  1020,  1036 
of  liyer,  481 
phosphorus,  1023 
Nephritis,  735 
'         acute  diffuse,  7-)) 

interstitial,  744 

kidney  of  pregnancy,  744 

parenchymatous.  742 

desiiuamatiye    papillary, 

744 
glomeriilitis,  743 
hemorrhagic,  743 
chronic  diffuse,  746 

^lonierulitis,  746 
hemorrhagic,  746 
interstitial,  747  _ 

primary  contracted  kidney,  <.>0 
Buppurative,_751 
Nephrolithiasis,  703 
Nephroptosis,  406 
Ner\e8,  (lorinheral,  atn)phy  of,  UOd 
inflammations  of,  600 
lepn)sy  of,  602 
syphilis  of,  002 
tulx-rculosis  of,  602 
tumors  of,  (i03 
Neuritis,  peripheral,  600 
Neuron  concept,  515 
Neuropathic  ci-dema,  113,  8>m.  >m* 
Neuroretinitis,  *i47 
Nevi,  908,  9(» 
Noma  of  face,  383 

yulvu,  813 
Nutmeg  liver.  4."i0 


(><-H«oNosi.s,  1062 

( hlontinoid.  390 

Odontoma,  ii'.K) 

(I'klema  gloltidis,  269,  273 

(ilsoph.Hgitis,  399 

(Ksophagomalacia,  402 

(K.sophagus,  actinomycons  of,  491 

congenital  anomalies  of,  .39( 

dicubitus  of,  402 

dilatation  of,  397,  398 

diverticula  of,  3SW 

hemorrhage  of,  399 

(esophageal  varices,  399 

leukoplakia,  402 

ii'sophagitis,  399 
catarrhal,  399 
ctjrrosive,  400 
exfoliative.  400 
i  follicular,  400 


INDEX 


1075 


(l-jiophagui),    a-HophagitiH,   membranous, 

phlegnionouH,  400 

pustular,  400 
a-sophafrnmalacia,  402 
peptic  incer,  402 
perforation  of,  399 
stenosis  of,  397 
svphilis  of,  401 
thrush,  401 
tuberculosis  of,  401 
tumors  of,  402 

<  >liKPmia,  22 
Oligohydramnios,  878 
t>li({una,  723 
Omentum,  .'}07 
Onychia,  973 
On'ychogni-phosia,  973 
Onvchomvcosis,  973 

<  )nvx,  624 

( Wphoritis,  8.50 

Opaline  plu(|UPs,  385,  512 

Ophthalmia  neonatorum.  010 

<  >phthalmitis  sympathetica,  632 

<  iptic  nerve,  atrophy  of,  IH8 

cololwma  of.  646 
conftestion  of,  t»46 
neuritis,  646 

neuroretiiiitis,  *>47 
papillitis,  ti46,  647 
retrobulbar,  648 
oedema  of,  646 
scotoma,  648 
syphilis  of,  648 
tuberculosis  of,  648 
tumors  of,  648 
( M>it,  inflammations  of,  654 

tumors  of,  tiiii 
Orchitis,   7m» 

<  )riental  furuncle,  92(i 
Osteitis.   101!) 

delormans.  1057 
Osteo-arthropathv.   hvpertntphic   pul- 

rnoimri-,  1019,  ■l024' 
OKt«>op'm'»is  imp<'riecta,  1011 
« )Nteonialacin.  1037 
Osteomvelitis.  1020 
OMt<'opliytes,  1041 
( )steopomsis,  i03Ci 
Osteopsathyrosis,   1013,  1034 
Osteosclerosis,  1021,  1024.  HHl 
( >thematonia,  6.')7 
Otitis,  externa.  6.59 

interna  (labyrinthitis).  672 

media,  6<)6 
Otomycosis,  6(iO 

<  (varies,  atrophy  of,  8.52 

circulatory  disturbanci'N  of,  8,50 
conf(enital  anomalies  of.  848 
cysts  of.  8.5.5 
dislocations  of.  849 
hydrocele  of,  844 
hv-perplasia  of,  8.5:1 
inflammations  of,  8.50 
syphilis  of,  8.52 
tunerculosis  of,  852 


Ovaries,  tumors  of,  854 
Ovula  nabothi,  830 
( )zu>na,  '266 

syphilitica,  266 


Pachydehuia  lari-ugis,  274 
Paget's  disease  of'boncs,  1023 

of  nipple,  899.  970 
I'alsy,  infantile  cerebi      535 
I'ancreas,  atrophy  of,  499 
calculi  of,  498 

circulator}-  disturbances  of,  493 
cysts  of,  503 
fat-necn)sis  of,  500 
inflammations  of,  494 
self-digestion,  501 
sialodochitis  pancreatica,  494 
syphilis  of,  499 
tunerculosis  of,  498 
tumors  of,  501 
Pancreatitis,  acute  hemorrhagic,  496 
ehn)nic,  497 

(Icfjenerative  parenchymatous,  4?>5 
suppurative,  495,  497 
Panonhtnalmitis,  632 
Papillitis,  Iv46,  647 
Papules,  914 
Paracystitis,  776 
Paradoxical  embolism,  49 
Paraeonimiasis,  320 
Paralysis  of  insane,  general,  561 

|jindr>''s,  .579 
Paramastitis,  884 
Parametritis.  828.  866 
Paranephritis.  7.54.  757 
Paraphimosis.  788 
Piinisites  of  bladder,  778 
tif  cerebrum,  .567 
of  Fallopian  tubes,  847 
of  heart,  150 
of  kidney,  769 
iif  liver, '477 
I  if  lungs,  319 
of  lymphatic  glaiwls.  215 
of  mammar>'  gland.  903 
of  me<liastinum,  %)6 
of  muscles,  987 
of  |)elvi8  of  kidney,  772 
of  retina,  644 
of  skin,  9:M 
of  uterus,  832 
of  vaf<ina,  819 
Parathyroids,  678,  687 
I'aratyphoid  fever.  439 
Pariniiud's  conjunctivitis,  611 
Paronychia.  973 
Parotitis,  395 

Passive  congestion,  general.  27 
i'atcnt  foramen  ux.-ilf.  143 
I'ectus  carinatiun,  1008 
Petliculosis,  932 
Pellagra,  947 
Pemphigus,  a37 


1076 


INDEX 


I'enU,  iiiuMnaliw  of,  787 
baUuiitU,  788 
cavemitU,  788 
chancroid  of,  7«0, 918 
chonlee  of,  783 
condyloma  of,  791 
cvuU  of,  792 
elephantiasis  of,  792 
herpes  of,  789 
injuries  of,  792 
keratosis,  791 
paraphimosis,  788 
phagedena,  790,  791 
phimosis,  788 
syphilis  of,  789,  918 
tuDcrculoBiB  of,  790 
tumors  of,  791 
Peptic  ulcer,  402,  414 
I'erforating  ulcer  of  foot,  !H9 
of  nasal  septum,  ^oo 
Periarteritis,  184 
nodosa,  192 
Periarthritis,  IWil 
I'crihronchitis,  301 
Pericanlitis,  acute.  13*. „„ 
drv  fibrinous,  1.18 
fibrinous,  1.37,  139 
hemorrhagic,  138 
Buppurative,  138 
chronic,  140 

syphilitic,  140 
tuberculous,  140 
Pericanlium,  circulatory  disturbances  <if 

136  .         r    1-.- 

congenital  anomalies  ol,  l*) 

diverticula  of,  13(5  _ 

inflammations,  137 

pneumatopericardium,  \Mt 

pyopericardium,  KW 

tiimors  of,  141 
Pericf  Uular  cirrhosis,  471 
Pericholangitis,  491 
Pericholecystitis,  491 
Pericystitis,  491 
Peripistritis,  412 
Perihepatitin,  472 
Pcrilymphadenitis.  211 
Perilymphangitis,  203 
Perimetritis,  SIM).  872 
Perinephritis,  7.'>:i 
PeriiMiphoritis,  8t)»> 
Periorchitis,  805 
PerioHtitis,  1020 
PoriBiilpingitis,  845 
i'crisplenitis,  225 
Pi'ritonitis,  .505 
Perityphlitis,  444 
Perivaginitis.  818 
Perls  test,  92,  481 
"  Perlsucht,"  XV) 
Pernicious  anemia,  92 
Pernio,  916 
Pes  planus,  1018 
PetechiiP,  78.911 
Phagc<lena  of  penis,  (90,  <91 
tropical,  92(> 


Phagedena  of  vulva.  813 
Pharyngitis,  391 
Phimosis,  788,  791 
Phlebectana,  201 
laryngu,  209 
Phlebi   '.  202 
Phlebolitha,  703 
PhleboscleroOB,  203 
Phlvctenulie,  613,  622 
Phtisphorus  necrosis.  1023 
Phthisis  bulbi,  632 
Phyma,  914 
PhVsometra,  826 
PhysopyoHftlpinx,  845 
Phytobezoar,  413 
I'ilimictio,  778 
Pineal  gland,  711 
Pinguecula,  615 

Pituitary  body.    See  Hypophysis. 
Pityriasis  rosea,  935 

rubra,  935 
Placenta,  875 
Plasmorrhexis,  88,  102 
Plasmoschisis,  62,  88,  102 
Plethora.  22 
Pleura-,  324 
Plica  polonica,  9.12 
Pneumatopericardium,  136 
Pneumonia,  aspiration,  302 
chnmic,  .105 
dissecans,  305 
hypostatic,  :102 
lobar,  297, 298 
lobuUr,  297,  :«H 
metastatic,  304 
niiliarv-,  297 
per  extensionein,  305 
pleurogenetic,  297 
pneumonic  phthisis,  314 
purulent,  303 
vagus  pneumonia,  302 
•■whitt""  pneumonia,  'MX 
Pneumonokimiosis,  305 
Pneumonomalacia,  321 
Pncuinonomycosis  asprgiUiiia,  .119 
I'neumoperitoneum.  51 1 
Pneumothorax,  246 
Poikilocytosis,  92 
.  Poliencephalitis,  556 
Poliomyelitis.  .576,  .586 
Poliosis  circumscripta,  950 
Polyarthritis,  lft51 
Polychromatophilia,  88 
Polvcoria.  628 
Polycythemia,  86 
Polvdactvlisin,  1016 
Polymastia,  883 
Polymyositis,  983 
Polyneuritis.  602 
Pol'yorchidism,  798 
PolVtheliii,  s.^:^ 
Polytrichia,  909 
Pompholyx,  9.18 
Porencephaly,  .526,  535,  556 
Portal  cirrhosis,  466 
pylephlebitis,  462 


INDEX 


1077 


Portal  thromlHimii,  402 
I'lwthitiii,  7H8 
I'utt'H  diseuxe,  1027 
I'n-gnaiicy,  kidney  of,  744 
I'n-putial  calculi,  7U0,  814 
I'nietitiH,  4S0 
I'rolap«e  of  uterus,  822 

of  vagina,  810 
Prostate,  amyloid  bodies  of,  794 

anoiiulies  of,  793 

atrophy  of,  79S 

echinococcus  cysts  of,  795 

hypertrophy  of,  796 

inifamniations  of,  7!K{ 

phlehflliths,  793 

tuberculosis  of,  793 

tumors  of,  797 
Prurigo,  934 

PHanmioina,  r>Mi,  5S(),  5««i,  (Wil,  W>7 
Pt«u<larthroi<is,  1043 
Pseudochylous  ascites,  111 
I'seudocirrhosis  of  liver,  472 
I'seudoelioma,  <>4() 
PacudohyiHTtrophy  of  muscles,  991 
Pseudoleukemia,  210 
Pseudoniyxonia,  805 
Pseudotuljerculosis,  317 
Psoriasis,  tl38,  940 
Pterygium,  015 

Pulmonary  vahe,  atresia  of,  144 
ihsuHiciency  of,  108 
stenosis  of,  144,  108 
Pulpitis,  39(1 

Pupillary  membrane,  persistent,  027 
Purpura,  91 1 
Pustule,  914 

malignant,  925 
Pvclitis.    See  Kidnev  [lelvis. 
Pylephlebitis,  jxirtal,  402 
Pyloric  stenosis,  400 
Pvocele,  retro-uterine,  833 
Pyomctra,  82<> 
Pyopcricardium,  138 
Pvorrhira  aheolaris,  383 
Pvosalpinx,  843,  845,  840 
Pvothorax,  329 
Pyrosis,  349 


Qi'ISc-ke'«  test,  92 


Uaihitic  "rosary,"  1008 
Uanula  pancreatica,  503 
HaynaiHi's  disease,  058,  949 
liecklinghaUBcn's  diseiise,  958 
lletina,  anemia  of,  (J37 

arter>'  of,  (>3H 

atrophy  of,  tM4 

culloidof,  044 

coloboma  of,  037 

cysts  of,  044 


Uetina,  fatty  degeneration  of,  044 

hemorrhage  of,  039 

liy()ereniiaof,  »i38 

ossification  of,  045 

imrasites  of,  *i>44 

pseudoglioma,  040 

retinitis,  04U 

separatum  of,  044 

xems,  dilatation  of,  040 
Uctinitis,  albuminuric,  041 

clinmic  diffuse,  M2 

circinate,  (J43 

dialx^tic,  042 

<liHH>minated,  042 

proliferans,  (i40 

punctata  albescens,  643 

!<implex,041 

Solaris,  044 

suppurative,  »»44 
Ketromammary  abscess,  8X4 
Hetroperitom-al  lipoma,  512 
Itetropharyngeal  alisccss,  392 
Khagades,  914 
Khinitis,  204 
lihinoliths,  20<i 
Khinosclenima,  300,  922 
•  Uice-bodies,"  1001,  lOS.'i 
Hickets,  1(;07 
Kingwonn,  928 
Ktxlent  ulcer.  970 
Itdsacea,  910 
Itiwola,  910 
Uupia,  940 
liupturc  of  fallopian  tiibes,  844 

of  heart,  154 

of  ii'sophagus,  399 
of  uterus,  820 


Saliva,  ;V54 
Salivary  calculi,  390 
Salpingitis,  844 
Salpingocele,  843 
Scabies,  931 
Scarlatina,  '.M2 
Scleritis,  •>20 
ScleriKlerma,  952 

Sclerosis,  amyotrophic  lateral,  596 
of  enilocanlium,  lti5 
lateral.  587 
Moenckebcrg's,  180 
posterior,  588 
Scoliosis,  1017,  1037 
Scotoma,  (V48 
Serophuldderma,  922 
Scnitum,  chimney-sweep's  cancer  of,  808 
elephantiasis  of,  808 
lyinphangiectasis  of,  8(W 
Sel>aeeous  glands,  acne  of,  970 
ncrticordon.  957.  970 
asteatosis  of,  975 
atheroma  of.  970 
conuMlo  of,  975 
milium  of.  970 


1078  '^««^ 

Sebsceouii  fcloiut"-  HetMirrhii-a  uf,  »74 
tiiu'H  iiycoitiH  of,  9711 
tunium  of,  977 
Sehorrhii'a,  974 
Secondan-  aiiemia,  91 
Segmentation  of  heart  fibers,  152 
Seminal  vesicles,  MM 
SeiiueHtKtion,  1()20 
Sial<Mlochitis  pancreatica,  494 
SinlolithH,  39ti,  498 
SiderowH,  ;107 

Skin,  actii.omyconis  of,  924 
ainhum  of,  949 
alliinixm,  908 
anemia  of,  012 

angioneurotic  cwlema  of,  91(> 
antlimx  of,  92S 
atr.iphv  of.  i>48 

lilnxtoniycetic  ilennatitiH  of,  9.T(> 
calluH  (calloHitaa)  of.  9.51 
chancre  of,  780 
chancnmi  of.  789 
comlyloma  of.  iK5tl 
cornii  cutaneiim  of,  9."i2 
craw-craw  of,  032 
ciitin  laxa.  9.58 
(lecubitUH  of,  !>48 
(IcnnatitiH  of,  913 
ambuHtioniH,  910 
calorica,  91  ti 
cimgelationiH.  91l> 
exfoliativa.  WiTi 
venenata.  0H> 
(lermatiilyHiH,  O.W 
<lennati>inyco8i»,  927 
drug  rashen  of.  947 
ecthyma  of,  918 
iwjtema  of,  935_ 
ergotism  of.  947 
erysipelas  of,  92t» 
erythema  of,  937 
erythrasma  of,  929 
exanthems  of,  941 
fuvus  of.  927 
frambesia  of.  !t2t'> 
gangrene  of,  '.MO 
glamler.  of,  92(i 
(iuinea-wonn,  032 
hemorrhage  into.  Oil 
herp»-K  of,  t(34 
hospital  gangrene  of,  917 
hyifroa  vacciniforme  of,  938 
hvpen-mia  o(,  910 
ichthyosis  of,  007,  052 
iniTM'tigo  of,  945 
keloid  of,  958 
keratiMlemiia  of,  9.52 
keratosis  of.  0.55 
leprosy  of,  923 
leiikiKlenna  of.  90S 
lichen  of,  n.'tO.  045 
liviHlo  of,  910 
lupvis  of,  010 

ervthematos\iB  of,  940 
Madura  f<M)t,  924 
nevi  of,  908 


Skin,  otlema  of,  910 
parasites  of,  031 
pellagra,  947 
pemphigus  of,  937 
perforating  ulcer  of,  W9 
pigmentation  of,  95U 
pityriasis  of,  036 
pompholyx  of,  938 
prurigo  of,  WW 
psoriasis  of,  938 
Kaynaud's  disease  of,  940 
rhiiioscleroma  of,  922 
ringworm,  928 
nslent  ulwr  of,  970 
nisaoes  of,  910 
roseola  of,  910 
scabies  of,  031 

sclerema  neonatorum  of,  953 
sclenMlerma  of,  9.52 
scrophulo<l»'rma  of,  022 
syphilis  of,  018,  944 
tvtt-angiectasis  of,  910 
tropical  phagetlena,  93« 
tuberculosis  of,  919 
ttunors  of,  957 
ulceration  of,  948 
urticaria  of,  9311 
\erruca  of,  95« 
xanthelasma  of,  961 
xenxlerma  of,  907 
xerosis  of,  907 
x-ray  bums  of,  915 
Smegmabacilli.  ;107,  757 
Snake-tongue,  381 
Sneezing,  252 
Spermatic  cord,  808 
Spemmtocvstitis,  800 
Spina  bifida,  524 

ventosa,  1026 
Spinal  cord,  acute  anterior  poliomyelitis, 
570 
ascendinf^  paralysis,  570 
suppurative  myelitis,  579 
transverse  myelitis,  .577 
amvotrophic    lateral    sclewfis, 

500 
chmiiic    anterior    poliomyelitis. 

.586 
circulatory  disturbances  of,  574 
compression  myelitis,  .583 
disseminated  sclerosis  of,  .585 
I'rii'iln'ich's ataxia,  .594 
henmt<imyelo|)ore,  .574 
hcmorrhavc  into,  574 
heterotO|).aof.  SIW 
lateral  sclen)sis  of.  587 
myelitis  of,  575 
pernicious  anemia  of,  596 
i  posterior  sclerosis  of,  .5h8 

posterolateral  sclerosis  of,  594 
syphilis  of,  .581_ 
syringomyelia,  5.10 
syringomyelocele.  525 
tuljcrculosis  of,  580 
tumors  of.  599 
meningitis,  570 


INDEX 


1079 


Spinal  nienini^tiH,  cprplm>-,  .Vi-i 
nyphilitir,  A7:) 
tiiberculoiM,    572 
Spiroehii'ta  pallitUt,  31H,  UIK,  »4t( 
Splanehnoptiiaia,  4U6 
Sptepti.  actinumycosu  of,  228 
annmalini  of,  222 
eireulstor>-  ilbturbancFs  of,  223 
elaiutera  of,  22K 
IpproHy  of,  22H 
rptroKmmvc  chaii{(pit  of,  22K 
Hplrnailenoms  of,  !220 
■plpnitiii,  22A 
Mvphiliii  of,  227 
tiiDprculoau  of,  227 
tiimon  of,  230 
Splpimih'Donia,  229 
Spli-nitiH,  225 

SponilvlitiHilefonniiiui,  1050 
Staplivloina,  020,  626 
Stiitu.-.  lyniphaticus,  200,  6W) 
StenodiK  of  aorta,  144,  168 
of  intestine*,  424 
of  mitral  valvo,  l<t8 
of  (iKMphaipui,  397 
of  piilmonar\'  valvco,  144,  168 
pylciric,  406 " 
of  triciupiU  valvp,  168 
of  iiteruit,  825 
Stortor,  240 
Still's  <li«-a«',  1053 
Stoniueh,  circulatory  tliHturbanwH  of, 
congenital  anomalicH  uf ,  404 
contraction  of,  407 
dilatation  of,  407 
diHplaecment  of,  406 
<liverticula  of,  404 
croxion  of,  416 

gastritiB.  acute  catarrlial,  410 
atrophic,  412 
chronic  catarrhal,  411 
follicular,  411 
heniatofcenous,  410 
hy(K'rtn>phic,  412 
nifinbranuus,  410 
p«'r  extcnsioncm,  410 
pliU'pfnionous,  411 
specific,  412 
hair  balls  of,  413 
hyutrtrophy  of,  4I(< 
pyloric  stenosis,  406 
retn)Kra<le  metan>orphose8,  414 
thrush  of,  412 
tumors  of,  417 
volvulus  of,  408 
Stomatitis,  382 
Strauss'  phcnonienon,  '<02 
Struma,  691,  JiSS 

liponwtoKa  sunrarenalis,  703 
Succiis  entericiis,  3(i3 
Swlamina,  974 
SuggiUations,  7S 
Suprarenal  kIiukIs,  679.  7(N> 
accessory,  701 
heniorrtmgp  into,  701 
syphilis  of,  703 


Suprarenal  Rbnds,  thntmhoHiw  of,  702 
tuberculosis  of,  702 
tumors  of,  703 
8weat-Rlan<b,  anidrusia,  973 
bromidrosis,  973 
ehiomidmsia,  974 
hematidroms,  974 
hydradenitis,  974 
hydrocvstoma,  974 
hyperiilrosis,  973 
hyphidrosis,  973 
siMJamina,  974 
uridrosis,  974 
Symblephanin,  617 
Syndesimisis,  1043 
.Synechia  of  iris,  629 
Synophthalmia,  S26,  607 
Synorchidism,  799 
Synostosis,  1043 

S'vno\  iai  sacs,  floating  cartilage,  1062 
f n<e  bodies  of,  10<i3 
hcmorrhaoe  of,  1051 
lipiiina  .".rborescens,  1064,  1058 
synovitis,  1051 
(ibrinosa,  1051 
pannosa,  1056 
I  purulenta,  1052 

serosa,  1051 
serofibrinosa,  1051 
syphilitica,  1056 
tunerculosa,  10.55 
408  urica,  10.53 

Syphilis  of  arteries,  192,  193,  196 
of  auricle,  660 
of  bladder  (urinar^•).  777 
of  Ixine,  1028 
of  hone-marrow,  2.32 
of  bronchi,  279 
of  buccal  cavity,  384 
of  cerebrum,  .5.59 
of  choroid,  636 
of  conjunctiva,  014 
of  cornea,  024 
of  dura  niatrr,  .538,  571 
i  dwarfism  and,  100.5 

I         of  endocardium,  167 
I         of  Eustachian  tube,  665 
j         of  Fallopian  tubes,  841 
i         of  heart,  149 

of  intestines,  443 
of  iris,  (KIO 
of  joints,  ia56 
I         ofkidnev,  7.58 

of  labyrinth,  072 
!         of  larynx,  273 
i         of  liver,  475 

of  lung,  305  318 

of  lymphatics,  214 

of  lyniph-noilt>s,  214 

of  nmnuiiar>'  gland,  887 

of  mediastinum,  XVi 

of  membrana  tympani.  603 

of  middle  ear,  070 

of  muscles,  986 

of  myocardium,  149 

of  nasal  cavity,  265 


1060 

Syphilb  of  (r«>pha||Uii,  M)\ 
of  optic  nene,  MH 
of  ovsrien,  HA2 
of  panerpan,  40tt 
of  pcni*,  7HU.  OIH 
i>f  pericsnlium,  140 
of  peripbend  nervra,  A03 
of  peritoneum,  51 1 
of  plutrvnx,  3tt5 
of  pia-aracbnoid,  547,  •'>72 
of  pituitary,  709 
of  pUeenU,  878 
of  pleum,  331 
of  ikin,  918,  044 
of  ipinal  cord,  581 
meDinges,  573 
of  iipleen,  &i 
of  iiU-maeh,  412 
of  ■upmrensl  glamtit,  703 
tabet  Uomalia  and,  5'^i 
of  textiH,  801 
of  thviniis  glantl,  OIH 
of  tlivroiil  rUikI,  UUl 
of  toDRil,  :ws 

of  tunica  vaginalis  testii,  fOl 
of  utenu,  ^2 
of  vagina,  818 
of  veins,  203 
of  vulva,  813 
Syringomyelia,  630 
Syringomyelocfli'.  525 


Taui'es,  lois 
Teeth,  31)0 

■relenngiccta»iK,  201 ,  010 
Temlinitiis,  !)9S 
Teiiiwynovitis,  WW 
Teratimia  of  moiilli.  -l^W 

of  ovary,  Ht)2 
Terminal  arteries.  :H.  :1S 
Testes,  coni^enitnl  anomalies  uf, 
glanders  of,  803 
iitehitic,  79i> 
periorciiitis,  H0.5 
Hvphilis  of.  sol 
tulierciilosis  of,  800 
tumors  of,  803 
Thelitis,  885 
Thn>ml«)-»rteritis,  1!H 
ThroiiilKJsinusitis  of  l>rain,  .i*) 

of  uterus,  870 
ThnniilKisis,  .W 
portui,  -102 

(il  suprarenal  vein,  702 
Thrush.  :iS4,  412 
'I'livniie  asthma,  tiStJ 
Thviniis  gland,  anatomy  of,  t>!t7 
foitsenitit!  si-toinnlie*  of. 
cv'isof,  OfW 
e'inhryolopy  of,  <>85 
thvmic  !i-thma,  (Wti 
tiii  Mirsol.  ti!«t 
Thvroid  glan.l,  aniil"tiiy  of,  (>7t>. 


ISDF.X 


r»8 


()0S 


(W7 


Thyntid  giond,  congenital  anonwUeii  of, 

088 
embryoloi^  of,  670,  »i88 
function  t7,  070 
goitre,  eta 

mflaninukUona  of,  UW) 
TitH>«  circinata,  WW 
favom,  027 
imbrieata,  020 
Nyeosia,  0!20 
liinHuraDa,  020 
versicolor,  0211 
TokeUu  ringwomi,  020 
Tongue,  382 
ronmllitii,  303 
I'oiMilii,  301 
Tophi,  057 
'Toxic  n>denui,  112 
Tracheitin,  270 
Trachoma,  012 
Trnunia  of  choniitl.  037 
of  eiHlocanlium,  ltl8 
of  heart,  140 
of  uterus,  82*1 
of  vagina,  816 
Tricbiaais,  013 
Trichinosis,  !t87 
'Trichorrhexis  niKlosa.  972 
'Tricuspid  \alve.  inauHiciency  of,  108 

stenoais  of,  108 
I'nipical  abscess  of  liver,  \M 

phagedena.  93»i 
TulH-rculosis  of  apix-ndix,  4.tO 
of  arteries,  192 
of  auricle,  tHiO 
of  bladder,  777 
of  lH>ne,  1024 
of  boiie-uuirrow,  232 
of  bnmd  ligaments.  8('>7 
bnmchitis.  278 
of  buccid  cavitv,  309 
of  burs:e.  KHIl" 
of  e«"rel)rum.  .WO 
of  chciniid,  030 
of  conjunctiva,  014 
of  coniea,  024 
of  dura,  .'>.18.  571 
of  endocardium,  107 
of  epididvinis,  800 
of  Kustachian  tulH!.  0<15 
of  Fallopian  tuln's,  840 
of  lieart,  149 
of  intestines,  439 
cf  iris,  630 
of  joints,  10.54 
of  kidney,  7.55 
Iielvis.  772 
of  lar>nx,  271 
of  liver,  474 
of  lungs,  307 
ol  lymphatics.  204 
of  lymph-iKxles,  212 
of  tii.immary  glaiHl,  880 
ol  iniHliastirium,  335 
of  membrana  tympani,  003 
of  muscles.  9H.5 


INDEX 


1081 


Tiibereukiaia  of  niyoeatOium,  140 
of  naaal  Mvity,  2SS 
of  cpfophagui,  401 
of  optie  nerve,  048 
of  ovariee,  852 
of  panereaa,  498 

of  penis,  700 

of  pericMdium,  140 

of  peripheni  nerve*.  (i02 

of  peritoneum,  810 

of  pi«-«nehnoid,  M5,  572 

of  pleura,  330 

of  pnwUle,  793 

of  Mminsl  veiielei,  800 

of  skin,  910 

of  ipinal  eoid,  5W) 

of  ipleen,  227 

of  ■upnrt-iuil  gUndu,  702 

of  tendon*,  900 

of  tcatia,  Ml2 

of  thymuH  iclanil,  (108 

of  thyroid  gUnd,  (MM 

of  tonsil*,  305 

of  tunica  vaginalis  teHti*,  N07 

of  ureter,  772 

of  un.  thr«,  784 

of  utenu,  M.')2 

of  vagina,  818 

of  vas  deferens,  Hi)0 

of  veins,  20!) 

of  vulva,  803 
TuboOvarian  ahuccfw,  H.")l 

cyst,  843 
Tumors  of  amiitory  nerve,  G51 

of  blatidcr,  780 

of  oereliruiti,  5»i3,  TM7 

of  conjunctiva,  610 

of  Kaliopian  tubes,  847 

of  lieart,  158 

of  intestines,  4,51 

of  iointx,  HHH 

of  kidnev,  7t>4 

of  livcr,'483 

of  lung,  322 

of  lymphatic  glands,  218 

of  mediastinum,  33(> 

of  muscles,  096 

of  ner%e8,  <)03 

of  (esophagus,  402 

of  optic  ner\-e,  »>48 

of  orbit,  654 

of  ovaries,  854 

of  pancreas,  501 

of  pelvis  of  kidney,  773 

of  penis,  701 

of  pericardium,  141 

of  prostate,  707 

of  sebaceous  glaiidn,  1)77 

of  skin,  !)57 

of  Kpinal  conl.  509 

of  spleen.  2.'10 

of  Ktonuicb,  417 

of  suprarenal  glamis,  703 

of  testes,  803 

of  thymus  gland,  600 

of  urethra,  784 


1  unior*  of  ut'-rus,  834 
of  vifii       .tlO 
of  vulva,  t-14 

Tvphlitis,  444 

r'vithohl  fever,  436 

Tyloma,  OCl 


I'U'ER,  peptic,  403 

IK-rfoisting,  of  foot,  049 
of  nasal  septum,  266 
nxk-nl.  07(1 
I'nibilical  conl,  877 
Irntic  infarcts,  763 
Ireter,  770 
I  ruthra,  781 
injuries,  785 
I  luiors,  784 
lirthntis,  782 
rridoHis,  074 
Trinary  calculi,  770 
I  (ems,  apoplexv  of,  827 
atn-^ia  of,  822 
ntruphy  of,  833 

circuU'torv-  disturbances  of,  827 
congenital  anomalies  of,  821 
<liviTticula  of,  826 
endometritis,  828 

ncutc,  catarrhal,  828 
diphtherial,  820 
hemorrhagic,  828 
inierNtitial,  820 
niembranouH,  829 
chninic  intenititial,  830 
proliferating,  820 
fistuli.    of,  827 
flexion!,  of,  822,  825 
loreign  iMxIies,  KXi 
hematoniii  >>|,  827 
liemntometra  of,  827 
hydrometra  of,  826 
hypertrophy  of,  833 
inversion  of,  822 
umlpoflitliiim  of,  822 
menorrhagia,  827 
metritis,  831 
nu-trorrhagia,  827 
ovula  Nal)<>thi,  830 
parametritis,  8(i4'> 
paraxites  of,  8.32 
p*'riiuetritis,  866 
physomctm.  826 
puerperal,  hemorrhag;,  869 

nydrorrhora  grn'  idanmi,  871 
inllammntions,  860 
injuries,  s(i!) 
lochiomi'tra,    827 
.  placental  jiolyps,  871 

!  Hvncytionia  malignum,  872 

I  moles,  876 

I  pyoiiietra,  826 

j  rupture  of,  826 
'  stenosis  of,  825 
I         syphilis  of,  832 


1082 

rierin,  thrtMnlKMinuMtia  irf,  H7U 
tmuma  uf.  N36 
tubereulowK  of,  H33 
tumun  of,  8M 


VAmxu,  M3 
V«c>lioiMi'ii  iliaPMe,  033 
Vagina,  atimU  of,  H15 

r«)lpohvp<TpUuii«  ey»tic«,  81H 
conRimiUl  anomnliM  of,  HIA 
eviti  of,  Hin 
(Mtula>  of,  NI6 
forcisn  bodiea  in,  Kltt 
hrmatokolpiNi,  HIO 
pMMitea  of,  Hl» 
pprivMginitia,  818 
prolapw  of,  8IU 
■lyphilis  of,  HI8 
trauma  of,  8ttt 
tubereulosia  of,  818 
tumora  of,  819 
N'aginitia,  adheaivc,  817 
aphthoua,  818 
catarrhal,  817 
MnphyaetnatouB,  818 
Fxfuliative,  817 
Kranul«r,  817 
membmnoiiit,  817 
phlrgmoiHHU,  818 
senile,  817 
VaKinitiM,  817 
Varicella,  M4 
Varicocele.  8U8,  80.5 
Varicooe  veins,  201 
Variola,  till,  BttS,  942 

uf  iMinea,  1033 
Veno<i8  occlusion,  46 
Vemica,  Witt 

tuhereutoaa,  919 
Vesicle*.  1)14 
Vibices,  <»I1 
Vicarious  roenstnwtii>n,  884 


IXDKX 


viiiii0.,  mi 

Vitreous  humor,  0A3 
Volvulus,  424 
Vomiting,  ^49 
Vulva,  atrophy  of,  81.1 
I         eondvl'Hna  of,  812 

cnnKpnitnl  anomaliea  of,  810 
I         ehanrroiil  of,  813 
t         elephantiaaiB  of,  814 
i         KanKrene  (noma)  of,  813 
I      ■  kraumslsof,  813 

lufrtis  of,  813 
'         pbacolena  of,  813 
syphilis  of,  813 
tiunun  «>f,  814 
Vulvitis,  811 


Wakt",  MR 

Wheals,  914 

"  White  Bwellinn,"  lOM 

Wilchs  milk,  883 


Xanthelakma  (xanthoma),  WU 
XcHxlerma.  907,  StM,  975 
Xerophthalmia,  612 
Xerosis.  614.  907 
X-ray  demtatitis,  015 


Yaw*,  036 


Zknkeh's  mcrosis,  992 
••  /.uckiTKUsulHT/.,"  140,  335 
•  /aickirguwle"*-.,"  335,  472 
Zuckerkancll'k  organ,  686 


